Blood transfusion therapy involves transfusing whole blood or blood components (specific portion or fraction

of blood lacking in patient). One unit of whole blood consists of 450 mL of blood collected into 60 to 70 mL of
preservative or anticoagulant. Whole blood stored for more than 6 hours does not provide therapeutic platelet
transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII).

Blood components include:

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Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of
whole blood), indicated to increase the oxygen-carrying capacity of blood with minimal expansion of blood.
Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic
reactions.
Platelets, either HLA (human leukocyte antigen) matched or unmatched.
Granulocytes ( basophils, eosinophils, and neutrophils )
Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors).
Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the
preferred product for reversal of Coumadin-induced anticoagulation.
Albumin, a plasma protein.
Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.

9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying
large volumes of plasma.
10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freezedrying large volumes of plasma.
11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.
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.
2. Packed RBCs
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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 recipients 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., Ringers 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 Willebrands 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.

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)

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Nursing Interventions
Verify doctors order. Inform the client and explain the purpose of the procedure.
Check for cross matching and typing. To ensure compatibility
Obtain and record baseline vital signs
Practice strict Asepsis
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.
Warm blood at room temperature before transfusion to prevent chills.
Identify client properly. Two Nurses check the clients identification.

8. Use needle gauge 18 to 19. This allows 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.
12. Do not mix medications with blood transfusion. To prevent adverse effects
o Do not incorporate medication into the blood transfusion
o 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 causes
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.

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Complications of Blood Transfusion

Allergic Reaction it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient
antigen.
Assessments:
Flushing
Rush, hives
Pruritus
Laryngeal edema, difficulty of breathing
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
Assessments:
Sudden chills and fever
Flushing
Headache
Anxiety
Septic Reaction it is caused by the transfusion of blood or components contaminated with bacteria.
Assessment:
Rapid onset of chills
Vomiting
Marked Hypotension
High fever
Circulatory Overload it is caused by administration of blood volume at a rate greater than the circulatory
system can accommodate.
Assessment:
Rise in venous pressure
Dyspnea
Crackles or rales
Distended neck vein
Cough
Elevated BP
Hemolytic reaction. It is caused by infusion of incompatible blood products.
Assessment:
Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood.
Chills
Feeling of fullness
Tachycardia
Flushing

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Tachypnea
Hypotension
Bleeding
Vascular collapse
Acute renal failure
Assessment findings
Clinical manifestations of transfusions complications vary depending on the precipitating factor.
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)
Clinical signs and laboratory findings in delayed hemolytic reaction include:
fever
mild jaundice
gradual fall of hemoglobin
positive Coombs test
Febrile non-hemolytic reaction is marked by:
Temperature rise during or shortly after transfusion
Chills
headache
flushing
anxiety
Signs and symptoms of septic reaction include;
Rapid onset of high fever and chills
vomiting
diarrhea
marked hypotension
Allergic reactions may produce:
hives
generalized pruritus
wheezing or anaphylaxis (rarely)
Signs and symptoms of circulatory overload include:
Dyspnea
cough
rales
jugular vein distention
Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously,
depending on the disease.
Characteristics of GVH disease include:
skin changes (e.g. erythema, ulcerations, scaling)
edema
hair loss

o hemolytic anemia
10. Reactions associated with massive transfusion produce varying manifestations

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Possible Nursing Diagnosis

Ineffective breathing pattern
Decreased Cardiac Output
Fluid Volume Deficit
Fluid Volume Excess
Impaired Gas Exchange
Hyperthermia
Hypothermia
High Risk for Infection
High Risk for Injury
Pain
Impaired Skin Integrity
Altered Tissue Perfusion

Planning and Implementation

1. Help prevent transfusion reaction by:
o Meticulously verifying patient identification beginning with type and cross match sample collection and labeling
to double check blood product and patient identification prior to transfusion.
o Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.
o 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).
o Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial
growth at warm room temperatures.
o Preventing infectious disease transmission through careful donor screening or performing pretest available to
identify selected infectious agents.
o Preventing GVH disease by ensuring irradiation of blood products containing viable WBCs (i.e., whole blood,
platelets, packed RBCs and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to
engraft and divide.
o Preventing hypothermia by warming blood unit to 37 C before transfusion.
o 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.
2. On detecting any signs or symptoms of reaction:
o Stop the transfusion immediately, and notify the physician.
o Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV
drug infusion.
o Send the blood bag and tubing to the blood bank for repeat typing and culture.
o Draw another blood sample for plasma hemoglobin, culture, and retyping.
o Collect a urine sample as soon as possible for hemoglobin determination.
3. Intervene as appropriate to address symptoms of the specific reaction:
o Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with
RBC hemolysis and hemoglobinuria.
o Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor
blood products may be recommended for subsequent transfusions.
o In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as
prescribed.
o 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.)

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For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent;
diuretics, oxygen and aminophylline may be prescribed.
Nursing Interventions when complications occurs in Blood transfusion
If blood transfusion reaction occurs. STOP THE TRANSFUSION.
Start IV line (0.9% Na Cl)
Place the client in fowlers position if with SOB and administer O2 therapy.
The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5
minutes.
Notify the physician immediately.
The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as
per physicians order or protocol.
Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC
hemolysis.
Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for
analysis.
Evaluation
The patient maintains normal breathing pattern.
The patient demonstrates adequate cardiac output.
The patient reports minimal or no discomfort.
The patient maintains good fluid balance.
The patient remains normothermic.
The patient remains free of infection.
The patient maintains good skin integrity, with no lesions or pruritus.
The patient maintains or returns to normal electrolyte and blood chemistry values.
Bowel Elimination
The Large Intestine
Primary organ of bowel elimination
Extends from the ileocecal valve to the anus
Functions
Completion of absorption of H2O, Nutrients (chyme from sm. intest. - 1-1.5 L)
Manufacture of some vitamins
Formation of feces
Expulsion of feces from the body
The Small and Large Intestines

Process of Peristalsis
Peristalsis is under control of nervous system
Contractions occur every 3 to 12 minutes
Mass peristalsis sweeps occur 1 to 4 times each 24-hour period
One-third to one-half of food waste is excreted in stool within 24 hours
Peristalic Movements in the Intestine Colonic peristalsis is slow. Mass peristalsis is strong, few waves per
day, stimulated by food in small intestine.

Factors that influence Bowel Elimination

1. Age
2. Diet
3. Position

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Pregnancy
Fluid Intake
Activity
Psychological
Personal Habits
Pain
Medications
Surgery/Anesthesia

Developmental Considerations
Infantscharacteristics of stool and frequency depend on formula or breast feedings
Toddler physiologic maturity is first priority for bowel training (1 2 yrs)
Child, adolescent, adultdefecation patterns vary in quantity, frequency, and rhythmicity
Older adultconstipation is often a chronic problem

Foods Affecting Bowel Elimination

Constipating foods cheese, lean meat, eggs, & pasta
Foods with laxative effectfruits and vegetables, bran, chocolate, alcohol, coffee
Gas-producing foodsonions, cabbage, beans, cauliflower

Effect of Medications on Stool

Aspirin, anticoagulants pink, red, or black stool
Iron saltsblack stool
Antacids white discoloration or speckling in stool
Antibioticsgreen-gray color

Physical Assessment of the Abdomen

Inspectionobserve contour, any masses, scars, or distension
Auscultationlisten for bowel sounds in all quadrants
Note frequency and character, audible clicks, and flatus
Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible Percussionexpect resonant sound or
tympany
Areas of increased dullness may be caused by fluid, a mass, or tumor
Palpationnote any muscular resistance, tenderness, enlargement of organs, masses

Physical Assessment of the Anus and Rectum

Inspection and palpation
Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass
Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining
Inspect perineal area for skin irritation secondary to diarrhea

Stool Collection
Medical aseptic technique is imperative
Wear disposable gloves
Wash hands before and after glove use
Do not contaminate outside of container with stool
Obtain stool and package, label, and transport according to agency policy

Patient Guidelines for Stool Collection

Void first so urine is not in stool sample
Defecate into the container rather than toilet bowl
Do not place toilet tissue in bedpan or specimen container
Notify nurse when specimen is available
get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc

Types of Direct Visualization Studies

Esophagogastroduodenoscopy (EGD)
Colonoscopy
Sigmoidoscopy
Wireless capsule endoscopy

Indirect Visualization Studies

Upper gastrointestinal (UGI)
Small bowel series
Barium enema

Scheduling Diagnostic Tests

1 fecal occult blood test
2 barium studies (should precede UGI) make sure ALL barium is removed*
3 endoscopic examinations

Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination

Patient has a soft-formed bowel movement every 1-3 days without discomfort
The relationship between bowel elimination and diet, fluid, and exercise is explained
Patient should seek medical evaluation if changes in stool color or consistency persist

Promoting Regular Bowel Habits

Timing -attend to urges promptly
Positioning have pt. sit up, gravity aids in BM
Privacy close door & pull curtain
Nutrition
Exercise abdominal muscles & thighs
Abdominal settings
Thigh strengthening

Individuals at High Risk for Constipation

Patients on bed rest taking constipating medications
Patients with reduced fluids or bulk in their diet
Patients who are depressed
Patients with central nervous system disease or local lesions that cause pain
*Valsalva maneuver (straining & holding breath) intrathoracic / intracranial pressure possible brain injury

Nursing Measures for the Patient With Diarrhea

Answer call lights immediately
Remove the cause of diarrhea whenever possible (e.g., medication)
If there is impaction, obtain physician order for rectal examination
Give special care to the region around the anus
After diarrhea stops, suggest the intake of fermented dairy products
Fecal seepage may indicate impaction

Preventing Food Poisoning

Never buy food with damaged packaging
Never use raw eggs in any form
Do not eat ground meat uncooked
Never cut meat on a wooden surface
Do not eat seafood that is raw or has unpleasant odor
Clean all vegetables and fruits before eating
Refrigerate leftovers within 2 hours of eating them
Give only pasteurized fruit juices to small children

Methods of Emptying the Colon of Feces

Enemas
Rectal suppositories
Rectal catheters
Digital removal of stool

Types of Enemas
Cleansing high volume

Retention - oil
Return-flow bag of solution taken in (100-300 ml fluid) for pt with gas

Retention Enemas

Oil-retentionlubricate the stool and intestinal mucosa easing defecation

Carminativehelp expel flatus from rectum
Medicatedprovide medications absorbed through rectal mucosa
Anthelminticdestroy intestinal parasites
Nutritiveadminister fluids and nutrition rectally

Bowel Training Programs

Manipulate factors within the patient's control
Food and fluid intake, exercise, time for defecation
Eliminate a soft, formed stool at regular intervals without laxatives
When achieved, discontinue use of suppository if one was used

Types of Colostomies each has different stool consistency

Sigmoid colostomy
Descending colostomy
Transverse colostomy
Ascending colostomy
Ileostomy
Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy
Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy
Location of an Ileostomy

Colostomy Care
Keep patient as free of odors as possible; empty appliance frequently
Inspect the patient's stoma regularly
Note the size, which should stabilize within 6 to 8 weeks
Keep the skin around the stoma site clean and dry
Measure the patient's fluid intake & output
Explain each aspect of care to the patient and self-care role
Encourage patient to care for and look at ostomy
Normal-Appearing Stoma

Patient Teaching for Colostomies

Community resources are available for assistance
Initially encourage patients to avoid foods high in fiber
Avoid foods that cause diarrhea or flatus
Drink two quarts of water daily
Teach about medications
Teach about odor control (intake of dark green vegetables helps control odor)
Resume normal activity including work and sexual relations
Comfort Measures
Encourage recommended diet and exercise
Use medications only as needed
Apply ointments or astringent (witch hazel)
Use suppositories that contain anesthetics

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Characteristics of Normal Stool

Color varies from light to dark brown foods & medications may affect color
Odor aromatic, affected by ingested food and persons bacterial flora
Consistency formed, soft, semi-solid; moist
Frequency varies with diet (about 100 to 400 g/day)
Constituents small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein,
dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates)

Common Bowel Elimination Problems

1. Constipation abnormal frequency of defecation and abnormal hardening of stools
2. Impaction accumulated mass of dry feces that cannot be expelled
3. Diarrhea increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and
increased amount; accompanied by urgency, discomfort and possibly incontinence
4. Incontinence involuntary elimination of feces
5. Flatulence expulsion of gas from the rectum
6. Hemorrhoids dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon
defecation.
Charting
Purpose of Charting:
To make record of
1. The significant observation of the patients condition both mental and physical.
2. The medication, treatment, diets and nursing care given and the reaction of the patient to this care.
3. The incident which might have some bearing on the patients condition.

1.

General Rules for Charting:

All recording on the chart must be printed, except the written signature of the nurse.

2. The written signature of the nurse should consist of her initial of first name and fill last name.
(a) The signature should stand alone on the line just below the notations recorded by her.
(b) The signature of the nurse should be of a size that will insure legibility without attracting attention.
3. A nurse making a series of statements or notations signs for the series and not for each individual statement
or notation.
4. The nurse should not go off duty without making the necessary notations on the charts of each patient
assigned to her to cover the time of the assignment.
5. All recording on the chart should be neat, legible, intelligent and meaningful.
6. Statements must be accurate, relevant and concise.
(a) Terse statements instead of complete sentence are used.
(b) Correct spelling and only acceptable and official abbreviations are to be used.
7. Authentic recording is essential as a chart often plays an important part in the presentation of court evidence.
8. Print the proper headings for all new pages or sheets to be added to the chart using blue or black ink.
9. Keep all recordings within limits provided by the pale. Begin each separate notation on the horizontal lines
where it intersects the vertical limiting lines.
10. Do not use ornamental lettering for recording on the chart.
11. Blue or black ink should be used for recording between the hours of 7:00am to 11:00pm.
12. Red ink should be used for recording between the hours of 11:00pm to 7:00am.
13. The midnight lines are to be drawn in red ink. Write the date and the day of the new day between the midnight
lines.
14. In the hour column, record the time of treatment, medication, appearance of symptoms, doctors visit, etc.
15. In the observations column:
(a) Record any of all symptoms, complaints or change in the condition of the patient.
(b) Record all start and p.r.n. treatments and medications given.
(c) Record the results and effects of the medications and treatments.
(d) Record routine nursing procedures involved in the care of the patient.
(e) Record each time the attending physician visits the patient.
16. Never print the word patient when charting. The chart in itself is a record for the individual patient and all
notations are in regard to the person for whom the record is kept.
17. Do not write the orders of the doctor as Dr. Smith ordered backrest elevated two inches.
18. Arrange the different sheets on the chart in correct order.
19. Errors in charting:
(a) Do not erase errors made in charting
(b) When an error has been made, draw a line through the error from the upper left hand corner to the lower
right hand corner to inchide the necessary space containing the error and write the word ERROR under which
the nurse signs her name.
(c) An error in charting should not necessarily invoke recopying of the entire page. Consult the supervisor or
headnurse before copying a page on which you have made an error. It is necessary to recopy, the original page
must be filed at the back of the chart.

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General Rules for Printing:

Printing is the most consistently legible of all forms of writing for that reason should be used for recording on
hospital charts.
Print well formed, individual letters in each ward.
Properly space all printed letters and words.
Do not use more than one space for each letter, regardless of the shape of that letter.
Separate printed words by a space the size of single letter.
Do not use unnecessary curves tails or fancy strokes in making the printed letters.
Make all printed letters stand erect.
To avoid illegibility, do not make too much of a forward backward slant to the letters.
Make all printed letters conform in appearance to those in the sample alphabet.

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Make each printed letter rest on the line.

Always make the small letter 2/3 the height of capital ones.
Make the letter U curved at the bottom, make the letter V with art acute angle at the bottom.
Cross the letter t, horizontally at the upper third of its height.
Make the use of the word bed to remember on which side of the stem to make the loop for the letters b
and d.
15. For practice in printing use only those letters which are illustrated in the sample alphabet.
16. Print numbers that are to be used in charting as well as letters.
Example of Data to be Charted:
1. All doctors orders.
(a) Medicines given, the time at which they are, and when, used to relieve a condition that should respond to
treatment within a short time.
(b) Inspections, or punctures done, time result, and by whom.
(c) Treatment given, time and effect on patients condition during or after the treatment, or results of flow in
cases or irrigations, etc.
(d) Operation delivery, kinds, time, TPR after.
2. When recording the dressing of wound, state condition of the letter, if there is discharge, mention and
change in the treatment or dressing by whom and time.
3. Symptoms
a. Subjective
b. Objectives:
(b1)All conditions that call for particularly careful attention to their record e.g. following surgical operation or
X-ray or other treatment that may-have harmful effects, accidents, chills, convulsions and when patient is very
ill.
(b2)Menstruation.
(b3)Nature of excreta or order discharges, etc.
4. Amount of sleep.
5. Appetite and amount of food taken.

Communication
Definition
It is the process of exchanging information or feelings between two or more people. It is a basic component of
human relationship, including nursing.
The Communication process

Referent
Or stimulus motivates a person to communicate with another. It may be an object, emotion, idea or act.
Sender
Also called the encoder, is the person who initiates the interpersonal communication or message
Message
The information that is sent or expressed by the sender.
Channels
It means, conveying messages such as through visual, auditory and tactile senses.
Receiver
Also called the decoder, is the person to whom the message is sent
Feedback
Helps to reveal whether the meaning of the message is received

Modes of Communication
Verbal communication- uses the spoken or written word
1. Pace and Intonation

The manner of speech, as in the pace or rhythm and intonation, will modify the feeling and impact of the
message. For example, speaking slowly and softly to an excited client may help calm the client.
2. Simplicity

Includes the use of commonly understood words, brevity, and completeness.

Nurses need to learn to select appropriate, understandable terms based on the age, knowledge, culture and
education of the client. For example, instead of saying to a client, the nurses will be catheterizing you
tomorrow for a urinalysis, I would be more appropriate to say, Tomorrow we need to get a sample of your
urine, so we will collect it by putting a small tube into your bladder.
3. Clarity and Brevity

A message that is direct and simple will be more effective. Clarity is saying precisely what is meant, and
brevity is using the fewest words necessary.
The goal is to communicate clearly so that all aspects of a situation or circumstances are understood. To ensure
clarity in communication, nurses also need to speak slowly and enunciate carefully.
4. Timing and Relevance

No matter how clearly or simply words are stated or written, the timing needs to be appropriate to ensure that
words are heard.
This involves sensitivity to the clients needs and concerns. E.g., a client who is enmeshed in fear of cancer may
not hear the nurses explanations about the expected procedures before and after gallbladder surgery.
5. Adaptability

What the nurse says and how it is said must be individualized and carefully considered. E.g., a nurse who usually
smiles, appears cheerful, and greets his clients with an enthusiastic Hi, Mrs. Jones! notices that the client is
not smiling and appears distressed. It is important for the nurse to then modify his tone of speech and express
concern in his facial expression while moving toward the client.
6. Credibility

Means worthiness of belief, trustworthiness, and reliability. Nurses foster credibility by being consistent,
dependable, and honest.
Nurses should convey confidence and certainly in what they are saying, while being to acknowledge their
limitations (e.g., I dont know the answer to that, but I will find someone who does.

7. Humor

The use of humor can be a positive and powerful tool in nurse- client relationship, but it must be used with
care. When using humor, it is important to consider the clients perception of what is considered humorous.
Non-verbal Communication- uses other forms, such as gestures or facial expressions, and touch.
1. Personal Appearance

When the symbolic meaning of an object is unfamiliar the nurse can inquire about its significance, which may
foster rapport with the client.
How a person dresses is often an indicator of how person feels. E.g. For acutely ill clients n hospital or home
care settings, a change in grooming habits may signal that the client is feeling better. A man may request a
shave, or a woman may request a shampoo and some makeup.
2. Posture and Gait
The ways people walk and carry themselves are often reliable indicators of self-concept, current mood, and
health. Erect posture and an active, purposeful stride suggest a feeling of well being. Slouched posture and
slow, shuffling gait suggest depression or physical discomfort.
The nurse clarifies the meaning of the observed behavior, e.g. You look like it really hurts you to move. Im
wondering how your pain is and if you might need something to make you more comfortable?
3. Facial Expression
No part of the body is as expressive as the face
Although he face may express the persons genuine emotions, it is also possible to control these muscles so the
emotion expresses does not reflect what the person is feeling. When the message is not clear, it is important
to get feedback to be sure of the intent of expression.
Nurses need to be aware of their own expressions and what they are communicating to others. It is impossible
to control all facial expression, but the nurse must learn to control expressions of feelings such as fear or
disgust in some circumstances.
Eye contact is another essential element of facial communication
4. Gesture
Hand and body gestures may emphasize and clarify the spoken word, or they may occur without words to
indicate a particular feeling or give a sign
Electronic Communication- many health care agencies are moving toward electronic medical records where
nurses document their assessments and nursing care.
E-mail

Most common form of electronic communication.

Advantage: It is fast, efficient way to communicate and it is legible. It provides a record of the date and time
of the message that was sent or received.
Disadvantage: risk of confidentiality
When Not to Use Email:
a. When information is urgent
b. Highly confidential information (e.g. HIV status, mental health, chemical dependency)
c. Abnormal lab data
Agencies usually develop standards and guidelines in use of e-mail
Factors Influencing the Communication Process

1. Development

Language, psychosocial, and intellectual development move through stages across the lifespan.
2. Gender

Girls tend to use language to seek confirmation, minimize differences, and establish intimacy. Boys use language
to establish independence and negotiate status within a group.
3. Values and Perception

Values are the standards that influence behavior, and perceptions are the personal view of event.
4. Personal Space

Personal space is the distance people prefer in interactions with others.

Proxemics is the study of distance between people in their interactions
Communication 4 distances:
a. Intimate: Touching to 1
b. Personal: 1 to 4 feet
c. Social: 4 to 12 feet
d. Public: 12 to 15 feet
5. Territoriality

Is a concept of the space and things that an individual considers as belonging to the self
6. Roles and Relationships

Choice of words, sentence structure, and tone of voice vary considerably from role to role. (E.g. nursing
student to instructor, client and primary care provider, or parent and child).
7. Environment

People usually communicate most effectively in a comfortable environment.

8. Congruence

The verbal and nonverbal aspects of message match. E.g., when teaching a client how to care for a colostomy,
the nurse might say, You wont have any problem with this. However, if the nurse looks worried or disgusted
while saying this, the client is less likely to trust the nurses words.
9. Interpersonal Attitudes

Attitudes convey beliefs, thoughts, and feelings about people and events.
Caring and warmth convey a feeling of emotional closeness
Respect is an attitude that emphasizes the other persons worth and individuality. A nurse coveys respect by
listening open mindedly even if the nurse disagrees.Acceptance emphasizes neither approval nor disapproval
.The nurse willingly receives the clients honest feelings.
Diagnostic Tests
PPD test

1. Read result 48 72 hours after injection.

2. For HIV positive clients, in duration of 5 mm is considered positive
Bronchography
1.

Secure consent

2. Check for allergies to seafood or iodine or anesthesia

3. NPO 6-8 hours before the test
4. NPO until gag reflex return to prevent aspiration
Thoracentesis (Aspiration of fluid in the pleural space.)
1.
2.
3.
4.
5.

Secure consent, take V/S

Position upright leaning on over bed table
Avoid cough during insertion to prevent pleural perforation
Turn to unaffected side after the procedure to prevent leakage of fluid in the thoracic cavity
Check for expectoration of blood. This indicate trauma and should be reported to MD immediately.
Holter Monitor

1. It is continuous ECG monitoring, over 24 hours period

2. The portable monitoring is called telemetry unit
Echocardiogram
1. Ultrasound to assess cardiac structure and mobility
2. Client should remain still, in supine position slightly turned to the left side, with HOB elevated 15-20 degrees
Electrocardiography
1.

If the patients skin is oily, scaly, or diaphoretic, rub the electrode with a dry 4x4 gauze to enhance electrode
contact.
2. If the area is excessively hairy, clip it
3. Remove client`s jewelry, coins, belt or any metal
4. Tell client to remain still during the procedure
Cardiac Catheterization
1.
2.
3.
4.
5.
6.
7.
8.
9.

Secure consent
Assess allergy to iodine, shellfish
V/S, weight for baseline information
Have client void before the procedure
Monitor PT, PTT, and ECG prior to test
NPO for 4-6 hours before the test
Shave the groin or brachial area
After the procedure : bed rest to prevent bleeding on the site, do not flex extremity
Elevate the affected extremities on extended position to promote blood supply back to the heart and prevent
thrombophlebitis
10. Monitor V/S especially peripheral pulses
11. Apply pressure dressing over the puncture site
12. Monitor extremity for color, temperature, tingling to assess for impaired circulation.
MRI
1. Secure consent,
2. The procedure will last 45-60 minute
3. Assess client for claustrophobia

4.
5.
6.
7.
8.
9.

Remove all metal items

Client should remain still
Tell client that he will feel nothing but may hear noises
Client with pacemaker, prosthetic valves, implanted clips, wires are not eligible for MRI.
Client with cardiac and respiratory complication may be excluded
Instruct client on feeling of warmth or shortness of breath if contrast medium is used during the procedure
UGIS Barium Swallow

1.
2.
3.
4.
5.
6.
7.

Instruct client on low-residue diet 1-3 days before the procedure

Administer laxative evening before the procedure
NPO after midnight
Instruct client to drink a cup of flavored barium
X-rays are taken every 30 minutes until barium advances through the small bowel
Film can be taken as long as 24 hours later
Force fluid after the test to prevent constipation/barium impaction
LGIS Barium Enema

1.
2.
3.
4.
5.
6.

Instruct client on low-residue diet 1-3 days before the procedure

Administer laxative evening before the procedure
NPO after midnight
Administer suppository in AM
Enema until clear
Force fluid after the test to prevent constipation/barium impaction
Liver Biopsy

1.
2.
3.
4.
5.

Secure consent,
NPO 2-4 hrs before the test
Monitor PT, Vitamin K at bedside
Place the client in supine at the right side of the bed
Instruct client to inhale and exhale deeply for several times and then exhale and hold breath while the MD
insert the needle
6. Right lateral post procedure for 4 hours to apply pressure and prevent bleeding
7. Bed rest for 24 hours
8. Observe for S/S of peritonitis
Paracentesis
1. Secure consent, check V/S
2. Let the patient void before the procedure to prevent puncture of the bladder
3. Check for serum protein. Excessive loss of plasma protein may lead to hypovolemic shock.
Lumbar Puncture
1.
2.
3.
4.
5.

Obtain consent
Instruct client to empty the bladder and bowel
Position the client in lateral recumbent with back at the edge of the examining table
Instruct client to remain still
Obtain specimen per MDs order

Documenting and Reporting

Guidelines for Good Documentation and Reporting
1. Fact information about clients and their care must be factual. A record should contain descriptive,
objective information about what a nurse sees, hears, feels and smells
2. Accuracy information must be accurate so that health team members have confidence in it
3. Completeness the information within a record or a report should be complete, containing concise and
thorough information about a clients care. Concise data are easy to understand
4. Currentness ongoing decisions about care must be based on currently reported information.
At the time of occurrence include the following:
a. Vital signs
b. Administration of medications and treatments
c. Preparation of diagnostic tests or surgery
d. Change in status
e. Admission, transfer, discharge or death of a client
f. Treatment fro a sudden change in status
5. Organization the nurse communicate in a logical format or order
6. Confidentiality a confidential communication is information given by one person to another with trust
and confidence that such information will not be disclosed

Documentation

Anything written or printed that is relied on as a record of proof fro authorized persons.
Purposes of Records

1.
2.
3.
4.
5.
6.
7.
8.

Communication
Planning Client Care
Auditing Health Agencies
Research
Education
Reimbursement
Legal Documentation
Health Care Analysis
Documentation Systems
1. Source Oriented Record
a. The traditional client record
b. Each person or department makes notations in a separate section or sections of the clients chart
c. It is convenient because care providers from each discipline can easily locate the forms on which to record
data and it is easy to trace the information
d. Example: the admissions department has an admission sheet; the physician has a physicians order sheet, a
physicians history sheet & progress notes
e. NARRATIVE CHARTING is a traditional part of the source-oriented record
2. Problem Oriented Medical Record (POMR)

a. Established by Lawrence Weed

b. The data are arranged according to the problems the client has rather than the source of the information.
The four (4) basic components:
i. Database consists of all information known about the client when the client first enters the health
care agency. It includes the nursing assessment, the physicians history, social & family data
ii. Problem List derived from the database. Usually kept at the front of the chart & serves as an index to the
numbered entries in the progress notes. Problems are listed in the order in which they are identified & the
list is continually updated as new problems are identified & others resolved
iii. Plan of Care care plans are generated by the person who lists the problems. Physicians write
orders or medical care plans; nurses write nursing orders or nursing care plans

physicians

iv. Progress Notes chart entry made by all health professionals involved in a clients care; they all use the
same type of sheet fro notes. Numbered to correspond to the problems on the problem list and may be
lettered for the type of data
Example: SOAP Format or SOAPIE and SOAPIER
S Subjective data
O Objective data
A Assessment
P Plan
I Intervention
E Evaluation
R- Revision

Advantages of POMR:
It encourages collaboration
Problem list in the front of the chart alerts caregivers to the clients needs & makes it easier to track the
status of each problem.
Disadvantages of POMR:
Caregivers differ in their ability to use the required charting format
Takes constant vigilance to maintain an up-to-date problem list
Somewhat inefficient because assessments & interventions that apply to more than one problem must be
repeated.
3. PIE (Problems, Interventions, and Evaluation)
a. Groups information in to three (3) categories
b. This system consists of a client care assessment floe sheet & progress notes
c. FLOW SHEET uses specific assessment criteria in a particular format, such as human needs or
functional
health patterns
d. Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes
4. Focus Charting
a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns fro recording are usually used: date & time, focus & progress notes
5. Charting by Exception
a. Documentation system in which only abnormal or significant findings or exceptions to norms are recorded
b. Incorporates three (3) key elements:

i. Flow sheets
ii. Standards of nursing care
iii. Bedside access to chart forms
6. Computerized Documentation
a. Developed as a way to manage the huge volume of information required in contemporary health care
b. Nurses use computers to store the clients database, add new data, create & revise care plans & document
client progress.
7. Case Management
a. Emphasizes quality, cost-effective care delivered within an established length of stay
b. Uses a multidisciplinary approach to planning & documenting client care, using critical pathways.

Nursing Care Plan (NCP)

Two Types:
1. Traditional Care Plan written fro each client; it has 3 columns: nursing diagnoses, expected outcomes &
nursing interventions.
2. Standardized Care Plan based on an institutions standards of practice; thereby helping to provide a high
quality of nursing care

KARDEX
Widely used, concise method of organizing & recording data about a client, making information quickly
accessible to all health professionals. Consists of a series of cards kept in a portable index file or on computer
generated forms.
Information may be organized into sections:
1. Pertinent information about the client
2. List of medications
3. List of IVF
4. List of daily treatments & procedures
5. List of Diagnostic procedures
6. Allergies
7. Specific data on how the clients physical need is to be met
8. A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge / Referral Summaries

Completed when the client is being discharged & transferred to another institution or to a home setting where
a visit by a community health nurse is required. Regardless of format, it includes some or all of the following:
1. Description of clients physical, mental & emotional state
2. Resolved health problems
3. Unresolved continuing health problems
4. Treatments that can be continued (e.g. wound care, oxygen therapy)
5. Current medications
6. Restrictions that relate to activity, diet & bathing
7. Functional/self-care abilities
8. Comfort level
9. Support networks
10. Client education provided in relation to disease process

11. Discharge destination

12. Referral Services (e.g. social worker, home health nurse)
Enemas
Cleansing Enemas
Stimulate peristalsis through irrigation of colon and rectum and by distention
1.

Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile soap in 1000 ml of
water
2. Tap water: Give caution o infants or to adults with altered cardiac and renal reserve
3. Saline: For normal saline enemas, use smaller volume of solution
4. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does not require further
preparation
Oil-Retention Enemas

Lubricates the rectum and colon; the feces absorb the oil and become softer and easier to pass
Carminative Enema

Provides relief from gaseous distention

Astringent Enema

Contracts tissue to control bleeding

Key Points: Administering Enema

1.

2.
3.
4.
5.
6.
7.
8.
9.

Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for children, 250 cc or less fro
an infant), 99 degrees F to 102 degrees F. Solutions that are too hot or too cold, or solutions that are instilled
too quickly, can cause cramping and damage to rectal tissues
Allow solution to run through the tubing so that air is removed
Place client on left side in Sims position
Lubricate the tip of the tubing with water-soluble lubricant
Gently insert tubing into clients rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3 inches for children),
past the external and internal sphincters
Raise the water container no more than 12 to 18 inches above the client
Allow solution to flow slowly. If the flow is slow, the client will experience fewer cramps. The client will also be
able to tolerate and retain a greater volume of solution
After you have instilled the solution, instruct client to hold solution for about 10 to 15 minutes
Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10 to 15 minutes.
Ethico-Moral Aspects in Nursing
Ethos - comes from Greek work w/c means character/culture
- Branch of Philosophy w/c determines right and wrong
Moral - personal/private interpretation from what is good and bad.

1.

Ethical Principles:
Autonomy the right/freedom to decide (the patient has the right to refuse despite the explanation of the
nurse) Example: surgery, or any procedure

2. Nonmaleficence the duty not to harm/cause harm or inflict harm to others (harm maybe physical, financial or
social)
3. Beneficence- for the goodness and welfare of the clients
4. Justice equality/fairness in terms of resources/personnel
5. Veracity - the act of truthfulness
6. Fidelity faithfulness/loyalty to clients

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Moral Principles:
Golden Rule
The principle of Totality The whole is greater than its parts
Epikia There is always an exemption to the rule
One who acts through as agent is herself responsible (instrument to the crime)
No one is obliged to betray herself You cannot betray yourself
The end does not justify the means
Defects of nature maybe corrected
If one is willing to cooperate in the act, no justice is done to him
A little more or a little less does not change the substance of an act.
No one is held to impossible
Law - Rule of conduct commanding what is right and what is wrong. Derived from an Anglo-Saxon term that
meansthat which is laid down or fixed
Court - Body/agency in government wherein the administration of justice is delegated.
Plaintiff - Complainant or person who files the case (accuser)
Defendant - Accused/respondent or person who is the subject of complaint
Witness- Individual held upon to testify in reference to a case either for the accused or against the accused.

Written orders of court

Writ legal notes from the court
1. Subpoena
a. Subpoena Testificandum a writ/notice to an individual/ordering him to appear in court at a specific
time and date as witness.
b. Subpoena Duces Tecum- notice given to a witness to appear in court to testify including all important
documents
Summon notice to a defendant/accused ordering him to appear in court to answer the complaint against him
Warrant of Arrest - court order to arrest or detain a person
Search warrant - court order to search for properties.
Private/Civil Law - body of law that deals with relationships among private individuals
Public law - body of law that deals with relationship between individuals and the State/government and
government
agencies. Laws for the welfare of the general public.

1.
o
o

Private/Civil Law :
Contract law involves the enforcement of agreements among private individuals or the payment of
compensation for failure to fulfill the agreements
Ex. Nurse and client nurse and insurance
Nurse and employer client and health agency
An agreement between 2 or more competent person to do or not to do some lawful act.
It maybe written or oral= both equally binding
Types of Contract:
1. Expressed when 2 parties discuss and agree orally or in writing the terms and conditions during the creation
of the
contract.
Example: nurse will work at a hospital for only a stated length of time (6 months),under stated conditions (as
volunteer, straight AM shift, with food/transportation allowance)
2. Implied one that has not been explicitly agreed to by the parties, but that the law considers to exist.
Example: Nurse newly employed in a hospital is expected to be competent and to follow hospital policies and
procedures even though these expectations were not written or discussed.
Likewise: the hospital is expected to provide the necessary supplies, equipment needed to provide competent,
quality nursing care.
Feature/Characteristics/Elements of a lawful contract:
1. Promise or agreement between 2 or more persons for the performance of an action or restraint from certain
actions.
2. Mutual understanding of the terms and meaning of the contract by all.
3. A lawful purpose activity must be legal
4. Compensation in the form of something of value-monetary
Persons who may not enter into a contract: minor, insane, deaf, mute and ignorant

o
o

Tort law
Is a civil wrong committed against a person or a persons property.
Person/persons responsible for the tort are sued for damages
Is based on:
ACT OF COMMISSION something that was done incorrectly
ACT OF OMMISION something that should have been done but was not.
Classification of Tort
Unintentional Tort

1. Negligence
Misconduct or practice that is below the standard expected of ordinary, reasonable and prudent person
Failure to do something due to lack of foresight or prudence
Failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstance.
An act of omission or commission wherein a nurse fails to act in accordance with the standard of care.
Doctrines of Negligence:
a. Res ipsa loquitor the thing speaks for itself the injury is enough proof of negligence
b. Respondeat Superior let the master answer command responsibility
c. Force majuere unforeseen event, irresistible force

2. Malpractice
stepping beyond ones authority
6 elements of nursing malpractice:
a. Duty the nurse must have a relationship with the client that involves providing care and following an
acceptable
standard of care.

b. Breach of duty
the standard of care expected in a situation was not observed by the nurse
is the failure to act as a reasonable, prudent nurse under the circumstances
something was done that should not have been done or nothing was done when it should have been done
c. Foreseeability a link must exist between the nurses act and the injury suffered
d. Causation it must be proved that the harm occurred as a direct result of the nurses failure to follow
the
standard of care and the nurse should or could have known that the failure to follow the
standard of care could
result in such harm.
e. harm/injury physical, financial, emotional as a result of the breach of duty to the client Example: physical
injury,
medical cost/expenses, loss of wages, pain and suffering
f. damages amount of money in payment of damage/harm/injury

o
o

o
o

o
o
o

Intentional Tort
Unintentional tort do not require intent bur do require the element of HARM
Intentional tort the act was done on PURPOSE or with INTENT
No harm/injury/damage is needed to be liable
No expert witnesses are needed
Assault
An attempt or threat to touch another person unjustifiably
Example:
A person who threatens someone with a club or closed fist.
Nurse threatens a client with an injection after refusing to take the meds orally.
Battery
Willful touching of a person, persons clothes or something the person is carrying that may or may not cause
harm but the touching was done without permission, without consent, is embarrassing or causes injury.
Example:
A nurse threatens the patient with injection if the patient refuses his meds orally. If the nurse gave the
injection without clients consent, the nurse would be committing battery even if the client benefits from the
nurses action.
False Imprisonment
Unjustifiable detention of a person without legal warrant to confine the person
Occurs when clients are made to wrongful believe that they cannot leave the place
Example:
Telling a client no to leave the hospital until bill is paid
Use of physical or chemical restraints
False Imprisonment Forceful Restraint=Battery
Invasion of Privacy
intrusion into the clients private domain
right to be left alone
Types of Invasion the client must be protected from:

1.
2.
3.
4.

1.
o
1.
2.
o

1.
2.
3.
4.
5.
6.

use of clients name for profit without consent using ones name, photograph for advertisements of HC agency
or provider without clients permission
Unreasonable intrusion observation or taking of photograph of the client for whatever purpose without
clients consent.
Public disclosure of private facts private information is given to others who have no legitimate need for that.
Putting a person in a false/bad light publishing information that is normally considered offensive but which is
not true.
Defamation
communication that is false or made with a careless disregard for the truth and results in injury to the
reputation of a person
Types:
Libel defamation by means of print, writing or picture
Example:
o writing in the chart/nurses notes that doctor A is incompetent because he didnt respond immediately to a
call
Slander defamation by the spoken word stating unprivileged (not legally protected) or false word by which a
reputation is damaged
Example:
Nurse A telling a client that nurse B is incompetent
Person defamed may bring the lawsuit
The material (nurses notes) must be communicated to a 3rd party in order that the persons reputation maybe
harmed
Public Law:
Criminal Law deals with actions or offenses against the safety and welfare of the public.
homicide self-defense
arson- burning or property
theft stealing
sexual harassment
active euthanasia
illegal possession of controlled drugs
Homicide killing of any person without criminal intent may be done as self-defense
Arson willful burning of property
Theft act of stealing
History of Nursing in the Philippines
Early Beliefs, Practices and Care of the sick

Early Filipinos subscribed to superstitious belief and practices in relation to health and sickness
Diseases, their causes and treatment were associated with mysticism and superstitions
Cause of disease was caused by another person (an enemy of witch) or evil spirits
Persons suffering from diseases without any identified cause were believed bewitched by mangkukulam
Difficult childbirth were attributed to nonos
Evil spirits could be driven away by persons with powers to expel demons
Belief in special Gods of healing: priest-physician, word doctors, herbolarios/herb doctors
Early Hospitals during the Spanish Regime

Religious orders exerted efforts to care for the sick by building hospitals in different parts of the Philippines:

1. Hospital Real de Manila San Juan de Dios Hospital

2. San Lazaro Hospital Hospital de Aguas Santas
3. Hospital de Indios
Prominent personages involved during the Philippine Revolution
1.
2.
3.
4.
5.
6.
7.

Josephine Bracken wife of Jose Rizal installed a field hospital in an estate in Tejeros that provided nursing
care to the wounded night and day.
Rose Sevilla de Alvaro converted their house into quarters for Filipino soldiers during the Phil-American
War in 1899.
Hilaria de Aguinaldo wife of Emlio Aginaldo organized the Filipino Red Cross.
Melchora Aquino (Tandang Sora) nursed the wounded Filipino soldiers, gave them shelter and food.
Captain Salomen a revolutionary leader in Nueva Ecija provided nursing care to the wounded when not in
combat.
Agueda Kahabagan revolutionary leader in Laguna also provided nursing services to her troops.
Trinidad Tecson (Ina ng Biak na Bato) stayed in the hospital at Biac na Bato to care for the wounded soldiers.
School Of Nursing

1. St. Pauls Hospital School of Nursing, Intramuros Manila 1900

2. Iloilo Mission Hospital Training School of Nursing 1906
o 1909 Distinction of graduating the 1st trained nurses in the Phils. With no standard requirements for
admission of applicants except their willingness to work
o April 1946 a board exam was held outside of Manila. It was held in the Iloilo Mission Hospital thru the
request of Ms. Loreto Tupas, principal of the school.
3. St. Lukes Hospital School of Nursing 1907; opened after four years as a dispensary clinic.
4. Mary Johnston Hospital School of Nursing 1907
5. Philippines General Hospital school of Nursing 1910
College of Nursing
1.
2.
3.
4.
5.

UST College of Nursing 1st College of Nursing in the Phils: 1877

MCU College of Nursing June 1947 (1st College who offered BSN 4 year program)
UP College of Nursing June 1948
FEU Institute of Nursing June 1955
UE College of Nursing Oct 1958
1909

3 female graduated as qualified medical-surgical nurses

1919

The 1st Nurses Law (Act#2808) was enacted regulating the practice of the nursing profession in the
Philippines Islands. It also provided the holding of exam for the practice of nursing on the 2nd Monday of June
and December of each year.
1920

1st board examination for nurses was conducted by the Board of Examiners, 93 candidates took the exam, 68
passed with the highest rating of 93.5%-Anna Dahlgren
Theoretical exam was held at the UP Amphitheater of the College of Medicine and Surgery. Practical exam at
the PGH Library.

1921

Filipino Nurses Association was established (now PNA) as the National Organization Of Filipino Nurses
PNA: 1st President Rosario Delgado
Founder Anastacia Giron-Tupas
1953

Republic Act 877, known as the Nursing Practice Law was approved.
History of Nursing Periods
Intuitive Nursing

From Prehistoric times up to the early Christian Era

Untaught and Instinctive
Nursing performed out of compassion
Nursing belonged to women
Apprentice Nursing

o
o
o

From the founding of the Religious orders in the 11th century up to 1836 with the establishment of the
Kaiserwerth Institute for training of Deaconesses
Period of on-the-job training
Nursing performed without any formal education and by people who were directed by more experienced nurses
Important personalities in this period:
St. Clare-gave nursing care to the sick and the afflicted
St. Elizabeth of Hungary- Patrones of nurses
St. Catherine of Siena- First lady with a lamp
Dark period of Nursing
From the 17th century up to 19th century
Nursing became the work of the least desirable of women
Educated Nursing

Began on June 15, 1860 when Florence Nightingale School of nursing opened St. Thomas Hospital in London
Development of nursing was strongly influenced by trends resulting from wars, from an arousal of social
consciousness, from the increased educational opportunities offered to women
Contemporary Nursing

Covers the period after the world war II to the present

Marked by scientific and technological developments as well as social changes
IV Fluid/Solution Quick Reference Guide
Listed below is a table which may serve as your quick reference guide on the different intravenous
solutions.
Type

Description

Osmolality

Normal
Saline
(NS)

0.9% NaCl in
WaterCrystalloid
Solution

Isotonic
(308 mOsm)

Increases

circulating plasma
volume when red
cells are

adequate

Replaces losses
without altering
fluid concentrations.
Helpful for Na+
replacement

Hypotonic

Raises total fluid

Useful for daily

1/2

0.45% NaCl in

Use

Miscellaneous

Normal
Saline
(1/2 NS)

WaterCrystalloid
Solution

(154 mOsm)

volume

Lactated
Ringers
(LR)

Normal saline
with electrolytes
and buffer

Isotonic
(275 mOsm)

Replaces fluid
and buffers pH

D5W

Dextrose 5% in
water Crystalloid
solution

D5NS

maintenance of body
fluid, but is of less
value for
replacement
of NaCldeficit.
Helpful for
establishing renal
function.
Fluid replacement
for clients who dont
need extra glucose
(diabetics)
Normal saline with
K+, Ca++, and lactate
(buffer)
Often seen with
surgery

Isotonic (in
the bag)
*Physiologically
hypotonic
(260 mOsm)

Raises total fluid

volume.Helpful in
rehydrating and
excretory

purposes.

Provides 170-200
calories/1,000cc for
energy.
Physiologically
hypotonic -the
dextrose is
metabolized quickly
so that only water
remains a
hypotonic fluid

Dextrose 5% in
0.9% saline

Hypertonic
(560 mOsm)

Replaces fluid

sodium, chloride,
and calories.

Watch for fluid

volume overload

D5 1/2
NS

Dextrose 5% in
0.45% saline

Hypertonic
(406 mOsm)

Useful for daily

maintenance of
body fluids and
nutrition, and for
rehydration.

Most common
postoperative fluid

D5LR

Dextrose 5% in
Lactated
Ringers

Hypertonic
(575 mOsm)

Same as LR plus
provides about
180 calories per
1000ccs.

Watch for fluid

volume overload

Normosol

Isotonic
(295 mOsm)

Replaces fluid
and buffers pH

pH 7.4
Contains sodium,
chloride,
calcium,
potassiu
m and magnesium
Common fluid for
OR and PACU

NormosolR

Laboratory and Diagnostic Examination

Urine Specimen

1. Clean-Catch mid-stream urine specimen for routine urinalysis, culture and sensitivity test
a. Best time to collect is in the morning, first voided urine
b. Provide sterile container
c. Do perineal care before collection of the urine
d. Discard the first flow of urine
e. Label the specimen properly
f. Send the specimen immediately to the laboratory
g. Document the time of specimen collection and transport to the lab.
h. Document the appearance, odor, and usual characteristics of the specimen.
2. 24-hour urine specimen
a. Discard the first voided urine.
b. Collect all specimens thereafter until the following day
c. Soak the specimen in a container with ice
d. Add preservative as ordered according to hospital policy
3. Second-Voided urine required to assess glucose level and for the presence of albumen in the urine.
a. Discard the first urine
b. Give the patient a glass of water to drink
c. After few minutes, ask the patient to void
4. Catheterized urine specimen
a. Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequate specimen
can
be collected.
b. Clamping the drainage tube and emptying the urine into a container are contraindicated after a
genitourinary
surgery.

Stool Specimen
1. Fecalysis to assess gross appearance of stool and presence of ova or parasite
a. Secure a sterile specimen container
b. Ask the pt. to defecate into a clean, dry bed pan or a portable commode.
c. Instruct client not to contaminate the specimen with urine or toilet paper (urine inhibits bacterial growth
and
paper towel contain bismuth which interfere with the test result.
2. Stool culture and sensitivity test

To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics.
3. Fecal Occult blood test

Are valuable test for detecting occult blood (hidden) which may be present in colo-rectal cancer, detecting
melena stool
a. Hematest- (an Orthotolidin reagent tablet)
b. Hemoccult slide- (filter paper impregnated with guaiac)

*Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours.

c. Colocare a newer test, requires no smear

Instructions
1.
2.
3.
4.
5.
6.

Advise client to avoid ingestion of red meat for 3 days

Patient is advice on a high residue diet
Avoid dark food and bismuth compound
If client is on iron therapy, inform the MD
Make sure the stool in not contaminated with urine, soap solution or toilet paper
Test sample from several portion of the stool.
Venipuncture
Pointers

1.
2.
3.
4.
5.

Never collect a venous sample from the arm or a leg that is already being use d for I.V therapy or blood
administration because it mat affect the result.
Never collect venous sample from an infectious site because it may introduce pathogens into the vascular
system
Never collect blood from an edematous area, AV shunt, site of previous hematoma, or vascular injury.
Dont wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine iodine.
If the patient has a clotting disorder or is receiving anticoagulant coagulant therapy, maintain pressure on the
site for at least 5 min after withdrawing the needle.
Arterial puncture for ABG test

1. Before arterial puncture, perform Allens test first.

2. If the patient is receiving oxygen, make sure that the patients therapy has been underway for at least 15 min
before collecting arterial sample
3. Be sure to indicate on the laboratory request slip the amount and type of oxygen therapy the patient is having.
4. If the patient has just received a nebulizer treatment, wait about 20 minutes before collecting the sample.
Blood specimen
1.
o
2.
o

No fasting for the following tests:

CBC, Hgb, Hct, clotting studies, enzyme studies, serum electrolytes
Fasting is required:
FBS, BUN, Creatinine, serum lipid (cholesterol, triglyceride)
Sputum Specimen
1. Gross appearance of the sputum
a. Collect early in the morning
b. Use sterile container
c. Rinse the mount with plain water before collection of the specimen
d. Instruct the patient to hack-up sputum
2. Sputum culture and sensitivity test
a. Use sterile container
b. Collect specimen before the first dose of antibiotic

3. Acid-Fast Bacilli
a. To assess presence of active pulmonary tuberculosis
b. Collect sputum in three consecutive mornings
4. Cytologic sputum exam
a. To assess for presence of abnormal or cancer cells.
Leavell and Clarks Three Levels of Prevention
Primary Prevention

Seeks to prevent a disease or condition at a prepathologic state; to stop something from ever happening.
Health Promotion

health education
marriage counseling
genetic screening
good standard of nutrition adjusted to developmental phase of life
Specific Protection

use of specific immunization

attention to personal hygiene
use of environmental sanitation
protection against occupational hazards
protection from accidents
use of specific nutrients
protections from carcinogens
avoidance to allergens
Secondary Prevention

Also known as Health Maintenance. Seeks to identify specific illnesses or conditions at an early stage with
prompt intervention to prevent or limit disability; to prevent catastrophic effects that could occur if proper
attention and treatment are not provided
Early Diagnosis and Prompt Treatment

case finding measures

individual and mass screening survey
prevent spread of communicable disease
prevent complication and sequelae
shorten period of disability
Disability Limitations

Adequate treatment to arrest disease process and prevent further complication and sequelae.
Provision of facilities to limit disability and prevent death.
Tertiary Prevention

Occurs after a disease or disability has occurred and the recovery process has begun; Intent is to halt the
disease or injury process and assist the person in obtaining an optimal health status. To establish a high-level
wellness. To maximize use of remaining capacities
Restoration and Rehabilitation

Work therapy in hospital

Use of shelter colony
Maslows Hierarchy of Basic Human Needs
Definition

Each individual has unique characteristics, but certain needs are common to all people.
A need is something that is desirable, useful or necessary. Human needs are physiologic and psychological
conditions that an individual must meet to achieve a state of health or well-being.

Physiologic
1.
2.
3.
4.
5.
6.
7.

Oxygen
Fluids
Nutrition
Body temperature
Elimination
Rest and sleep
Sex
Safety and Security

1. Physical safety
2. Psychological safety
3. The need for shelter and freedom from harm and danger
Love and belonging

1.
2.
3.
4.

The
The
The
The

need
need
need
need

to love and be loved

to care and to be cared for.
for affection: to associate or to belong
to establish fruitful and meaningful relationships with people, institution, or organization

Self-Esteem Needs
1.
2.
3.
4.

Self-worth
Self-identity
Self-respect
Body image
Self-Actualization Needs

1.
2.
3.
4.

The
The
The
The

need
need
need
need

to learn, create and understand or comprehend

for harmonious relationships
for beauty or aesthetics
for spiritual fulfillment

Characteristics of Basic Human Needs

1.
2.
3.
4.
5.

Needs are universal.

Needs may be met in different ways
Needs may be stimulated by external and internal factor
Priorities may be deferred
Needs are interrelated
Maslows Characteristics of a Self-Actualized Person

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

Is realistic, sees life clearly and is objective about his or her observations
Judges people correctly
Has superior perception, is more decisive
Has a clear notion of right or wrong
Is usually accurate in predicting future events
Understands art, music, politics and philosophy
Possesses humility, listens to others carefully
Is dedicated to some work, task, duty or vocation
Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes
Is open to new ideas
Is self-confident and has self-respect
Has low degree of self-conflict; personality is integrated
Respect self, does not need fame, and possesses a feeling of self-control
Is highly independent, desires privacy
Can appear remote or detached
Is friendly, loving and governed more by inner directives than by society
Can make decisions contrary to popular opinion
Is problem centered rather than self-centered
Accepts the world for what it is
Metro Manila Development Screening Test (MMDST)

Definition

Simple and clinically useful tool

To determine early serious developmental delays
Dr. William K. Frankenburg
Modified and standardized by Dr. Phoebe D. Williams DDST to MMDST
Developed for health professionals (MDs, RNs, etc) It is not an intelligence test
It is a screening instrument to determine if childs development is within normal
Children 6 years and below
Purposes

Measures developmental delays

Evaluates 4 aspects of development
Aspects of development

In the care of pediatric clients, growth and development are not in isolation. Nurses being competent in the
aspects of growth and development particularly principles, theories and milestones are in best position to
counsel clients on these aspects. Having background knowledge on growth and development, nurses are
equipped with assessment skills to determine developmental delays through the aid of screening tests.
The Metro Manila Developmental Screening Test (MMDST) is a screening test to note for normalcy of the
childs development and to determine any delays as well in children 6 years old and below. Modified and
standardized by Dr. Phoebe Williams from the original Denver Developmental Screening Test (DDST) by Dr.
William K. Frankenburg, MMDST evaluates 4 sectors of development:
Personal-Social tasks which indicate the childs ability to get along with people and to take care of himself
Fine-Motor Adaptive tasks which indicate the childs ability to see and use his hands to pick up objects and
to draw
Language tasks which indicate the childs ability to hear, follow directions and to speak
Gross-Motor tasks which indicate the childs ability to sit, walk and jump
MMDST KIT. Preparation for test administration involves the nurse ensuring the completeness of the test
materials contained in the MMDST Kit. These materials should be followed as specified:
MMDST manual
test Form
bright red yarn pom-pom
rattle with narrow handle
eight 1-inch colored wooden blocks (red, yellow, blue green)
small clear glass/bottle with 5/8 inch opening
small bell with 2 inch-diameter mouth
rubber ball 12 inches in circumference
cheese curls
pencil
EXPLAINING THE PROCEDURE. Once the materials are ready, the nurse explains the procedure to the
parent or caregiver of the child. It has to be emphasized that this is not a diagnostic test but rather a
screening test only. When conducting the test, the parents or caregivers of the child under study should be
informed that it is not an IQ test as it may be misinterpreted by them. The nurse should also establish
rapport with the parent and the child to ensure cooperation.
AGE & THE AGE LINE. To proceed in the administration of the test, the nurse is to compute for the exact
age of the child, meaning the age of the child during the test date itself. The age is the most crucial
component of the test because it determines the test items that will be applicable/ administered to the

child. The exact age is computing by subtracting the childs birth date with the test date. After computing,
draw the age line in the test form.
TEST ITEMS. There are 105 test items in MMDST but not all are administered. The examiner prioritizes
items that the age line passes through. It is however imperative to explain to the parent or caregiver that the
child is not expected to perform all the tasks correctly. If the sequence were to be followed, the examiner
should start with personal-social then progressing to the other sectors. Items that are footnoted with R can
be passed by report.
SCORING. The test items are scored as either Passed (P), Failed (F), Refused (R), or Nor Opportunity
(NO). Failure of an item that is completely to the left of the childs age is considered a developmental delay.
Whereas, failure of an item that is completely to the right of the childs age line is acceptable and not a delay.
CONSIDERATIONS:
Manner in which each test is administered must be exactly the same as stated in the manual, words or direction
may not be changed
If the child is premature, subtract the number of weeks of prematurity. But if the child is more than 2 years
of age during the test, subtracting may not be necessary
If the child is shy or uncooperative, the caregiver may be asked to administer the test provided that the
examiner instructs the caregiver to administer it exactly as directed in the manual
If the child is very shy or uncooperative, the test may be deferred
Nasogastric and Intestinal Tubes
Nasogastric Tubes
1. Levin Tube single lumen
a. Suctioning gastric contents
b. Administering tube feedings
2. Salem Sump Tube double lumen (smaller blue lumen vents the tube & prevents suction on the gastric
mucosa, maintains intermittent suction regardless of suction source)
a. Suctioning gastric contents
b. Maintaining gastric decompression
Key Points

1. Prior to insertion, position the client in High-Fowlers position if possible.

2. Use a water-soluble lubricant to facilitate insertion
3. Measure the tube from the tip of the clients nose to the earlobe and from the nose to the xiphoid process to
determine the approximate amount of tube to insert to reach the stomach
4. Flex the clients head slightly forward; this will decrease the chance of entry into the trachea
5. Insert the tube through the nose into the nasopharyngel area; ask the client to swallow, and as the swallow
occurs, progress the tube past the area of the trachea and into the esophagus and stomach. Withdraw tube
immediately if client experiences respiratory distress
6. Secure the tube to the nose; do not allow the tube to exert pressure on the upper inner portion of the nares
7. Validating placement of tube.
o Aspirate gastric contents via a syringe to the end of the tube
o Measure ph of aspirate fluid
o Place the stethoscope over the gastric area and inject a small amount of air through the NGT. A characteristic
sound of air entering the stomach from the tube should be heard
8. Characteristics of nasogastric drainage:
o Normally is greenish-yellowish, with strands of mucous
o Coffee-ground drainage old blood that has been broken down in the stomach

o
o

Bright red blood bleeding from the esophagus, the stomach or swallowed from the lungs
Foul-smelling (fecal odor) occurs with reverse peristalsis in bowel obstruction; increase in amount of drainage
with obstruction
Intestinal Tubes

Provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease intestinal distention.

Placement of a tube containing a mercury weight and allowing normal peristalsis to propel tube through the
stomach into the intestine to the point of obstruction where decompression will occur
1. Types of Intestinal Tubes
a. Cantor and Harris Tubes
i. Approximately 6-10 feet long
ii. Single lumen
iii. Mercury placed in rubber bag prior to tube insertion
b. Miller-Abbot Tubes
i. Approximately 10 feet long
ii. Double lumen
iii. One lumen utilized for aspiration of intestinal contents
iv. Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into the
stomach
2. Nursing Implications
a. Maintain client on strict NPO
b. Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray
c. After the tube has been placed in the stomach, position client on the right side to facilitae passage
through the pyloric valve
d. Advance the tube 2 to 4 inches at regular intervals as indicated by the physician
e. Encourage activity, to facilitate movement of the tube through the intestine
f. Evaluate the type of gastric secretions being aspirated
g. Do not tape or secure the tube until it has reached the desired position
h. Tubes may attached to suction and left in place for several days
i. Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce thirst
j. Removal of the tube depends on the relief of the intestinal obstruction
k. May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or mouth
l. May be allowed to progress through the intestines and expelled via the rectum.

How to Insert a Nasogastric (NG) Tube

Check physicians order.

Check clients identaband and if able have client state name.
Discuss procedure to client.
Provide privacy.
Gather equipment.
Position client at 45 degree angle or higher with head elevated.

1.

Wash hands and don clean gloves.

Provide regular oral and nasal hygiene.
Remove gloves and wash hands.
Position client for comfort.
Document procedure.
Nasal Gavage
I. Definition:
In this method of feeding, liquid is introduced into the stomach through a rubber catheter which is passed
through the anterior and posterior nose and the pharynx into the esophagus. When forced feeding is
necessary, this method is less exhausting as the mouth does not have to be forced or kept open.
II. Therapeutic Uses:
When a patient is weakened and cannot swallow food.

2. Sometimes in the operation of the mouth such as carcinoma of the tongue, a cleft palate or fracture of the jaw
etc.
3. In the operation of the throat and sometimes after tracheotomy.
4. In tetanus or meningitis with a locked jaw.
5. In forced feeding for irrational and violet patients.
6. In very weak patient who cannot swallow food vary well.

III. Equipment:
Tray with:
Medium size rubber catheter
Sterile (No.2 French catheter for adult)
Sterile glass syringe or a small glass funnel attached
O.S
Kidney basin
Dressing rubber
Draw sheet
Lubricant
A flask containing the nourishment ordered at temperature of 104 to 105F

IV. Procedure
Food consists of any liquid for which will readily pass through the tube.
The temperature should be warm, not hot, as the lining of the nose is much sensitive than that of the mouth.
The danger of burning the patient is greater when feeding by this method

1.
2.
3.
4.
5.
6.
7.

The position of the patient may be lying down with the head turned to one side or sitting up with the head
titled forward. An Infant should lie across knees of the nurse with head turned away from the nurse.
Expel the air and lubricate the tube.
Insert the curve thru the nose and backward inward the septum. Instruct the patient to make motion of
swallowing till about 3 inches of the catheter is introduced.
Tell patient to open the mouth and look if the catheter has passed if patient coughs, wait before moving down
the catheter.
Introduce 6 to 8 inches. Wait until the patient is accustomed to the presence of the tube.
Connect the funnel to the catheter; then pour the liquid slowly at the sides. Raise 3 to 4 inches above the
nostril and release food slowly.
Wait for a few minutes then pinch the tube and withdraw. In some cases the tube is left and hold in place by
adhesive.
VI. Precautionary Measures While Doing the Nasal Gavage

1.
2.

3.

4.

5.
6.
7.

The following precautions should be strictly observe during a nasal gavage:

The catheter should first be lubricated and in inserting it should be directed toward the septum of the nose.
If there is difficulty in passing it, the tube should be removed and inserted again in the other nostril.
As the catheter is small, there is considerable danger of its passing into the larynx therefore the patients
color and breathing should be observed closely before pouring in the solution which if the tube should be in the
larynx would down the patient.
Even a small amount of food in the lungs would cause a severe irritation, and dyspnea and if, allowed to remain
(that is if not cough up) would decompose and probably lead to a lung abscess or septic pneumonia, if the tube is
in the trachea a whistling sound will be heard when the funnel is hold to ear, while if in the esophagus probably
a gurgling sound will be heard.
As the tube is soft it may become coiled upon itself in the mouth or in the throat. If the fluid, is poured in
while the tube is in this position it will cause gagging, checking and gasping. And will almost certainly enter the
larynx causing dyspnea, cyanosis and later a possible abscess and septic pneumonia. Look in the mouth or pass
the finger to the back of the throat to sea the tube is in position.
Before pouring in the solution, wait until the patient is at rest, until all distress has subsided and normal
breathing is established and to make sure that the tube is in the esophagus.
Pour in only few drops at first, then pour the balance in very slowly, if there are not symptoms of checking
After all the fluid has left the funnel, pinch the catheter and quickly withdraw.
Nursing Jurisprudence
Jurisprudence
It embraces:

1.
2.
3.
4.

All laws enacted by the legislative body.

All regulations promulgated by those in authority.
Court decisions.
Formal principles upon which laws are based.
Nursing Jurisprudence

1.

Defined as the department of law that comprises all the legal rules and principles affecting the practice of
nursing. It includes not only the study but also the interpretation of all these rules and principles and their
application in the regulation of the practice of nursing.
It deals with:
All laws, rules and regulations.

2. Legal principles and doctrines governing and regulating the practice of nursing.
3. Legal opinions and decisions of competent authority in cases involving nursing practice.
Sources of Nursing Jurisprudence in the Philippines
The sources are the following:
1. The Constitution of the Republic of the Philippines, particularly the Bill of Rights.
2. Republic Act No. 7164 otherwise known as the Philippine Nursing Law of 1991.
3. Rules and regulations promulgated by the Board of Nursing and/or Professional Regulation Commission
pertaining to nursing practice.
4. Decisions of the Board of Nursing and/or Professional Regulation Commission on nursing cases.
5. Decisions of the Supreme Court on matters relevant to nursing.
6. Opinions of the Secretary of Justice in like cases.
7. The Revised Penal Code.
8. The New Civil Code of the Philippines.
9. The Revised Rule of Courts.
10. The National Internal Revenue Code as amended
Nursing Theorist
Nursing
As defined by the INTERNATIONAL COUNCIL OF NURSES as written by Virginia Henderson.

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities
contributing to health, its recovery, or to a peaceful death the client would perform unaided if he had the
necessary strength, will or knowledge.
Help the client gain independence as rapidly as possible.
Nursing Theory
Over the years, nursing has incorporated theories from non-nursing sources, including theories of systems,
human needs, change, problem solving, and decision making. Barnum defines theory as a construct that
accounts for or organizes some phenomenon. A nursing theory, then, describes or explains nursing.
With the formulation of different theories, concepts, and ideas in nursing it:

It guides nurses in their practice knowing what is nursing and what is not nursing.
It helps in the formulations of standards, policies and laws.
It will help the people to understand the competencies and professional accountability of nurses.
It will help define the role of the nurse in the multidisciplinary health care team.
Four Major Concepts
Nurses have developed various theories that provide different explanations of the nursing discipline. All
theories, however, share four central concepts: Person refers to all human beings. People are the recipients of
nursing care; they include individuals, families, communities, and groups. Environment includes factors that
affect individuals internally and externally. It means not only in the everyday surroundings but all setting
where nursing care is provided. Health generally addresses the persons state of well-being. The concept
of Nursing is central to all nursing theories. Definitions of nursing describe what nursing is, what nurses do,
and how nurses interact with clients. Most nursing theories address each of the four central concepts implicitly

or explicitly.

Betty Neuman
(1972, 1982, 1989, 1992)

Health Care System Model

The Neuman System Model or Health Care System Model

Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or
tertiary level of prevention.
To address the effects of stress and reactions to it on the development and maintenance of health. The
concern of nursing is to prevent stress invasion, to protect the clients basic structure and to obtain or
maintain a maximum level of wellness. The nurse helps the client, through primary, secondary, and tertiary
prevention modes, to adjust to environmental stressors and maintain client stability.
Metaparadigm

Person

A client system that is composed of physiologic, psychological, sociocultural, and environmental variables.

Environment

Internal and external forces surrounding humans at any time.

Health

Health or wellness exists if all parts and subparts are in harmony with the whole person.

Nursing

Nursing is a unique profession in that it is concerned with all the variables affecting an individuals response to
stressors.
Dorothea Orem
(1970, 1985)

Self-Care Deficit Theory

Self-Care Deficit Theory

Defined Nursing: The act of assisting others in the provision and management of self-care to
maintain/improve human functioning at home level of effectiveness.
Focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-being.
Has a strong health promotion and maintenance focus.
Identified 3 related concepts:
1. Self-care - activities an Individual performs independently throughout life to promote and maintain personal
well-being.
2. Health - results when self-care agency (Individuals ability) is not adequate to meet the known self-care needs.
3. Nursing System - nursing interventions needed when Individual is unable to perform the necessary self-care
activities:
Wholly compensatory - nurse provides entire self-care for the client.
Example: care of a new born, care of client recovering from surgery in a post-anesthesia care unit
Partial compensatory - nurse and client perform care; client can perform selected self-care activities, but also
accepts care done by the nurse for needs the client cannot meet independently.
Example: Nurse can assist post operative client to ambulate, Nurse can bring a meal tray for client who can
feed himself
Supportive-educative - nurses actions are to help the client develop/learn their own self-care abilities
through knowledge, support and encouragement.
Example: Nurse guides a mother how to breastfeed her baby, Counseling a psychiatric client on more adaptive
coping strategies.

Dorothy E. Johnson
(1980)

Behavioral System Model

Behavioral System Model

Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can move
more easily through recovery.

1.
2.
3.
4.
5.
6.
7.

Viewed the patients behavior as a system, which is a whole with interacting parts.
The nursing process is viewed as a major tool.
To reduce stress so the client can recover as quickly as possible. According to Johnson, each person as a
behavioral system is composed of seven subsystems namely:
Ingestive. Taking in nourishment in socially and culturally acceptable ways.
Eliminated. Riddling the body of waste in socially and culturally acceptable ways.
Affiliative. Security seeking behavior.
Aggressive. Self protective behavior.
Dependence. Nurturance seeking behavior.
Achievement. Master of oneself and ones environment according to internalized standards of excellence.
Sexual role identity behavior
In addition, she viewed that each person strives to achieve balance and stability both internally and externally
and to function effectively by adjusting and adapting to environmental forces through learned pattern of
response. Furthermore, She believed that the patient strives to become a person whose behavior is
commensurate with social demands; who is able to modify his behavior in ways that support biologic
imperatives; who is able to benefit to the fullest extent during illness from the health care professionals
knowledge and skills; and whose behavior does not give evidence of unnecessary trauma as a consequence of
illness.
Metaparadigm

Person

A system of interdependent parts with patterned, repetitive, and purposeful ways of behaving.

Environment

All forces that affect the person and that influence the behavioral system

Health

Focus on person, not illness. Health is a dynamic state influenced by biologic, psychological, and social factors

Nursing

Promotion of behavioral system, balance and stability. An art and a science providing external assistance
before and during balance disturbances

Ernestine Wiedenbach
(1964)

The Helping Art of Clinical Nursing

The Helping Art of Clinical Nursing

Developed the Clinical Nursing A Helping Art Model.

She advocated that the nurses individual philosophy or central purpose lends credence to nursing care.
She believed that nurses meet the individuals need for help through the identification of the needs,
administration of help, and validation that actions were helpful. Components of clinical practice: Philosophy,
purpose, practice and an art.
Metaparadigm
Person

Any individual who is receiving help from a member of the health profession or from a worker in the field of
health.
Environment

Not specifically addressed

Health

Concepts of nursing, client, and need for help and their relationships imply health-related concerns in the
nurseclient relationship.
Nursing

The nurse is a functional human being who acts, thinks, and feels. All actions, thoughts, and feelings underlie
what the nurse does.
Faye Glenn Abdellah
(1960)

Twenty One Nursing Problems

Twenty One Nursing Problems

Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgement.
Introduced Patient Centered Approaches to Nursing Model She defined nursing as service to individual and
families; therefore the society. Furthermore, she conceptualized nursing as an art and a science that molds the
attitudes, intellectual competencies and technical skills of the individual nurse into the desire and ability to
help people, sick or well, and cope with their health needs.
21 Nursing Problems

1.
2.
3.
4.

To
To
To
To

maintain good hygiene.

promote optimal activity; exercise, rest and sleep.
promote safety.
maintain good body mechanics

5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

To facilitate the maintenance of a supply of oxygen

To facilitate maintenance of nutrition
To facilitate maintenance of elimination
To facilitate the maintenance of fluid and electrolyte balance
To recognize the physiologic response of the body to disease conditions
To facilitate the maintenance of regulatory mechanisms and functions
To facilitate the maintenance of sensory functions
To identify and accept positive and negative expressions, feelings and reactions
To identify and accept the interrelatedness of emotions and illness.
To facilitate the maintenance of effective verbal and non-verbal communication
To promote the development of productive interpersonal relationship
To facilitate progress toward achievement of personal spiritual goals
To create and maintain a therapeutic environment
To facilitate awareness of self as an individual with varying needs.
To accept the optimum possible goals
To use community resources as an aid in resolving problems arising from illness.
To understand the role of social problems as influencing factors
Metaparadigm

Person

The recipients of nursing care having physical, emotional, and sociologic needs that may be overt or covert.

Environment

Not clearly defined. Some discussion indicates that clients interact with their environment, of which nurse is a
part.

Health

A state when the individual has no unmet needs and no anticipated or actual impairment.

Nursing

Broadly grouped in 21 nursing problems, which center around needs for hygiene, comfort, activity, rest,
safety, oxygen, nutrition, elimination, hydration, physical and emotional health promotion, interpersonal
relationships, and development of self-awareness. Nursing care is doing something for an individual

Florence Nightingale
(1860)

Environmental Theory

Environmental Theory

Defined Nursing: The act of utilizing the environment of the patient to assist him in his recovery.
Focuses on changing and manipulating the environment in order to put the patient in the best possible
conditions for nature to act.
Identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness/sanitation and
light/direct sunlight.
Considered a clean, well-ventilated, quiet environment essential for recovery.
Deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, the body
could repair itself.
Developed the described the first theory of nursing. Notes on Nursing: What It Is What It Is Not. She
focused on changing and manipulating the environment in order to put the patient in the best possible
conditions for nature to act.
Metaparadigm

Person

An individual with vital reparative processes to deal with disease.

Environment

External conditions that affect life and individuals development.

Health

Focus is on the reparative process of getting well

Nursing

Goal is to place the individual in the best condition for good healthcare

Evelyn Tomlin, Helen Erickson, and Mary Ann Swain

(1983)

Modeling and Role Modeling Theory

Modeling and Role Modeling Theory

Developed Modeling and Role Modeling Theory. The focus of this theory is on the person. The nurse models
(assesses), role models (plans), and intervenes in this interpersonal and interactive theory.
They asserted that each individual unique, has some self-care knowledge, needs simultaneously to be attached
to the separate from others, and has adaptive potential. Nurses in this theory, facilitate, nurture and accept
the person unconditionally.
Metaparadigm

Person

A differentiation is made between patients and clients in this theory. A patient is given treatment and
instruction; a client participates in his or her own care. Our goal is for nurses to work with clients. A client is
one who is considered to be a legitimate member of the decision-making team, who always has some control
over the planned regimen, and who is incorporated into the planning and implementation of his or her own care
as much as possible.

Environment

Environment is not identified in the theory as an entity of its own. The theorist see environment in the social
subsystems as the interaction between self and others both cultural and individual. Biophysical stressors are
seen as part of the environment.

Health

Health is a state of physical, mental and social well-being, not merely the absence of disease or infirmity. It
connotates a state of dynamic equilibrium among the various subsystems [of a holistic person].

Nursing

The nurse is a facilitator, not an effector. Our nurse-client relationship is an interactive, interpersonal
process that aids the individual to identify, mobilize, and develop his or her own strengths.

Hildegard Peplau
(1951)

Interpersonal Relations Theory

Interpersonal Relations Theory

Defined Nursing: An interpersonal process of therapeutic interactions between an Individual who is sick or in
need of health services and a nurse especially educated to recognize, respond to the need for help.
Nursing is a maturing force and an educative instrument
Identified 4 phases of the Nurse - Patient relationship:
1. Orientation - individual/family has a felt need and seeks professional assistance from a nurse (who is a
stranger). This is the problem identification phase.
2. Identification - where the patient begins to have feelings of belongingness and a capacity for dealing with the
problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of
appropriate professional assistance.
3. Exploitation - the nurse uses communication tools to offer services to the patient, who is expected to take
advantage of all services.
4. Resolution - where patients needs have already been met by the collaborative efforts between the patient and
the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from
identifying with the nurse as the helping person.
Metaparadigm

Person

An organism striving to reduce tension generated by needs

Environment

The interpersonal process is always included, and psychodynamic milieu receives attention, with emphasis on the
clients culture and mores.

Health

Ongoing human process that implies forward movement of personality and other ongoing human processes in the
direction of creative, constructive, productive, personal, and community living.

Nursing

Interpersonal therapeutic process that functions cooperatively with others human processes that make health
possible for individuals in communities. Nursing is an educative instrument, a maturing force that aims to
promote forward movement of personality.

Ida Jean Orlando

(1961)

The Dynamic Nurse-Patient Relationship

The Dynamic Nurse-Patient Relationship

Conceptualized The Dynamic Nurse Patient Relationship Model.

She believed that the nurse helps patients meet a perceived need that the patient cannot meet for themselves.
Orlando observed that the nurse provides direct assistance to meet an immediate need for help in order to
avoid or to alleviate distress or helplessness.
She emphasized the importance of validating the need and evaluating care based on observable outcomes.
To interact with clients to meet immediate needs by identifying client behaviors, nurses reactions, and nursing
actions to take
Metaparadigm

Person

Unique individual behaving verbally nonverbally. Assumption is that individuals are at times able to meet their
own needs and at other times unable to do so

Environment

Not defined

Health

Not defined. Assumption is that being without emotional or physical discomfort and having a sense of well-being
contribute to a healthy state.

Nursing

Professional nursing is conceptualized as finding out and meeting the clients immediate need for help.
Imogene King
(1971, 1981)

Goal Attainment Theory

Goal Attainment Theory

Nursing process is defined as dynamic interpersonal process between nurse, client and health care system.
Postulated the Goal Attainment Theory. She described nursing as a helping profession that assists individuals
and groups in society to attain, maintain, and restore health. If is this not possible, nurses help individuals die
with dignity.
In addition, King viewed nursing as an interaction process between client and nurse whereby during perceiving,
setting goals, and acting on them transactions occurred and goals are achieved.
Metaparadigm

Person

Biopsychosocial being

Environment

Internal and external environment continually interacts to assist in adjustments to change.

Health

A dynamic life experience with continued goal attainment and adjustment to stressors.

Nursing

Perceiving, thinking, relating, judging, and acting with an individual who comes to a nursing situations
Jean Watson
(1979)

The Philosophy and Science of Caring

The Philosophy and Science of Caring

Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring health.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Nursing is a human science of persons and human health-illness experiences that are mediated by professional,
personal, scientific, esthetic and ethical human care transactions
She defined caring as a nurturing way or responding to a valued client towards whom the nurse feels a personal
sense of commitment and responsibility. It is only demonstrated interpersonally that results in the satisfaction
of certain human needs. Caring accepts the person as what he/she may become in a caring environment
Carative Factors:
The formation of a humanistic-altruistic system of values
Instillation of faith-hope
The cultivation of sensitivity to ones self and others
The development of a helping- trust relationship
The promotion and acceptance of the expression of positive and negative feelings.
The systemic use of the scientific problem-solving method for decision making
The promotion of interpersonal teaching-learning
The provision for supportive, protective and corrective mental, physical, socio-cultural and spiritual
environment
Assistance with the gratification of human needs
The allowance for existential phenomenological forces
Metaparadigm

Person

A valued being to be cared for, respected, nurtured, understood, and assisted, a fully functional, integrated
self

Environment

Social environment, caring and the culture of caring affect health

Health

Physical, mental, and social wellness

Nursing

A human science of people and human health; illness experiences that are mediated by professional, personal,
scientific, aesthetic, and ethical human care transactions.
Joyce Travelbee
(1966, 1971)

Interpersonal Aspects of Nursing

Interpersonal Aspects of Nursing

She postulated the Interpersonal Aspects of Nursing Model. She advocated that the goal of nursing individual
or family in preventing or coping with illness, regaining health finding meaning in illness, or maintaining maximal
degree of health.
She further viewed that interpersonal process is a human-to-human relationship formed during illness and
experience of suffering
She believed that a person is a unique, irreplaceable individual who is in a continuous process of becoming,
evolving and changing.
Metaparadigm

Person

A unique, irreplaceable individual who is in a continuous process of becoming, evolving, and changing.

Environment

Not defined

Health

Heath includes the individuals perceptions of health and the absence of disease.

Nursing

An interpersonal process whereby the professional nurse practitioner assists an individual, family, or
community to prevent or cope with the experience of illness and suffering, and if necessary, to find meaning in
these experiences.
Lydia Hall
(1964)

Core, Care and Cure Model

Core, Care and Cure Model

The client is composed of the ff. overlapping parts: person (core), pathologic state and treatment (cure) and
body (care).
Introduced the model of Nursing: What Is It? Focusing on the notion that centers around three components
of Care, Core and Cure.
Care represents nurturance and is exclusive to nursing. Core involves the therapeutic use of self and
emphasizes the use of reflection. Cure focuses on nursing related to the physicians orders. Core and cure are
shared with the other health care providers.
The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the
development of the core.
Metaparadigm

Person

Client is composed of body, pathology, and person. People set their own goals and are capable of learning and
growing.

Environment

Should facilitate achievement of the clients personal goals.

Health

Development of a mature self-identity that assists in the conscious selection of actions that facilitate growth.

Nursing

Caring is the nurses primary function. Professional nursing is most important during the recuperative period.
Madeleine Leininger
(1978, 1984)

Transcultural Care Theory and Ethnonursing

Transcultural Care Theory and Ethnonursing

Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of
helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or
maintain a health condition.
Nursing is a learned humanistic and scientific profession and discipline which is focused on human care
phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or
regain their well being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps
or death.
Transcultural nursing as a learned subfield or branch of nursing which focuses upon the comparative study and
analysis of cultures with respect to nursing and health-illness caring practices, beliefs and values with the goal
to provide meaningful and efficacious nursing care services to people according to their cultural values and
health-illness context.
Focuses on the fact that different cultures have different caring behaviors and different health and illness
values, beliefs, and patterns of behaviors.
Awareness of the differences allows the nurse to design culture-specific nursing interventions.
Martha Rogers
(1970)

Science of Unitary Man

Science of Unitary Man

1.
2.
3.
4.
5.

Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human and
is concerned with the nature and direction of human development. The goal of nurses is to participate in the
process of
Nursing interventions seek to promote harmonious interaction between persons and their environment,
strengthen the wholeness of the Individual and redirect human and environmental patterns or organization to
achieve maximum health.
5 basic assumptions:
The human being is a unified whole, possessing individual integrity and manifesting characteristics that are
more than and different from the sum of parts.
The individual and the environment are continuously exchanging matter and energy with each other
The life processes of human beings evolve irreversibly and unidirectionally along a space-time continuum
Patterns identify human being and reflect their innovative wholeness
The individual is characterized by the capacity for abstraction and imagery, language and thought, sensation
and emotion
Metaparadigm

Person

Unitary man, a four-dimensional energy field.

Environment

Encompasses all that is outside any given human field. Person exchanging matter and energy.

Health

Not specifically addressed, but emerges out of interaction between human and environment, moves forward,
and maximizes human potential.

Nursing

A learned profession that is both science and art. The professional practice of nursing is creative and
imaginative and exists to serve people.
Myra Estrin Levine
(1973)

Conservation Model

Conservation Model
Believes nursing intervention is a conservation activity, with conservation of energy as a primary concern, four
conservation principles of nursing: conservation of client energy, conservation of structured integrity,
conservation of personal integrity, conservation of social integrity.
Described the Four Conversation Principles. She advocated that nursing is a human interaction and proposed
four conservation principles of nursing which are concerned with the unity and integrity of the individual. The
four conservation principles are as follows:
1. Conservation of energy. The human body functions by utilizing energy. The human body needs energy producing
input (food, oxygen, fluids) to allow energy utilization output.
2. Conservation of Structural Integrity. The human body has physical boundaries (skin and mucous
membrane) that must be maintained to facilitate health and prevent harmful agents from entering the body.
3. Conservation of Personal Integrity. The nursing interventions are based on the conservation of the individual
clients personality. Every individual has sense of identity, self worth and self esteem, which must be preserved
and enhanced by nurses.
4. Conservation of Social integrity. The social integrity of the client reflects the family and the community in
which the client functions. Health care institutions may separate individuals from their family. It is important
for nurses to consider the individual in the context of the family.
Metaparadigm

Person

A holistic being

Environment

Broadly, includes all the individuals experiences

Health

The maintenance of the clients unity and integrity

Nursing

A discipline rooted in the organic dependency of the individual human being on his or her relationship with
others
Rosemarie Rizzo Parse
(1981)

Theory of Human Becoming

Theory of Human Becoming

Nursing is a scientific discipline, the practice of which is a performing art
Three assumption about Human Becoming
Human becoming is freely choosing personal meaning in situation in the intersubjective process of relating value
priorities
2. Human becoming is co-creating rhythmic patterns or relating in mutual process in the universe
3. Human becoming is co-transcending multidimensionality with emerging possibilities.
Metaparadigm

1.

Person

A major reason for nursing existence

Environment

Man and environment interchange energy to create what is in the world, and man chooses the meaning given to
the situations he creates

Health

A lived experience that is a process of being and becoming

Nursing

Nursing Practice is directed toward illuminating and mobilizing family interrelationships in light of the meaning
assigned to health and its possibilities as language in the co created patterns of relating.
Sister Callista Roy
(1979)

Adaptation Model

Adaptation Model
Viewed humans as Biopsychosocial beings constantly interacting with a changing environment and who cope with
their environment through Biopsychosocial adaptation mechanisms.
Presented the Adaptation Model. She viewed each person as a unified biopsychosocial system in constant
interaction with a changing environment. She contented that the person as an adaptive system, functions as a
whole through interdependence of its part. The system consists of input, control processes, output feedback.
Focuses on the ability of Individuals, families, groups, communities, or societies to adapt to change.
The degree of internal or external environmental change and the persons ability to cope with that change is
likely to determine the persons health status.
Nursing interventions are aimed at promoting physiologic, psychologic, and social functioning or adaptation.
To identify the types and demands placed on a client and clients adaptation to the demands.
Metaparadigm

Person

Biopsychological being and the recipient of nursing care.

Environment

All conditions, circumstances, and influences surrounding and affecting the development of an organism or
groups of organisms

Health

The person encounters adaptation problems in changing the environment.

Nursing

A theoretical system of knowledge that prescribes a process of analysis and action related to the care of the
ill or potentially ill persons
Virginia Henderson
(1955)

The Nature of Nursing Model

The Nature of Nursing Model

Introduced The Nature of Nursing Model. She identified fourteen basic needs.
She postulated that the unique function of the nurse is to assist the clients, sick or well, in the performance of
those activities contributing to health or its recovery, the clients would perform unaided if they had the
necessary strength, will or knowledge.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

She further believed that nursing involves assisting the client in gaining independence as rapidly as possible, or
assisting him achieves peaceful death if recovery is no longer possible.
Defined Nursing: Assisting the individual, sick or well, in the performance of those activities contributing to
health or its recovery (or to peaceful death) that an individual would perform unaided if he had the necessary
strength, will or knowledge.
Identified 14 basic needs :
Breathing normally
Eating and drinking adequately
Eliminating body wastes
Moving and maintaining desirable position
Sleeping and resting
Selecting suitable clothes
Maintaining body temperature within normal range
Keeping the body clean and well-groomed
Avoiding dangers in the environment
Communicating with others
Worshipping according to ones faith
Working in such a way that one feels a sense of accomplishment
Playing/participating in various forms of recreation
Learning, discovering or satisfying the curiosity that leads to normal development and health and using available
health facilities.
Metaparadigm

Person

Individual requiring assistance to achieve health and independence or a peaceful death. Mind and body are
inseparable.

Environment

All external conditions and influences that affect life and development

Health

Equated with independence, viewed in terms of the clients ability to perform 14 components of nursing care
unaided: breathing, eating, drinking, maintaining comfort, sleeping, resting clothing, maintaining body
temperature, ensuring safety, communicating, worshiping, working, recreation, and continuing development.

Nursing

Assists and supports the individual in life activities and the attainment of independence.
Nutrition
Principles of Nutrition

1.
2.
3.
4.
5.

Digestion process by which food substances are changed into forms that can be absorbed through cell
membranes
Absorption the taking in of substance by cells or membranes
Metabolism sum of all physical and chemical processes by which a living organism is formed and maintained
and by which energy is made available
Storage some nutrients are stored when not used to provide energy; e.g. carbohydrates are stored either as
glycogen or as fat
Elimination process of discarding unnecessary substances through evaporation, excretion

Nutrients
1. Carbohydrates the primary sources are plant foods
Types of Carbohydrates
a. Simple (sugars) such as glucose, galactose, and fructose
b. Complex such as starches (which are polysaccharides) and fibers (supplies bulk or roughage to the
diet)
2. Proteins organic substances made up of amino acids
3. Lipids organic substances that are insoluble in water but soluble in alcohol and ether.
o
o

Fatty acids the basic structural units of all lipids and are either saturated (all the carbon atoms are filled
with hydrogen) or unsaturated (could accommodate more hydrogen than it presently contains)
Food sources of lipids are animal products (milk, egg yolks and meat) and plants and plant products (seeds,
nuts,oils)
4. Vitamins organic compounds not manufactured in the body and needed in small quantities to
catalyze metabolic processes.
a. Water-soluble vitamins include C and B-complex vitamins
b. Fat-soluble vitamins include A, D, E, and K and these can be stored in limited amounts in the
body
5. Minerals compounds that work with other nutrients in maintaining structure and function of the
body
a. Macronutrients calcium, phosphate, sodium, potassium, chloride, magnesium and sulfur
b. Micronutrients (trace elements) iron, iodine, copper, zinc, manganese and fluoride The best
sources are vegetables, legumes, milk and some meats

6. Water the bodys most basic nutrient need; it serves as a medium for metabolic reactions within
cells and a transporter fro nutrients, waste products and other substances
Surgical Suture Commonly Use Materials:Size and Techniques

Suture also known as stitches a piece of thread like material use to secure wound edges or body partstogether
after an injury or surgery. A variety of suture exists in size strength and durability.Stitches placeddeep inside
the wound always requires the use of dissolvable (absorbable) sutures, whereas stitches visible on the skin
(placed superficially) may use dissolvable or non-dissolving (non-absorbable) sutures.

Suture Classification

Surgical sutures as defined by the U.S.P. (United States Pharmacopoeia) are divided into two
majorclassifications based on their reactions with body tissues
1.Absorbable sutures
Description: capable of being absorbed by living mammalian tissue, yet may be treated to modify resistance to
absorption source is both natural and synthetic.
Tissue interaction: absorbable sutures are digested by body enzymes by first losing their strength then
gradually disappearing form the tissue.
2.Non Absorbable sutures
Description: material not affected by enzyme activity or absorption in living tissues and are natural and
synthetic sources.
Tissue interaction: non absorbable sutures become encapsulated in fibrous tissue during the healingprocess
and remains embedded in body tissues unless they are surgically removed.
a.Class 1-silk or synthetic fibers of monofilament, twisted of branded construction.
b.Class 2 -cotton or linen fibers or coated natural or synthetic fibers. The coating forms a thickness, yet does
not contribute to its strength.
3 Monofilament suture is a single strand that is non capillary (Resistant to fluids soaking into the suture) it is
designed by the U.S.P.

4 Multifilament suture on the other hand is multiple strands of suture held together by a process of
twisting,braiding of spinning the material. All multifilament sutures have certain capacity to absorb body
fluid(capillarity),which elicits a higher degree of tissue reaction and are classified by the U.S.P. as Type A.

Commonly Use Suture Materials

Suture

Type

Color

Raw
Material

Interaction

Freq

Surgical Gut

Plain

Yellowish tan
Blue (Dyed)

Collagen
derived
from
healthy
mammals

Absorbed relatively
quickyl by body
tissues

Ligat
subc
that
pres
Opht

Chromic

Brown
Blue (Dyed)

Collagen
derived
form
healthy
mammals
treated to
resit
digestion
by body
tissues

Absorbed more slowly

by body tissues due
to chemical
treatment

Fasc
supp
mate
tissu
infec
Opth

Coated
VICRYL(Polyglactin
910)

Braided

Violet (Undyed)

Absorbed by slow
hydrolysis in tissues

Ligat
abso
exce
stre

Surgical Silk

Braided

Black
White

Copolymer
of lactide
and
glycolide
coated with
polyglactin
370
and calcium
stearate
Natural
protein
fiber spun
by silkworm

Very slowly absorbed;

remains encapsulated
in body tissues

Most
sutu
Opht

Surgical Cotton

Twisted

White,blue,pink

Natural
cotton
fibers

Nonabsorbable;remais
encapsulated in body
tissues

Most
sutu

Surgical Steel

Monofilament
ormultifilament

Silver colored

An alloy of
iron

ETHILON Nylon

Monofilament

Green

Polyamide
polymer

Gene
closu
repa
Skin
surg

NUROLON Nylon

Braided

Black

Polyamide

Nonabsorbable;remais
encapsulated in body
tissues
Non
absorbable;remains
encapsulated in body
tissues
Non

Most

polymer

absorbable;remains
encapsulated in body
tissues

sutu
closu

MERSILENE
Polyester Fiber

Braided

Green,white

Synthetic
material
made from
chemicals

Non
absorbable;remains
encapsulated in body
tissues

Card

ETHIBOND
Polyester Fiber

Braided

Green,white

Polyester
fiber
material
treated
with
polybutilate

Non
absorbable;remains
encapsulated in body
tissues

Abdo
and p

PROLENE
Polypropylene

Monofilament

Clear,blue

Polymer of
propylene

Non
absorbable;remains
encapsulated in body
tissues

Gene
surg

Suture Size
The size of suture material is measured by its width or diameter and is vital to proper wound closure. As a
guide the following are specific areas of their usage:

1-0 and 2-0: Used for high stress areas requiring strong retention, i.e. deep
fascia repair
3-0: Used in areas requiring good retention, i.e. scalp, torso, and hands
4-0: Used in areas requiring minimal retention, i.e. extremities. Is the most common size utilized for
superficial wound closure.
5-0: Used for areas involving the face, nose, ears, eyebrows, and eyelids.
6-0: Used on areas requiring little or no retention. Primarily used for cosmetic effects.
Suturing Techniques
When suturing the edges of a wound together, it is important to evert the skin edges that is, to get the
underlying dermis from both sides of the wound to touch. For the wound to heal, the dermal elements must
meet and heal together. If the edges are inverted (the epidermis turns in and touches the epidermis of the
other side), the wound will not heal as quickly or as well as you would like. The suture technique that you choose
is important to achieve optimal wound healing.
Theoretical Foundation of Nursing Overview
Differentiation of Terms

Concept
Conceptual framework
Paradigm
Metaparadigm

Theory
Concepts

Abstract ideas or mental images of phenomena or reality

Often called the building blocks of theories
Examples: mass, energy, ego, id
Paradigm

A pattern of shared understanding and assumptions about reality and the world
Include notions of reality that are largely unconscious or taken for granted
Derived from cultural beliefs
Examples: time, space
Metaparadigm

o
o
o
o

Concepts that can be superimposed on other concepts

Four major metaparadigms in nursing
Person
Environment
Health
Nursing
Theory

Supposition or system of ideas proposed to explain a given phenomenon

Attempt to explain relationships between concepts
Offer ways to conceptualize central interests of a discipline
Example: Freuds theory of the Unconscious
Purposes of Nursing Theory

1. Link among nursing theory, education, research, and clinical practice

2. Contributes to knowledge development
3. May direct education, research, and Practice
The Living Tree of Nursing Theories

Criteria for Evaluating Theoretical Work

Clarity- How clear is this theory?

Words often have multiple meanings within and across disciplines; therefore words should be defined carefully
and specifically to the framework (philosophy, conceptual model, or theory) from which it is derived.
Diagrams and examples may facilitate clarity and should be consistent.
Simplicity- How simple is the theory?

Theory should have as few concepts as possible with simplistic relations to aid clarity.
The most useful theory provides the greatest sense of understanding.
Generality- How general is this theory?

To determine the generality of theory, the scope of concepts and goals within the theory are examined.
The broader the scope, the greater the significance of the theory.
Empirical precision- How accessible is the theory?

Empirical precision is linked to the testability and ultimate use of a theory and it refers to theextent that the
defined concepts are grounded in observable reality.
Derivable Consequences- How important is this theory?

Propose that if research, theory, and practice are to be meaningfully related, then nursing theory should lend
itself to research testing and research testing should lead to knowledge that guides practice.
Indicates that to be considered useful, it is essential for theory to develop and guide practice.

Theoretical Framework of Nursing Practice

Nursing

As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia Henderson: The unique
function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing
to health. Its recovery, or to a peaceful death that the client would perform unaided if he had the necessary
strength, will or knowledge.
Help the client gain independence as rapidly as possible.
Conceptual and Theoretical Models of Nursing Practice

Theorist
FLORENCE
NIGHTINGALE

Description

Developed the first theory of nursing.

Focused on changing and manipulating the environmentin
order to put the patient in the best possible conditions for
nature to act.

HILDEGARD PEPLAU

Introduced the Interpersonal Model.

She defined nursing as a therapeutic, interpersonal process
which strives to develop a nurse-patient relationship in which
the nurse serves as a resource person, counselor and
surrogate.

FAYE ABDELLAH

Defined nursing as having a problem-solving approach, with

key nursing problems related to health needs of people;
developed list 21 nursing problem areas

IDA JEAN ORLANDO

Developed the three elements client behavior, nurse

reaction and nurse action compose the nursing situation.
She observed that the nurse provide direct assistance to
meet an immediate need for help in order to avoid or to
alleviate distress or helplessness.

MYRA LEVINE

1.
2.
3.
4.

Described the Four Conservation Principles.

conservation of energy
conservation of structured integrity
conservation of personal integrity
conservation of social integrity

DOROTHY JOHNSON

1.

Developed the Behavioral System Model.

Patients behavior as a system that is a whole with
interacting parts
2. how the client adapts to illness
3. Goal of nursing is to reduce so that the client can move more
easily through recovery.

MARTHA ROGERS

Conceptualized the Science of Unitary Human Beings. She

asserted that human beings are more than different from
the sum of their parts; the distinctive properties of the
whole are significantly different from those of its parts.

DOROTHEA OREM

Emphasizes the clients self care needs; nursing care

becomes necessary when client is unable to fulfill biological,
psychological, developmental or social needs.

IMOGENE KING

Nursing process is defined as dynamic interpersonal

process between nurse, client and health care system.

BETTY NEUMAN

Stress reduction is a goal of system model of nursing

practice. Nursing actions are in primary, secondary or
tertiary level of prevention

SISTER CALLISTA ROY

Presented the Adaptation Model. She viewed each person

as a unified bio-psychosocial system in constant interaction
with a changing environment. The goal of nursing is to help
the person adapt to changes in physiological needs, selfconcept, role function and interdependent relations during
health and illness.

LYDIA HALL

Introduced the notion that nursing centers around three

components: person (core), pathologic state and treatment
(cure) and body(care).

Conceptualized the Human Caring Model. She emphasized

that nursing is the application of the art and human science
through transpersonal caring transactions to help persons
achieve mind-body-soul harmony, which generates selfknowledge, self-control, self-care and self-healing.

Introduced the Theory of Human Becoming. She emphasized

free choice of personal meaning in relating to value priorities,
co-creating of rhythmical patterns, in exchange with the
environment and contranscending in many dimensions as
possibilities unfold.

Developed the Transcultural Nursing Model. She advocated

that nursing is a humanistic and scientific mode of helping a
client through specific cultural caring processes (cultural
values, beliefs and practices) to improve or maintain a health
condition

JEAN WATSON

ROSEMARIE RIZZO
PARSE

MADELEINE LENINGER

Respect and empathy for the client.

Good communication skills.
Tolerance of values and beliefs different from ones own.

Therapeutic
Communicati
on
Purposes

Esta
blishing a
therapeutic
providerclient
relationship.

Iden
tify clients
concerns and
problem.

Asse
ss clients
perception
of the
problem.

Reco
gnize clients
needs.

Guid
e client
towards a
satisfying
and socially
acceptable
solution
The
Qualities of
a Good
Communicato
r

Unbiased attitudes.
Patience.
Awareness of gender issues
Attentive Listening

Listening actively, using all the senses, as opposed to listening passively with just the ear
It involves paying attention to the total message, both verbal and non verbal, and noting whether these
communications are congruent.
Physical Attending

1.
2.
3.
4.
5.

The manner of being present to

5 specific ways to convey physical attending:

Face the other person squarely
Adopt an open posture
Lean toward the person
Maintain good eye contact
Try to be relatively relaxed

Therapeutic Communication Technique

TECHNIQUE

DESCRIPTION

EXAMPLES

Using silence

Accepting pauses or
silences that may
extend for several
seconds or minutes
without interjecting any
verbal response.

Sitting quietly (or walking with the client)

and waiting attentively until the client is
able to put thoughts and feelings into
words.

Providing
general leads

Using statements or
questions that (a)
encourage the client to
verbalize, (b) choose a
topic of conversation,
and (c) facilitate
continued verbalization.
Making statements that
are specific rather than
general, and tentative
rather than absolute.

Can you tell me how it is for you?

Perhaps you would like to talk about.
Would it help to discuss your feelings?
Where would you like to begin?
And then what?

Asking broad questions

that lead or invite the
client to explore
(elaborate, clarify,
describe, compare, or
illustrate) thoughts and

Id like to hear more about that.

Tell me about.
How have you been feeling lately?
What brought you to the hospital?
What is you opinion?
You said you were frightened yesterday.

Being specific
and tentative

Using openended question

Rate your pain on a scale of 0-10. (specific

statement
Are you in pain? (general statement)
You seem unconcerned about your
diabetes? (tentative statement)
You dont care about your diabetes and you
will never will (absolute statement)

Using touch

Restating or
paraphrasing

Seeking
Clarification

Perception
checking or

feelings. Open-ended
question specify only the
topic to be discussed
and invite answers that
are longer than one or
two words.
Providing appropriate
forms of touch to
reinforce caring
feelings. Because tactile
contacts vary
considerably among
individuals, families, and
cultures, the nurse must
be sensitive to the
differences in attitudes
and practices of clients
and self.
Actively listening for
the clients basic
message and then
repeating those
thoughts and /or
feelings in similar words.
This conveys that the
nurse has listened and
understood the clients
basic message and also
offers clients a clearer
idea of what they have
said.
A method of making the
clients broad overall
meaning of the message
more understandable. It
is used when
paraphrasing is difficult
or when the
communication is
rambling or garbled. To
clarify the message, the
nurse can restate the
basic message or
confess confusion and
ask client to repeat or
restate the message.
Nurses can also clarify
their own message with
statements.

How do you feel now?

A method similar to
clarifying that verifies

Client: My husband never gives me any

presents.

Putting an arm over the clients shoulder.

Placing your hand over the clients hand.

Client: I couldnt manage to eat any dinner

last night-not even the dessert.
Nurse: You had difficulty eating
yesterday.
Client: Yes, I was very upset after my
family left.
Client: I have trouble talking with the
strangers.
Nurse:You find it difficult talking to people
you do not know?

Im puzzled.
Im not sure I understand that
Would you please say that again?
Would you tell me more?
I meant this rather than that.
Im sorry that wasnt very clear.
Let me try o explain another way.

seeking
consensual
validation

the meaning of specific

words rather than the
overall meaning of a
message.

Nurse:You mean he has never given you a

present for your birthday or Christmas?
Client: Well not ever. He does get me
something for my birthday and Christmas,
but he never thinks of giving me anything at
any other time.

Offering self

Suggesting ones
presence, interest, or
wish to understand the
client without making
any demands or
attaching conditions
that the client must
comply with to receive
the nurses attention.

Ill stay with you until your daughter

arrives.
We can sit here quietly for awhile; we dont
need to talk unless you would like to.
Ill help you to dress to go home, if you
like.

Giving
information

Providing in a simple and

direct manner, specific
factual information the
client may or may not
request. When
information is not
known, the nurse states
this and indicates who
has it or when the nurse
will obtain it.
Giving recognition, in a
non judgmental way, of a
change in behavior, an
effort the client has
made, or a contribution
to a communication.
Acknowledgment may be
with or without
understanding, verbal or
non verbal.
Helping the client
clarify an event,
situation, or happening in
relationship to time.

Your surgery is schedule for 1 am

tomorrow.
You will feel a puling sensation when the
tube is removed from your abdomen.
I do not know the answer to that, but I will
find out from Mrs. King, the nurse in
charge.

Presenting
reality

Helping the client to

differentiate the real
from the unreal.

That telephone ring came from the program

on television.
I see shadows from the window coverings.
Your magazine is here in the drawer .It has
not been stolen.

Focusing

Helping the client

expand on and develop a

Client:My wife says she will look after me,

but I dont think she can, what with the

Acknowledging

Clarifying time
or sequence

You trimmed your beard and mustache and

washed your hair.
I noticed you keep squinting your eyes. Are
you having difficulty seeing?
You walk twice as far today with your
walker.

Client:I vomited this morning.

Nurse:Was that after breakfast?
Client:I feel that I have been asleep for
weeks.
Nurse:You had your operation Monday, and
today is Tuesday.

Reflecting

Summarizing
and planning

topic of importance. It
is important for the
nurse to wait until the
client finishes stating
the main concerns
before attempting to
focus. The focus may be
an idea or a feeling;
however, the nurse
often emphasizes a
feeling to help the client
recognize an emotion
disguised behind words.
Directing ideas, feelings,
questions, or content
back to clients to enable
them to explore their
own ideas and feelings
about a situation.

children to take care of, and theyre always

after her about something--- clothes,
homework, whats for dinner that night.
Nurse: Sounds like you are worried about
how well she can manage.

Stating the main points

of a discussion to clarify
the relevant points
discussed. This
technique is useful at
the end on an interview
or to review a health
teaching session. It
often acts as an
introduction to future
care planning

During the past hour we have talked

about
Tomorrow afternoon we may explore this
further.
In a few days Ill review what you have
learned about the actions and effects of
your insulin.
Tomorrow, I will look at your feeling
journal.

Client: What can I do?

Nurse: What do you think would be
helpful?
Client: Do you think I should tell my
husband?
Nurse:You seem unsure about telling your
husband.

Barriers of Communication
TECHNIQUE
Stereotyping

DESCRIPTION
Offering generalized and
oversimplified beliefs about groups
of people that are based on
experiences too limited to be valid.
These responses categorize clients
and negate their uniqueness as
individuals.

EXAMPLES
Two-year-olds are brats.
Women are complainers.
Men dont cry.
Most people dont have any
pain after this type of
surgery.

Agreeing and
disagreeing

Akin to judgmental responses,

agreeing and disagreeing imply
that the client is either right or
wrong and that the nurse is in a
position to judge this. These
responses deter clients from
thinking through their position and
may cause a client to become

Client: I dont think Dr. Broad

is a very good doctor. He
doesnt seem interested in his
patients.
Nurse: Dr. Broad is head of
the department of surgery and
is an excellent surgeon.

Being defensive

Challenging

Probing

defensive.
Attempting to protect a person or
health care services from negative
comments. These responses
prevent the client from expressing
true concerns. The nurse is saying,
You have no right to complain.
Defensive responses protect the
nurse from admitting weaknesses
in the health care services,
including personal weaknesses.
Giving a response that makes
clients prove their statement or
point of view. These responses
indicate that the nurse is failing to
consider the clients feelings,
making the client feel it necessary
to defend a position.

Asking for information chiefly out

of curiosity rather than with the
intent to assist he client. These
responses are considered prying
and violate the clients privacy.
Asking why is often probing and
places the client in a defensive
position.

Client: Those night nurses

must sit around and talk all
night. They didnt answer my
light for over an hour.
Nurse: Ill have you know we
literally run around on nights.
Youre not the only client you
know.

Client: I felt nauseated after

that red pill.
Nurse: Surely you dont think
I gave you the wrong pill?
Client: I feel as if I am dying.
Nurse: How can you feel that
way if your pulse is 60?
Client: I believe my husband
doesnt love me.
Nurse: You cant say that;
why, he visits you every day.
Client: I was speeding along
the street and didnt see the
stop sign.
Nurse: Why were you
speeding?
Client: I didnt ask the doctor
when he was here.
Nurse: Why didnt you?

Testing

Asking questions that make the

client admit to something .These
responses permit the client only
limited answers and often meet
the nurses need rather than the
clients.

Who do you think you are?

(forces people to admit their
status is only that of client)
Do you think I am not busy?
(forces the client to admit
that the nurse is really busy)

Rejecting

Refusing to discuss certain topics

with the client. These responses
often make clients feel that the
nurse is rejecting not only their
communication but also the client
themselves.

I dont want to discuss that.

Lets talk about.
Lets discuss other areas of
interest to you rather than the
two problems you keep
mentioning.
I cant talk now. Im on my way
for coffee break.

Changing topics

Directing the communication into

Client: Im separated from my

and subjects

areas of self-interest rather than

considering the clients concerns is
often a self-protective response
to a topic that causes anxiety.
These responses imply that what
the nurse considers important will
be discussed and that clients
should not discuss certain topics.

wife. Do you think I should

have sexual relations with
other woman?
Nurse: I see that your 36 and
that you like gardening. This
sunshine is good for my roses.
I have a beautiful rose
garden.

Unwarranted
reassurance

Using clichs or comforting

statements of advice as a means to
reassure the client. These
responses block the fears,
feelings, and other thoughts of
the client.

Youll feel better soon.

Im sure everything will turn
out all right.
Dont worry.

Passing judgment

Giving opinions and approving or

disapproving responses, moralizing,
or implying ones own values. These
responses imply that the client
must think as the nurse thinks,
fostering client dependence.

Thats good (bad).

You shouldnt do that.
Thats not good enough.
What you did was wrong
(right).

Giving common
advice

Telling the client what to do.

These responses deny the clients
right to be an equal partner. Note
that giving expert advice rather
than common advice is therapeutic.

Client: Should I move from my

home to a nursing home?
Nurse: If I were you, Id go o
nursing home, where youll get
your meals cooked for you.

Therapeutic Diet
Clear- Liquid Diet
Purpose:

Relieve thirst and help maintain fluid balance.

Use:

Post-surgically and following acute vomiting or diarrhea.

Foods Allowed:

carbonated beverages; coffee (caffeinated and decaff.); tea; fruit-flavored drinks; strained fruit juices; clear,
flavored gelatins; broth, consomme; sugar; popsicles; commercially prepared clear liquids; and hard candy.
Foods Avoided:

Milk and milk products, fruit juices with pulp, and fruit.
Full- Liquid Diet
Purpose:

Provide an adequately nutritious diet for patients who cannot chew or who are too ill to do so.

Use:

Acute infection with fever, GI upsets, after surgery as a progression from clear liquids.
Foods Allowed:

clear liquids, milk drinks, cooked cereals, custards, ice cream, sherbets, eggnog, all strained fruit juices,
creamed vegetable soups, puddings, mashed potatoes, instant breakfast drinks, yogurt, mild cheese sauce or
pureed meat, and seasoning.
Foods Avoided:

nuts, seeds, coconut, fruit, jam, and marmalade

Soft Diet
Purpose:

Provide adequate nutrition for those who have troubled chewing.

Use:

patient with no teeth or ill-fitting dentures; transition from full-liquid to general diet; and for those who
cannot tolerate highly seasoned, fried or raw foods following acute infections or gastrointestinal disturbances
such as gastric ulcer or cholelithiasis.
Foods Allowed:

very tender minced, ground, baked broiled, roasted, stewed, or creamed beef, lamb, veal, liver, poultry, or fish;
crisp bacon or sweet bread; cooked vegetables; pasta; all fruit juices; soft raw fruits; soft bread and cereals;
all desserts that are soft; and cheeses.
Foods Avoided:

coarse whole-grain cereals and bread; nuts; raisins; coconut; fruits with small seeds; fried foods; high fat
gravies or sauces; spicy salad dressings; pickled meat, fish, or poultry; strong cheeses; brown or wild rice; raw
vegetables, as well as lima beans and corn; spices such as horseradish, mustard, and catsup; and popcorn.
Sodium- Restricted Diet
Purpose:

Reduce sodium content in the tissue and promote excretion of water.

Use:

Heart failure, hypertension, renal disease, cirrhosis, toxemia of pregnancy, and cortisone therapy.
Modifications:

Mildly restrictive 2 g sodium diet to extremely restricted 200 mg sodium diet.

Foods Avoided:

Table salt; all commercial soups, including bouillon; gravy, catsup, mustard, meat sauces, and soy sauce;
buttermilk, ice cream, and sherbet; sodas; beet greens, carrots, celery, chard, sauerkraut, and spinach; all
canned vegetables; frozen peas;

All baked products containing salt, baking powder, or baking soda; potato chips and popcorn; fresh or canned
shellfish; all cheeses; smoked or commercially prepared meats; salted butter or margarine; bacon, olives; and
commercially prepared salad dressings.
Renal Diet
Purpose:

Control protein, potassium, sodium, and fluid levels in the body.

Use:

Acute and chronic renal failure, hemodialysis.

Foods Allowed:

High-biological proteins such as meat, fowl, fish, cheese, and dairy products range between 20 and 60 mg/day.
Potassium is usually limited to 1500 mg/day.
Vegetables such as cabbage, cucumber, and peas are lowest in potassium.
Sodium is restricted to 500 mg/day.
Fluid intake is restricted to the daily volume plus 500 mL, which represents insensible water loss.
Fluid intake measures water in fruit, vegetables, milk and meat.
Foods Avoided:

Cereals, bread, macaroni, noodles, spaghetti, avocados, kidney beans, potato chips, raw fruit, yams, soybeans,
nuts, gingerbread, apricots, bananas, figs, grapefruit, oranges, percolated coffee, Coca-Cola, orange crush,
sport drinks, and breakfast drinks such as Tang or Awake
High- Protein, High- Carbohydrate Diet
Purpose:

To correct large protein losses and raises the level of blood albumin. May be modified to include lowfat, lowsodium, and low-cholesterol diets.
Use:

Burns, hepatitis, cirrhosis, pregnancy, hyperthyroidism, mononucleosis, protein deficiency due to poor eating
habits, geriatric patient with poor intake; nephritis, nephrosis, and liver and gall bladder disorder.
Foods Allowed:

General diet with added protein.

Foods Avoided:

Restrictions depend on modifications added to the diet. The modifications are determined by the patients
condition.
Purine- Restricted Diet
Purpose:

Designed to reduce intake of uric acid-producing foods.

Use:

High uric acid retention, uric acid renal stones, and gout.
Foods Allowed:

General diet plus 2-3 quarts of liquid daily.

Foods Avoided:

Cheese containing spices or nuts, fried eggs, meat, liver, seafood, lentils, dried peas and beans, broth, bouillon,
gravies, oatmeal and whole wheat, pasta, noodles, and alcoholic beverages. Limited quantities of meat, fish, and
seafood allowed.
Bland Diet
Purpose:

Provision of a diet low in fiber, roughage, mechanical irritants, and chemical stimulants.
Use:

Gastritis, hyperchlorhydria (excess hydrochloric acid), functional GI disorders, gastric atony, diarhhea, spastic
constipation, biliary indigestion, and hiatus hernia.
Foods Allowed:

Varied to meet individual needs and food tolerances.

Foods Avoided:

Fried foods, including eggs, meat, fish, and sea food; cheese with added nuts or spices; commercially prepared
luncheon meats; cured meats such as ham; gravies and sauces; raw vegetables;
potato skins; fruit juices with pulp; figs; raisins; fresh fruits; whole wheats; rye bread; bran cereals; rich
pastries; pies; chocolate; jams with seeds; nuts; seasoned dressings; caffeinated coffee; strong tea; cocoa;
alcoholic and carbonated beverages; and pepper.

Low-Fat, Cholesterol- Restricted Diet

Purpose:

Reduce hyperlipedimia, provide dietary treatment for malabsorption syndromes and patients having acute
intolerance for fats.
Use:

Hyperlipedimia, atherosclerosis, pancreatitis, cystic fibrosis, sprue (disease of intestinal tract characterized
by malabsorption), gastrectomy, massive resection of small intestine, and cholecystitis.
Foods Allowed:

Nonfat milk; low-carbohydrate, low-fat vegetables; most fruits; breads; pastas; cornmeal; lean meats;
unsaturated fats
Foods Avoided:

Remember to avoid the five Cs of cholesterol- cookies, cream, cake, coconut, chocolate; whole milk and wholemilk or cream products, avocados, olives, commercially prepared baked goods such as donuts and muffins,
poultry skin, highly marbled meats
Butter, ordinary margarines, olive oil, lard, pudding made with whole milk, ice cream, candies with chocolate,
cream, sauces, gravies and commercially fried foods.

Diabetic Diet
Purpose:

Maintain blood glucose as near as normal as possible; prevent or delay onset of diabetic complications.
Use:

Diabetes mellitus
Foods Allowed:

1.
2.
3.

Choose foods with low glycemic index compose of:

45-55% carbohydrates
30-35% fats
10-25% protein
Coffee, tea, broth, spices and flavoring can be used as desired.
Exchange groups include: milk, vegetable, fruits, starch/bread, meat (divided in lean, medium fat, and high fat),
and fat exchanges.
The number of exchanges allowed from each group is dependent on the total number of calories allowed.
Non-nutritive sweeteners (sorbitol) in moderation with controlled, normal weight diabetics.
Foods Avoided:

Concentrated sweets or regular soft drinks.

Acid and Alkaline Diet
Purpose:

Furnish a well balance diet in which the total acid ash is greater than the total alkaline ash each day.
Use:

Retard the formation of renal calculi. The type of diet chosen depends on laboratory analysis of the stone.
Acid and alkaline ash food groups:

1. Acid ash: meat, whole grains, eggs, cheese, cranberries, prunes, plums
2. Alkaline ash: milk, vegetables, fruits (except cranberries, prunes and plums.)
3. Neutral: sugar, fats, beverages (coffee, tea)
Foods allowed:

Breads: any, preferably whole grain; crackers; rolls

Cereals: any, preferable whole grains
Desserts: angel food or sunshine cake; cookies made without baking powder or soda; cornstarch,
Pudding, cranberry desserts, ice cream, sherbet, plum or prune desserts; rice or tapioca pudding.
Fats: any, such as butter, margarine, salad dressings, Crisco, Spry, lard, salad oil, olive oil, etc.
Fruits: cranberry, plums, prunes
Meat, eggs, cheese: any meat, fish or fowl, two serving daily; at least one egg daily
Potato substitutes: corn, hominy, lentils, macaroni, noodles, rice, spaghetti, vermicelli.
Soup: broth as desired; other soups from food allowed
Sweets: cranberry and plum jelly; plain sugar candy
Miscellaneous: cream sauce, gravy, peanut butter, peanuts, popcorn, salt, spices, vinegar, walnuts.

Restricted foods:

1.
2.
3.
4.
5.
6.

No more than the amount allowed each day

Milk: 1 pint daily (may be used in other ways than as beverage)
Cream: 1/3 cup or less daily
Fruits: one serving of fruits daily (in addition to the prunes, plums and cranberries)
Vegetable: including potatoes: two servings daily
Sweets: Chocolate or candies, syrups.
Miscellaneous: other nuts, olives, pickles.
High- Fiber Diet
Purpose:

Soften the stool

Exercise digestive tract muscles
Speed passage of food through digestive tract to prevent exposure to cancer causing agents in food
Lower blood lipids
Prevent sharp rise in glucose after eating.
Use:

diabetes, hyperlipedemia, constipation, diverticulitis, anticarcinogenics (Colon)

Foods Allowed:

recommended intake about 6 g crude fiber daily

All bran cereal
Watermelon, prunes, dried peaches, apple with skin; parsnip, peas, Brussels sprout, sunflower seeds.
Low Residue Diet
Purpose:

Reduce stool bulk and slow transit time

Use:

Bowel inflammation during acute diverticulitis, or ulcerative colitis, preparation for bowel surgery, esophageal
and intestinal stenosis.
Foods Allowed:

Eggs; ground or well-cooked tender meat, fish, poultry; milk, cheeses; strained fruit juice (except prune):
cooked or canned apples, apricots, peaches, pears; ripe banana; strained vegetable juice: canned, cooked, or
strained asparagus, beets, green beans, pumpkin, squash, spinach; white bread; refined cereals (Cream of
Wheat)
Triage Principles
Triage Principles
Mettag: RED Priority I Immediate attention. Identifier is a Mettag torn to the red stripe or Roman numeral
I placed on the forehead or back of left hand. First priority casualties are those that have life-threatening
injuries that are readily correctable. For purposes of priority for dispatch to the hospital, however, a second
sorting or review may be necessary so only those transportable cases are taken early. Some will require
extensive stabilization at the scene before transport may be safely undertaken. A red tag may be used as an
additional means of identification.

Contents
1.

1 Triage Principles

2. 2 Triage Category Guidelines

1.

2.1 For multiple casualty incidents involving up to 80 victims:

2. 2.2 For multiple casualty incidents with an overwhelming number of survivors or over 80 victims:
Mettag: YELLOW Priority II Delayed attention. Identifier is the Mettag torn to the yellow stripe or Roman
numeral II placed on the forehead or back of left hand. Delayed category casualties are all those whose
therapy may be delayed without significant threat of life or limb and those for whom extensive or highly
sophisticated procedures are necessary to sustain life.
Mettag: GREEN Minor injuries. Casualties with minor injuries will receive minimum first aid treatment. They
will not be transported to hospitals until all Priority I and II patients have received care. They will be sent
from the triage area to a designated area away from the disaster scene in order to reduce confusion. If they
are capable, they may also be used as litter bearers or first aid providers.
Mettag: BLACK Dead. Identifier is the Mettag torn up to the black stripe or an X on the forehead and
covered with a sheet, blanket or other opaque material as soon as possible. Unless absolutely necessary, they
should be left in place until released by the coroner. The temporary morgue should be an area away from the
scene of the triage area.
Persons who are psychologically disturbed, who interfere with casualty handling, should be isolated from the
incident scene as quickly as possible. Campus Police will be requested to escort individuals to a designated area
away from the disaster scene.

Triage Category Guidelines

For multiple casualty incidents involving up to 80 victims:

1.
2.
3.
4.
5.
6.
7.

RED: IMMEDIATE (Priority I)

Asphyxia
Respiratory obstruction from mechanical causes
Sucking cheat wounds
Tension pneumothorax
Maxillofacial wounds in which asphyxia exists or is likely to develop
Shock caused by major external hemorrhage
Major internal hemorrhage

8.
9.
10.
11.
12.
13.
14.
15.

Visceral injuries or evisceration

Cardio/pericardial injuries
Massive muscle damage
Severe burns over 25%
Dislocations
Major fracture
Major medical problems readily correctable
Closed cerebral injuries with increasing loss of consciousness
Simple Treatment and Rapid Treatment (START): Quick identifiers for Red

Ventilation > 30/min

Perfusion <>
Mental status: unable to follow simple directions
YELLOW: DELAYED (Priority II)
Vascular injuries requiring repair
Wounds of the genitourinary tract
Thoracic wounds without asphyxia
Severe burns under 25%
Spinal cord injuries requiring decompression
Suspected spinal cord injuries without neurological signs
Lesser fractures
Injuries of the eye
Maxillofacial injuries without asphyxia
Minor medical problems
Victims with little hope of survival under the best of circumstances of medical care

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

For multiple casualty incidents with an overwhelming number of survivors or over 80 victims:

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

RED: IMMEDIATE (Priority I)

Asphyxia
Respiratory obstruction from mechanical causes
Sucking cheat wounds
Tension pneumothorax
Maxillofacial wounds in which asphyxia exists or is likely to develop
Shock caused by major external hemorrhage
Dislocations
Severe burns under 25%*
Lesser fractures*
Major medical problems that can be handled readily

YELLOW: DELAYED (Priority II)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

Major fractures (if able to stabilize)*

Visceral injuries or evisceration*
Cardio/pericardial injuries*
Massive muscle damage*
Severe burns over 25%*
Vascular injuries requiring repair
Wounds of genitourinary tract
Thoracic wounds without asphyxia
Closed cerebral injuries with increasing loss of consciousness*
Spinal cord injuries requiring decompression
Suspected spinal cord injuries without neurological signs
Injuries of the eye
Maxillofacial injuries without asphyxia
Complicated major medical problems*
Minor medical problems
Victims with little hope of survival under the best of circumstances of medical care

Legend= * Conditions which have changed categories