Académique Documents
Professionnel Documents
Culture Documents
History of nursing
1st Hospital Temple of Hygeia, Greece
1st surgery Trephining
1st physician Shaman
1st nursing law Shushurutu
1st law code of Hamurabi
1st psych nursing Linda Richards
Founder of ARC (American Red Cross) Carla Barton
1st board exam London
1st Superintendent in nursing Dorothea Dix
1st nursing School St. Thomas Hospital school ofnursing
Modernization of nursing London
Mother of modern Nursing Florence Nightingale
Grandfather of nursing HYpocrates
1st Lady with lamp St. Catherine of Sienna in Italy
1st recorded name Genesis- Deborah
1st country to record India
Angels of Battlefield Harriet Tubman (moses of the people)
1st Nursing theorist Florence Nightingale
Lady of Nursing Virginia Henderson
3 saints in Nursing
Patroness St. Elizabeth of Hungary (statue found in
Mandaluyong)
Lady with lamp St. Catherine of Sienna in Italy
Founder of the order of St. Francis Assisi St. Claire Assissi
Philippines
1st Superintendent in Nursing Anastacia Giron Tupas
Founder of FNA Anastacia Giron Tupas
1st President of FNA Rosario Delgado
1st Chair BON Gufenia Gomez Tan
Editor in Chief of “The Message” Socorro Diaz
1st Magazine “The Message”
1st Dean of UP Julita Solejo
1st Chief of PGH Anastacia Giron Tupas
1st Board exam June 1920
Board Examiners Anastacia Giron Tupas and Juan
Cabanus
Florence Nightingale of Manila Julita Solejo
Florence Nightingale of Iloilo Loreto Tupaz
Florence Nightingale of Philippines Josefa Llanes Escoda
Angels of Battlefield Melchora Aquino and Gabriela
Silang
1st member of the USRN Anastacia Giron Tupas
Founder of PRG (Philippine Red Cross) Dona Hilaria de Aguinaldo
1
Stages
I. Intuitive (Pre-Nightingale Era)
Shamans(White Magic) and Wakiyas (Dark Magic)
Illness was considered caused by possession
II. Apprentice
Nightingale at the age of 30 went to Germany and met Theodore Fliedner
and Decones Frederica Fliedner who owned the Keisserswerth Institute
where Nightingale has undergone her apprenticeship in nursing.
III. Dark
Time of Martin Luther and the Civil war (There was no existence of practice
of art and science in nursing because it was suppressed)
IV. Educative
On june 15, 1860, Nightingale at the age of 40 has established the first
nursing school.
Start of the Modernization of nursing
1st curriculum was established
Eviidence based Practice
Modern Technology was used in the practice of nursing
V. Contemporary
The present time
Man
Forms the foundation of
Nursing
Four Components or Attributes of
Man
Capacity to think on an
Abstract Level
Establish a family
Establish a territory
Ability to use verbal symbols as language
Concept:
Animals form a family by instinct
Via hormonal scents
Nursing Concepts of Man
Biopsychosocial Spiritual Being
By Sister Calista Roy
Man interacts with the environment
Open System
By Martha Rogers
Man interacts with the environment
Exchanges matter with energy
Exchanges energy with environment
Unified Whole
By Martha Rogers
2
Man is composed of certain parts
Total of those parts is more than the sum of all parts
This is because man has attributes
Vital Reparative Process
By Florence Nightingale
Man is passive in influencing the nurse or the environment
Man is a whole. Man is complete
By Virginia Henderson
Man has fourteen (14) fundamental needs
Human Needs
Needs are physiologic and psychologic
Both these needs must be met in order to maintain wellbeing.
Key Concept:
Basic Human Needs are equivalent to COMMON NEEDS
Characteristics of Human Needs
Universal
Interrelated
One need is related to another need
May be stimulated by internal or external factors
Maslow’s Hierarchy of Needs
A. Physiologic
1. Oxygen
2. Fluids
3. Nutrition
4. Body temperature
5. Elimination
6. Rest and sleep
7. Sex
B. Safety and Security
1. Physical safety
2. Psychological safety
3. The need for shelter and freedom from harm and danger
C. Love and Belongingness
1. The need to love and be loved
2. The need to care and to be cared for
3. The need for affection ; to associate and belong
4. The need to establish fruitful and meaningful relatinships with people, institutions, or
organizations
D. Self Esteem Needs
1. Self-worth
2. Self-identity
3. Self respect
4. Body image
E. Self Actualization Needs
1. The need to learn, create and understand or comprehend
2. The need for harmonious relationships
3. The need for beauty and aesthetics
4. The need for spiritual fulfillment
3
Illness and Disease
Illness
Is a personal state in which the person fels unhealthy
Illness is a state in which person’s physical, emotional, intellectual, social,developmental,
or spiritual functioning is diminished or impaired compared with previous experiences
Illness is not synonymous with disease
Disease
An altearyion in body function resulting in reducation of capacities or a shortening of the
normal life span
5. Dorothy Johnson
Human Behavioral system---- starts at home; learned and can be unlearned
Role of the nurse: Facilitator
4
6. Imogene King
Goal Attainment Theory
Discharge patient from hospital and assist them to maintain Optimum Level of
Function (OLOF)
7. Myra Levine
4 consecutive Principles
1. Conservation of energy
2. Conservation of personal Integrity
(do not panic in any given situation)
3. Conservation of Social integrity
Maintain open line of communication
Endorse properly
Iron out misunderstanding
Communicate with respect
4. Conservation of structural integrity
Maintain an orderly station
Organize workplace
8. Joyce Travelbee
Human-human relationship
NO man is an island
We are all interconnected and interdependent
9. Faye Glenn Abdellah
21 nursing problem
Old definition of nursing---- Nursing is science and art, Nursing is a profession
10. Betty Newman
Health care system model
Promotive and preventive type of care
Promotion of self-reliance
Include patient in the course of care
Stress reduction Theory
Get rid of stressors
Avoid stress and manage if possible
Planyour work and work your plan
11. Sister Calixta Roy
Adaptation Model”
Man is highly flexible
Failure to adapt is the birth of illness
Phases of adaptation takes place
“Reconstitution”- Mastering how to adapt to situations
12. Dr. Martha Rogers
Same birthday with Nightingale
The only Doctor theories
Science of Unitary Human beings- the whole is greater than the sum of its part
Man is an energy field
Helicy--- cyclical or constant change
Integrated—Man and environmental integration
Resonancy—Evolution
5
4 dimentionality Pattern
1. Biophysiological
2. Spiritual-manual
3. Familial
4. Moral Ethics
13. Dorothea Orem
Self -Care and Self- Care Deficit
The 4 taxonomy
1. Self care--- can do activities of daily living
2. Self care deficit—Cannot do Activities of daily living
3. Self care agent—The nurse
4. Self care Agency—Mastering the activities of daily living
Levels of compensation
Levels Nursing role Patient
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Air
Water
Drainage
LEVELS OF PREVENTION:
1. Primary Prevention
Emphasis on:
o Generalized health promotion and specific protection
o Recipients are
GENERALLY HEALTHY PEOPLE When given:
o Before onset of illness or before onset of disease Examples:
o Generalized health education
Prevention of accidents
Standards of nutrition o Immunizations
Specific preventions
o Risk Assessment for specific disease
o Family Planning Services and Marriage Counseling
o Environmental Sanitation
o Recreation and Housing
2. Secondary Prevention
Emphasis placed on:
o Early detection / diagnosis
o Prompt treatment
o Health maintenance of persons already having health problems
o Prevention of complications When given:
o During illness
Examples:
o Screening survey o Encouraging regular check-ups
o Complying with regular check-ups
o Teaching Breast-selfexamination
o Teaching Testicularself-examination
3. Tertiary Prevention
Emphasis placed on:
o Support of the client to achieve the following:
Successful readaptation
Optimal reconstitution
Regain high level wellness
Therefore, the purpose is more of REHABILITATION
When given:
o Begins after the illness or when a defect or disability is fixed or
irreversible
Examples:
o Referring a client to support groups
o Teaching a diabetic client how to inject
insulin
ROLES OF A NURSE
1. Caregiver / Care Provider
To convey understanding and support
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Activities:
o Support and comfort measures (mothering aspect of nursing / nurturance aspect
of nursing)
2. Counselor
Involves helping patient identify and avoid stressful and psychological problems
Focuses on:
o Helping client establish capacity for successful interpersonal relations Helping
the patient develop new coping
skills
Concept:
Do not give advice!
o This is meant to facilitate decisionmaking on the part of the client
o This is observed so that the client would not develop DEPENDENCY
3. Client Advocate
Protects rights of patients
Activity:
Speaking on behalf of the patient
4. Change Agent
Brings change or adjustments
Nurse only influences a patient
Nurse does not change the patient
5. Teacher
Teaching
Imparting of knowledge
6. Leader
Application of interpersonal influence to bring out desired behavior (leadership)
7. Manager
Decision-making Planning
Giving directions
Monitoring operations
Facilitating staff development
Therefore, this is done on the supervisory level of organization
8. Researcher
After graduation, nurse cannot yet be a researcher
He can only be a researcher after he receives his Master of Arts in Nursing
(M.A.N) degree
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To establish plans
To deliver specific nursing care
Characteristics of Nursing
Process (MEMORIZE THIS!!!)
1. Goal-oriented and clientcentered
2. Cyclical (no absolute beginning and end), dynamic (moving) rather than static
3. Plan of care organized according to client problems rather than nursing goals
4. Basis of prioritizing nursing activities would be the problems and not the goals
5. Follows a logical sequence
6. Universally applicable (to any type of patient)
7. Interpersonal and collaborative
Work with patients and relatives
Work with colleagues and other members of the health team
8. Adaptation of problem-solving techniques and principles
9. Problem-oriented, flexible, open to new information
10.Allows creativity of nurse and patient
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IMPORTANT CONCEPT!
No conclusion is developed in the assessment phase
Purposes of the Assessment Phase
To create a data base of the client’s response to health and illness
To determine the nursing care needs of the patient
Four (4) types of Assessment:
1. Initial Assessment
When performed:
o At specified time after admission Where done:
o Done at the ward
Where Admitted:
o At the ward
Purpose of Initial Assessment:
o To create a data base for problem identification
o For reference and future comparison
2. Focus Assessment or On-going
Assessment
When performed:
o Integrated throughout the nursing process
Purpose of On-going Assessment:
o To identify problems overlooked earlier
o To determine the status of a health problem (i.e. hydration status every fifteen
minutes)
3. Emergency Assessment
When done:
During acute physiologic and psychologic crisis
Where done:
Emergency Room o Comfort Room
Anywhere!!!
On site!!!
Purpose of Emergency Assessment
o To identify life threatening condition
Framework or Principle in Emergency Assessment
o A – Airway
o B – Breathing
o C – Circulation o Utilize either Maslow’s Hierarchy of Needs or ABC
principle
4. Time-Lapsed Assessment When done:
o Several months after initial assessment
Purpose of Time-Lapsed Assessment
o To compare current status of patient with base line data (initial assessment)
ASSESSMENT PROCESS
Concepts:
Data is equivalent to information
What is the initial output of the Assessment Phase? Data or Recorded Data Never
validated data!!! Types of Data:
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1. Subjective or Covert Data Felt by the patient
During the recording of data, this should be stated using the patient’s own words
These are the symptoms felt by the patient
2. Objective or Overt Data
Capable of being observed by use of senses – sight, touch, smell, taste, hearing
These are the signs which are observable
Sources of Data:
1. Primary Source
Patient himself except when: o He is unconscious o Patient is a baby o Patient is insane
2. Secondary Source Patient’s record
Health care members
Related literature or journals
Significant others (they become primary source when patient is unconscious
Family or relatives
The person who brought the patient to the hospital
3. Environment of the Patient
Methods of Data Collection
Observing
Interviewing
Examining
1. Observing
It should be deliberate
Exert effort
Two (2) aspects of observation process:
Noticing the stimuli
Do an interpretation of the stimuli
2. Interviewing
Two (2) types of Interview:
Directive Type of Interview
o Structured
o Uses closed-ended questions calling for specific data
When used:
o When you need to elicit specific data
o When there is little time available
Concept:
Characteristics of Closed-ended questions:
Yes or No questions
Asks when or asks for the time when event happened
Asks how many
Point with finger when asking to provide clarity
Therefore, they call for highly specific answers
Non-Directive Type or Rapport-
Building Interview
Uses more open-ended questions
Advantage is that it allows the patient to volunteer
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information
Types of Interview Questions:
1. Open-Ended Questions
Questions not answerable by
“yes” or “no”
Questions that elicit information or explanation
2. Closed-Ended Questions
Questions answerable by
“yes” or “no”
Leading Questions
Phrasing of question suggests what answer the interviewer is expecting
3. Neutral Questions
Phrasing allows patient to answer with least pressure
Usually NOT addressed to patient personally (i.e. what is your opinion about…)
Raised as a general topic Planning the Interview Setting
Concepts:
Before the interview, determine what information you already know or what
information is available
An interview is a planned conversation with a purpose
An interview is a two-way process
When is it done?
o When patient is available
o When patient is comfortable
Recommended distance from the patient is three (3) to four (4) feet.
Stages of the Interview 1. Opening Stage Key Concept!!!
This is the most important part of the interview
Rationale
What was said and done during the opening stage sets the tone all throughout the
interview
2. Body of the Interview
Occurs when patient responds to questioning
3. Closing Stage
How to close the interview:
o Summarizing Technique
Validation of Data
Act of double-checking the data
Purposes of Data Validation o To ensure the:
Correctness
Completeness
Accuracy of the data
Guidelines in Validating Data
Compare subjective and objective data
Be familiar with word usage
(particularly if the patient is a child)
Reassess / double-check data which are extremely abnormal
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Be sure that your data contains CUES and not INFERENCES
Be sure that your data is FREE OF BIASES
Avoid jumping to conclusions
Data Recording Concepts:
Data Recording COMPLETES the Assessment Phase
Initial Output of the
Assessment Phase is DATA
Final Output of the
Assessment Phase is RECORDED DATA
DIAGNOSING PHASE OF THE NURSING PROCESS
Activities during the Diagnosing Phase:
This involves sorting, clustering, analyzing and interpreting data
Concept:
The final output in the Diagnosing Phase is a NURSING DIAGNOSIS!!!
Different Types of Nursing Diagnoses:
1. Actual Nursing Diagnosis
Problem present at the time the statement was made
2. High-Risk Nursing Diagnosis
A diagnosis that a patient is more vulnerable or susceptible compared with others in the
same situation
3. Possible Nursing Diagnosis
There is an evidence of a health problem but the causes are NOT fully understood
4. Wellness Nursing Diagnosis A positive statement Indicates a healthy response
Examples:
o Potential for increased compliance related to increased level of knowledge
o Potential for enhanced body image related to regular exercise
o Potential for effective coping related to adequate support systems
Domains of Nursing Diagnosis Key Concept!
It only includes health problems that a nurse is capable and licensed to treat
Parts of a Nursing Diagnosis
1. Problem Statement
Example:
Fluid Volume Deficit
2. Presumed Etiology
Example:
o …related to frequent loss of bowel
movement
3. Defining Characteristics
Example:
…as manifested by decreased skin turgor
Advantages of Using Standardized Diagnostic Terminology
Provides professional accountability and autonomy by defining and describing the
independent areas of practice
Provides effective vehicle of communication
Provides an organizing principle for meaningful research
Facilitates continuity and individualized care
PLANNING PHASE OF THE NURSING PROCESS
Concept:
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Planning means:
Determining ahead of time
Forecasting a course of action
Key Concept!!!
For your plans to be effective, involve the patient and the family
IMPORTANT CONCEPT!!!
Final output of the Planning
Phase is a NURSING CARE
PLAN or a WRITTEN CARE
PLAN
Types of Planning
1. Initial Planning
Done by the nurse When done:
o At specified time upon
or after admission of the patient
2. On-going Planning
Who are involved:
o Done by all nurses who
worked with the patient
o The patient himself o The family o But primarily, the NURSE
Purposes of On-going
Planning o To determine if the client’s health status has changed
o To decide which problems to focus on during the shift
o To set priorities for client care during the
shift
o To coordinate the patient care and activities so that more than one problem can
be addressed at the same time
3. Discharge Planning
Purpose of Discharge
Planning o To ensure continuity of care
Characteristics or the Planning
Process
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time bound
Man
Forms the foundation of
Nursing
14
Ability to use verbal symbols as language
Concept:
Animals form a family by instinct
Via hormonal scents
Open System
By Martha Rogers
Man interacts with the environment
Exchanges matter with energy
Exchanges energy with environment
Unified Whole
By Martha Rogers
Man is composed of certain parts
Total of those parts is more than the sum of all parts
This is because man has attributes
Vital Reparative Process
By Florence Nightingale
Man is passive in influencing the nurse or the environment
Human Needs
Needs are physiologic and psychologic
Both these needs must be met in order to maintain wellbeing.
Key Concept:
Basic Human Needs are equivalent to COMMON NEEDS
15
In order to prioritize nursing actions
1. Physiologic needs
Food, maintenance of homeostasis
2. Safety and security
3. Love and belongingness
4. Self-Esteem
Feeling good about one’s self
Two factors affecting Selfesteem
o Yourself
Sense of adequacy
Accomplishment o Others Appreciation
Recognition
Admiration
Belongingness
5. Self-Actualization
Able to fulfill needs and ambitions
Maximizing one’s full potential
6. Aesthetics
Beauty
Richard Kalish
Man needs stimulation
Needs to explore o Sex
o Activity o Novelty
Stimulator
Desire to come up with something of your own
Characteristics of Self-Actualized
Persons
Judges people correctly
Superior perception
Decisive o Capable of making decisions
Clear notion as to what is right and wrong
Open to new ideas o Not adopts new ideas o Not one track mind Highly creative and
flexible
Does not need fame
Problem-centered rather than self-centered
Concept:
16
Self-Actualization is very difficult to attain
It is impossible to attain
New needs come after getting one need
Illness
Highly subjective feeling of being sick or ill
Chronic Illness
Gradual in onset (most of the time, but not always)
Types of Chronic Illness o Exacerbation
Period
characterized by active signs and symptoms of the illness o Remission
Periods where no signs and symptoms are prese
Disease
Concepts:
Illness without disease is possible
Disease without illness is possible
Illness may or may not be related to a disease
One can have a disease without necessarily feeling ill
Deviance
Any behavior that goes against social norms
Shortens life span
Results to disrupted family and community
Concept:
Deviant behavior can be considered a disease
Rationale:
Because it also shortens the life span like a disease
Example:
Alcoholism o A disease rather than a
social problem
Wellness
Feeling of being well Definitions of Health
17
World Health Organization
Health is the complete physical, mental, social (totality) well-being and not merely the
absence of disease or infirmity
A high-level wellness!
Claude Barnard
Ability to maintain internal milieu
Walter Cannon
Ability to maintain homeostasis
A dynamic equilibrium
A state of balance of the internal environment while external environment is changing
Florence Nightingale
Health is using one’s power to the fullest
Being well
Can be maintained by manipulating the environment
Virginia Henderson
Viewed in terms of ability to perform the fourteen (14) fundamental needs or components
of nursing care UNAIDED
Martha Rogers
Positive health symbolizes wellness
Health is a value term defined by a certain culture
Dorothea Orem
Characterized by soundness and wholeness of DEVELOPED HUMAN
STRUCTURES and FUNCTIONS
Imogene King
A dynamic state in the life cycle (contrasted with illness) Illness is interference in the life
cycle
Betty Neuman
Wellness is that all parts and subparts are in harmony with each other and the whole
system
Dorothy Johnson
Elusive dynamic state influenced by biologic,
psychologic and social factors
18
Health-Illness Continuum
Dunn’s High Level Wellness and
Grid Model
X-axis is HEALTH
Y-axis is environment Quadrant 1
High-level wellness in favorable environment
Quadrant 2
Protected poor health in favorable environment
Quadrant 3
Poor health in unfavorable environment
Quadrant 4
Emergent high-level wellness in unfavorable environment
19
Expands to the MULTICAUSATION of a DISEASE
Definitions of a disease as to its cause is expanded to a multi-causation of a disease (i.e.
cancer is a multi-factorial disease)
Triad is composed of the agent, host and susceptible host
Based on the interplay of three components of the model
Stress
By Hans Selye
Is a non-specific response of the body to any demand placed upon it.
General Adaptation Syndrome (GAS)
Local Adaptation Syndrome
(LAS)
General Adaptation Syndrome Involves two (2) body systems: Nervous System
Endocrine System
20
Pale, Cool, Clammy Skin
Mineralocorticoids
Increased Aldosterone levels
Increases sodium retention and water retention
Increases circulating blood volume
Increases cardiac workload
(due to vasoconstriction)
Glucocorticoids
Increased hyperglycemia
(transient)
Increased glycogenolysis Increased neogenesis Increases blood sugar
Increases osmotic pressure
Increases fluid retention (glucose is a colloid which attracts water and adheres to it)
Increases cardiac workload
Concept:
Complications of Stress:
Cerebrovascular Attack
Increased Diabetic
Ketoacidosis (if patient is diabetic)
Hypertension leading to cardiac arrest
Concept:
Bradykinin, Histamine,
Prostaglandin, and Serotonin all increase swelling
21
Key Concept!
Hans Selye o Author of Physiologic Response to Stress
Lazarus
Stress is a transaction
Stress resulted from interaction of man with his environment and fellowman
Therefore, Lazarus describes the SOCIAL ASPECT OF STRESS
Also an adopted
PHYSIOLOGIC RESPONSE
Key Concept!
The most comprehensive concept of stress is the stress concept of LAZARUS as it
combines Physiologic and
Social aspects of stress.
Illness Behavior
Pertains to any activity undertaken by a person who feels ill in order to
Define his state of health
Discover a suitable remedy
3. Communication to others
4. Assessment of symptoms
Purpose is to verify the veracity of the complaint
5. Sick-Role Assumption
6. Concern Stage
22
7. Efficacy of treatment
Assess sources of treatment
Assess potential effectiveness of treatment
8. Selection of Treatment Stage Availability
Cost of Treatment
9. Treatment Proper
10. Assessment of Effectiveness of
Treatment
May go back to stage 7
(Efficacy of Treatment) if treatment is not effective
May go to next stage if treatment is effective
11. Recovery and Rehabilitation
Compliance
Adherence to professional’s advice
Factors Affecting Compliance
Client motivation
Degree of required change in lifestyle
Perceived severity of health problem
Difficulty of understanding instructions
Belief about the effectiveness of the therapy
Nature of the therapy itself o Adverse effects o Cost
Cultural influences
Degree of satisfaction with the relationship with health care providers
Guidelines to Enhance
Compliance
Be sure patient understand procedure by giving
information
Make sure patient is capable of performing activity
o Set realistic goals
Ensure that he is a WILLING participant
o Look for buying signals
23
Looking at wound
Looking at materials needed
LEVELS OF PREVENTION:
2. Secondary Prevention
Emphasis placed on:
o Early detection / diagnosis
o Prompt treatment o Health maintenance of persons already having health
problems
o Prevention of complications When given:
o During illness
Examples:
o Screening survey o Encouraging regular check-ups
o Complying with regular check-ups
o Teaching Breast-selfexamination
o Teaching Testicularself-examination
Concept:
o Most effective method of teaching is
DEMONSTRATION
Additional Examples of
Secondary Prevention o Assessment of growth and development
o General nursing assessment and care at the hospital, community and the home
3. Tertiary Prevention
Emphasis placed on:
o Support of the client to achieve the following:
Successful readaptation
24
Optimal
reconstitution
Regain highlevel wellness
Therefore, the purpose is more of REHABILITATION When given:
o Begins after the illness or when a defect or disability is fixed or
irreversible
Examples:
o Referring a client to support groups
o Teaching a diabetic client how to inject
insulin
ROLES OF A NURSE
2. Counselor
Involves helping patient identify and avoid stressful and psychological problems Focuses
on:
o Helping client establish capacity for successful interpersonal relations Helping the
patient develop new coping
skills
Concept:
Do not give advice!
o This is meant to facilitate decisionmaking on the part of the client
o This is observed so that the client would not develop
DEPENDENCY
3. Client Advocate
Protects rights of patients
Activity:
o Speaking on behalf of the patient
4. Change Agent
Brings change or adjustments
Nurse only influences a patient
Nurse does not change the patient
5. Teacher
Teaching
25
Imparting of knowledge
6. Leader
Application of interpersonal influence to bring out desired behavior (leadership)
7. Manager
Decision-making Planning
Giving directions
Monitoring operations
Facilitating staff developmentTherefore, this is done on the supervisory level of
organization
8. Researcher
After graduation, nurse cannot yet be a researcher
He can only be a researcher after he receives his Master of
Arts in Nursing (M.A.N) degree
Basic Guidelines
Develop a well-defined objective
Assess client’s readiness to learn
Start with what the client is concerned about
Assess and start with what the client already knows; proceed from the known to the
unknown
Start with the simple proceeding to the complex
Schedule a review of the content
Concept:
Areas of Learning Domain o Knowledge – cognitive o Skills – motor o Attitude – emotional
TEACHING STRATEGIES
2. One-to-one Discussion
Addresses affective and cognitive learning
3. Answering Questions
Cognitive
4. Demonstration
Motor
26
5. Discovery
Cognitive and Affective
Concept:
Learning is more effective if the learner discovers the content for himself. (That is, through
experience!)
6. Group Discussion
Affective and Cognitive
Sharing feelings during group dynamics
7. Practice
Motor
9. Role-playing
For pediatric and psychiatric nursing settings
10. Modeling
What you say is what you do
Concept:
The Nursing Process was introduced by LYDIA HALL!
Definition:
The Nursing Process is a systematic, organized, rational method of planning and providing
individualized, humanistic nursing care
Characteristics of Nursing
Process (MEMORIZE THIS!!!)
1. Goal-oriented and clientcentered
2. Cyclical (no absolute beginning and end), dynamic (moving) rather than static
3. Plan of care organized according to client problems rather than nursing goals
4. Basis of prioritizing nursing activities would be the problems and not the goals
5. Follows a logical sequence
27
6. Universally applicable (to any type of patient)
7. Interpersonal and collaborative
Work with patients and relatives
Work with colleagues and other members of the health team
8. Adaptation of problem-solving techniques and principles
9. Problem-oriented, flexible, open to new information
10.Allows creativity of nurse and patient
BENEFITS DERIVED FROM THE NURSING PROCESS
Concepts:
Both the nurse and the patient benefit from the nursing process Patient obtains greater
benefit
Remember:
Nursing process is CLIENTCENTERED or PATIENTCENTERED and NOT NURSE-
CENTERED
Concept:
Communication is the basic component of Human
Relationships
Elements of Communication
1. Message
Data
2. Sender
Encoder
3. Receiver
Decoder
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4. Feedback5. Context
Setting
Overall environment where the communication takes place
Modes of Communication
1. Verbal
Oral
Spoken
Written communication
Texted communication
Cable communication
Telex communication
Facsimile communication
Social Distance
4 feet to 12 feet
Public Distance
12 feet and beyond
Territoriality
o One person believes that the space and all the things in that space belongs to him
o Do not enter abruptly; this may result in breach of privacy
Roles and relationships
Therapeutic Communication in
Nursing
Using Silence
29
Supplement with non-verbal communication
Provide General Leads o
o Examples:
o “…go on”
o “…tell me more”
Open-ended questions
Use Touch
o But assess the culture of the patient
o If the patient is a child, touch the patient on the top of the head
o If the patient is an elderly, touch the
patient on the hand
o If the patient is of the same age level, touch the patient on the shoulder
Offering yourself o For autistic child
Stay nearby or stay beside the patient
Presenting Reality o Example:
“You are in the hospital”
Reflecting o Example:
“What do you think will make you happy”
o Never agree nor disagree
o Reflect it back or throw it back
Non-therapeutic Communication
Stumbling blocks to effective communication
Stereotyping
Generalizing
Agreeing and Disagreeing
No confrontation
No argument
Being defensive
Moralizing or Passing Judgment
Giving Common Advise Examples:
“If I were you…”
“You should have done it…”
Circadian Rhythm
A biological rhythm
A biological clock
Regulated from outside the person’s body
Types of Sleep
1. Rapid Eye Movement Sleep
(REM sleep)
Increased brain metabolism and activity
30
Also called PARADOXICAL SLEEP
Characterized by: o Vivid dreams o Easily recalled upon awakening
Concepts!
REM sleep is NOT AS RESTFUL as NON-REM
sleep
However, REM sleep is NEEDED
Dreaming is a psychological outlet of pent up emotions
Nursing Alert!
Deprivation of REM sleep results to: o Irritability
o Restlessness o Poor concentration
Concept!
Deprivation of Non-REM sleep causes:
o Physical exhaustion
o Decreased resistance against infection
31
o L-tryptophan is an amino acid with a natural sedative effect that induces one to
sleep
Side-to-side turning every two hours with back tapping
Support bedtime rituals
Remove all music in order to sleep
PROMOTING NUTRITION
Proteins
Macromolecules composed of o Carbon o Hydrogen
o Oxygen o Nitrogen
Concepts:
Glucose is a ready source of energy for metabolic
processes
Carbohydrates
When eaten are metabolized to glucose for energy
Excess carbohydrates are converted to glycogen and
stored in the liver
Other excess carbohydrates go to the fat cells
Key Concept!
During starvation, stored glycogen is converted to glucose via a process called
glycogenolysis
If glycogen is used up, fat resources are converted to glucose via a process called
gluconeogenesis
Nursing Alert!
Fat conversion to glucose produces waste products called KETONE BODIES
These give rise to metabolic acidosis as in Diabetic Ketoacidosis
Additional concepts!
During starvation protein reserves are converted to glucose via process called
gluconeogenesis
Gluconeogenesis
Production of glucose out of non-carbohydrate products
Lipoproteins
Substances composed of fats and proteins
32
Types of Lipoproteins
1. High Density Lipoproteins (HDL)
High-grade lipoprotein
Good grade lipoprotein
Good cholesterol
Function of HDLs o Transports the bad cholesterol from systemic
circulation to the liver for metabolism and eventual
elimination
Functions of Fats
Insulation
Heat Conservation
Source of Energy
Proteins
Two (2) types in terms of needs of the body: 1. Essential Proteins
Proteins that cannot be produced by the body itself
To be sourced out from food eaten
Animal protein is complete protein
Plant protein is considered as incomplete protein
2. Non-essential Proteins
Proteins that can be produced by the body
Functions of Protein
Main element of our cells.
o Building blocks of the cells are proteins
Resistance against infection
o Formation of
Immunoglobulins
(globular proteins)
Maintenance of normal intravascular fluid volume
o Works with glucose and sodium
Albumin
Main protein of blood
Acts as a colloid
Attracts water around it
33
Concepts!!!
If protein levels are decreased, sodium and glucose will not be enough to hold plasma
inside blood vessel resulting into edema
Review on Vitamins
Taxonomy Medical Name Sources Deficiency
A Retinol (animal) All yellow orange Xerophthalmia-
Carotene (Plants) fruits and Nightblindness
vegetables
B1 Thiamine Rice, chicken, Wernicke’s-
fish, nuts encephalopathy
Decreased level of
consciousness
due to increased
intracranial
pressure
Korsakoff
Psychosis-
confabulation
Severe Body
fatigue
Peripheral neuritis
Paresthesia
Paralysis
34
B7 Biotin Corn, aubergine, Burning feet
pork syndrome
B9 Folic acid/ Folate Milk Megaloblastic
anemia
Results: If >40% of
B12 is present in
urine—positive
pernicious anemia
Causes:
1. No intrinsic
factor (parietal
cells)
2. Decreased
B12
3. Removal of
ileum (Cancer
patients
undergoing
surgery)
MICRONUTRIENTS
Ferrous sulfate (FeSO4)
Forms:
35
o Tablet
o Liquid
o Injectable
Oral (tablet and liquid forms)
o Take on an empty stomach
o If there is GI distress
(i.e. diarrhea), take with food
o If GI distress subsides, take on an empty stomach Toxic effects:
o Constipation (first option)
o Oral Liquid Iron o Use dropper and apply at the back of the tongue or use a straw
▪ Rationale:
To avoid staining the teeth
Health Teaching!!!
o To enhance iron absorption, advice
taking orange juice
o Vitamin C in orange juice enhances iron absorption
o Do not take milk o Milk inhibits absorption of iron
o Too much fiber prevents absorption of iron
o Thus, do not take oats when taking iron.
Injectable Iron
o Route is deep I.M.
o Use Z-track technique
Gauge of Needle is at least 18
o Length of Needle is 1.5” to 2.0”
o Site of administration is the GLUTEAL MUSCLE ONLY!!!
o Rationale:
o To avoid staining the skin
Concept:
o Use an airlock
o Place 0.5 ml of air in syringe so that medication would not leak into
the subcutaneous tissues
Nursing Alert!
o Apply firm pressure for at least five (5) minutes after injection
Do NOT massage
SPECIAL DIETS
1. Light Diet
Given for post-operative patients
Plainly cooked
No spices
Large amounts of FAT omitted
Avoid bran and high fiber
2. Soft Diet
For people with difficulty with swallowing and chewing Generally low residue diet
Nursing Alert!
36
o Avoid the following:
Nuts
Seeds (tomato, guava, berry)
Raw fruits and vegetables
Fried Foods
Whole grains and cereals
3. Pureed Diet
Osteorized diet
7. Candidiasis Diet
Free of the following: o Fruits o Sugar o Yeast o Fermented foods
Acid-Ash Diet
To alkalinize urine
To soothe an irritated bladder and urethra
Give citrus fruits Give vegetables
Exceptions are: o Prune Juice o Cranberry Juice o Both produce ACIDIC URINE
Ash-Acid Diet
Given to acidify urine
To minimize or help control Urinary Tract Infections Give the following: o Protein o Meat
o Poultry
37
Anthropometric Measurements
SUPPORTING NUTRITION OF
PATIENT: ENTERAL AND PARENTERAL FEEDING
ENTERAL FEEDING
1. NASOGASTRIC TUBE FEEDING (NGT)
Purpose of NGT insertion o For gastric gavage and lavage
o For administration of food and medication
o To keep the stomach empty
o To prevent aspiration from regurgitation of gastric contents
o For gastric decompression
How to Insert NGT
o Depth of Insertion
Measure length from the tip of the nose to the ears to the tip of the xiphoid process
o Insertion:
o Position the patient in semi-Fowler’s or Fowler’s position
o While inserting to NASOPHARYNX Position the head in a hyperextended manner
o When glottis, epiglottis are approached, Flex the head to prevent entry of the tube
into the trachea
Nursing Alert!
o Watch for signs and symptoms of RESPIRATORY DIFFICULTY
If there are signs, WITHDRAW TUBE
o While inserting tube, observe for coughing or difficulty of breathing
After inserting, ascertain proper placement on the stomach
Concept!
o Most accurate method to test for proper placement of the NGT is via X-RAY
Other ways to test proper placement:
1. Let patient hum
If positive for humming, tube is in the esophagus and stomach
If negative for humming, tube is in the trachea
Nursing Alert!
o Small-bore tube allows patient to hum
o Therefore, this method is NOT RELIABLE
2. Determine the pH of the aspirate
Use litmus paper
38
Change of color from BLUE to RED indicates that the aspirate is acidic
and, therefore, from stomach contents
Change of color from RED to
BLUE indicates that the aspirate is basic and, therefore, from lung
contents
IMPORTANT CONCEPTS!!!
o To insure safety of the patient prior to feeding, CHECK THE FOLLOWING:
1. Placement of the tube
•
For patient safety
•To prevent LUNG aspiration of food
2. Patency of the tube
39
Tube must reach two (2) centimeters before or above the RIGHT ATRIUM
Nursing Responsibilities:
Watch out for signs and symptoms of embolism
Care of Insertion Site
PROMOTING OXYGENATION
DEEP BREATHING
Two (2) types of Deep Breathing:
1. APICAL DEEP BREATHING
Done to expand the upper portion of the lungs
Let the patient place palms on the upper chest
Concentrate on that area
Take a slow deep breath at a count of 1,2,3
Release it slowly through the nose or a pursed lip at a count of 4,5,6,7
Therefore, expiration is longer than inspiration Rationale:
o To prevent respiratory alkalosis
Taught to patients who will undergo:
o Upper abdominal surgery
Cholecystectomy
Incision site on diaphragm
Patient does not want to breathe
Predisposed to hypostatic pneumonia
40
o At least every two (2)
hours
Procedure o Teach the patient to inhale and exhale
o Tell the patient to inhale and exhale a second time
o Tell the patient to inhale and cough out
NURSING ALERT!!!
o Coughing is contraindicated in the following patients:
With increased intracranial pressure (ICP)
With increased intraoptical pressure (IOP)
With cardiac arrhythmias (but are allowed to do deep breathing)
Concepts!!!
Deep Breathing and Coughing o Purpose is to stimulate surfactant production
Yawning and sneezing also stimulate surfactant production
Concept!
Humidifier moistens the oxygen administered
Purpose o To avoid drying and irritation of the mucosal lining
o Also traps particulates from the tank
Iron oxide may be present in the tank (iron plus oxygen produces iron
oxide or rust)
Concept!
Fire Precaution o Place ‘NO SMOKING’ sign at the door or at the head part of the patient
Tank and oxygen do not explode
They merely support combustion
Other Concepts!
Do not use volatile substances
Acetone and alcohol can react with oxygen and lead to toxicity of patient
Do not use oil based or grease on any part of the oxygen set
Do not allow the patient to use an electric razor as sparks may trigger combustion
Nursing Alert!
Retrolental Fibroplasia occurs if there is excess oxygen administration in infants. Excess
oxygen leads to destruction of the retina and blindness
Modes of Administration
1. Low Flow Administration
Utilizes nasal cannula or nasal prongs or nasal catheters
41
Given to COPD patients
2. High Flow Administration
Uses a venturi mask
NEBULIZATION
With sodium chloride and salbutamol
A physiologic solution
Water liquefies secretions
Sodium chloride stimulates coughing
Salbutamol is a bronchodilator
Purpose:
o For expectoration of secretions
SPIROMETRY
Purpose is to expand the lungs
Done when inhaling
Instruction to the patient:
o Inhale from the spirometer and NOT blow to the spirometer
o Procedure:
• Inhale – exhale o Inhale – exhale fully
o Place mouthpiece between teeth
o Hold breath for four (4) seconds
o Then inhale, fully rising the ball
Upon inhalation, the ball rises
CHEST PHYSIOTHERAPY
This is a dependent procedure
There are no absolute contraindications to this procedure
Contraindicated for the following patients with:
Pacemakers
Lung abscess o Hemoptysis
Dangerous Arrhythmias
Active PTB (which goes to the other lobe)
Lung CA (malignancy goes to other lung)
Vibration
42
Palms of your hand are placed on chest or back of patient giving quivering motions
Palms remain in contact with the chest or back
Percussion
Use cupped hands
Hands alternate in rising and coming into contact with chest or back of patient
Postural Drainage
Drain secretions by gravity
Change positions
IMPORTANT CONCEPT!!!
o Rule out contraindications before performing chest physiotherapy
Pre-therapy Assessment for Vibration and Percussion
Assess breath sounds to know which lung fields have secretions
Then assess again after procedure to check effectiveness of the procedure.
Concepts!!!
Vibration and percussion are done to mechanically dislodge secretions
Nebulization is done to liquefy secretions
Suctioning is done to clear secretions
Postural Drainage is done to drain secretions using gravity
Postural Drainage When done: o Before meals o Two (2) hours after meals
Before doing the procedure, the following baseline data are needed: o Breath sounds o
Vital signs
o Continuous ECG monitoring
During the procedure:
o Ensure the comfort of the patient
o Provide a kidney basin and tissue paper
Nursing Alert!
o Watch out for signs of symptoms which may require stopping of the procedure:
Sudden dyspnea
Cyanosis
Extreme diaphoresis
Sudden alteration of blood pressure, respiratory rate, pulse rate
Appearance of arrhythmias
Hemoptysis
General intolerance of the procedure
Important Concept!
If any of the above occurs, STOP THE PROCEDURE and inform the physician
Concepts!
After the procedure assess the following:
o Breath sounds o Vital signs o Quantity and quality of sputum
o Overall response of the patient to the procedure
43
Give oral hygiene o Rationale:
To eliminate phlegm from the mouth
Important Concept!!!
Patients with cystic fibrosis benefit much from postural drainage
Oropharyngeal
Concepts!!!
Question:
o If you have only one (1) suction catheter, which will you suction first, the nose or the
mouth?
Answer:
If the patient is an infant or a newborn:
Start on the mouththen proceed to the nose
Rationale:
If you start on the nose, you will trigger the sneezing reflex and this would result into
aspiration
Answer:
o If the patient is an adult, suction the mouth first, then proceed to the nose
Rationale:
This is done for aesthetic reasons
44
Suctioning 10 – 15 Not more 20 – 30 Not more
If patient is conscious centimeters than 10 – seconds than 5
15 minutes
seconds
Fowler’s (high or
moderate); Head
turned to one side
(towards the
nurse)
If the patient is
unconscious 10 – 15 20 – 30 Not more
centimeters Not more seconds than 5
than 10 – minutes
Place on one side 15
(facing the nurse); seconds
Tilt neck to move
head slightly
forward towards
the basin to avoid
aspiration during
suctioning
Nasopharyngeal 20 – 30 Not more
Suctioning seconds than 5
From tip of Not more minutes
the nose to tip than 10 –
If the patient is of the earlobe 15
conscious Neck should be seconds
hyperextended;
Fowler’s position
Flat on bed with
head turned to the
nurse
From tip of
the nose to
the tip of the Not more
earlobe Not more 20 – 30 than 5
If the patient is Lateral position than 10 – seconds minutes
unconscious may be 15
assumed seconds
TYPES OF SUCTIONING
45
If patient is Measure from Not more 20 – 30 Not more than
conscious mouth than 10 seconds 5
to mid- seconds minutes
sternum
Low to
semifowler’s
position
If the patient Measure from Not more 20 – 30 Not more than
is mouth than 10 seconds 5
to mid- seconds minutes
unconscious Flat on sternum
bed;
Suction
trachea
through the
mouth
Nasotracheal Low to From tip of Not more 20 – 30 Not more than
Suctioning semifowler’s the nose to than 10 seconds 5
position earlobe to seconds minutes
If the patient is dominating
conscious side
of
neck to the
thyroid
cartilage
46
Endotracheal Semi-Fowler’s 12.5 5 – 10 2–3 Not more
Tube if not centimeters or seconds minutes than 5
Suctioning contraindicated 6 inches; minutes
Insert as far
as it goes until
you meet
resistance
or until
patient coughs
Important Concepts!!!
For Endotracheal Suctioning
o NO TUBE IS USED HERE
o This is suctioning of the trachea through the mouth or through the nose
Two (2) types of Endotracheal Suctioning
47
o Orotracheal Suctioning: Oral approach
o Nasotracheal Suctioning: Nasal approach
General Conditions for Suctioning
For Endotracheal and Tracheostomy (Naso and Oral and Tube)
o Before suctioning, HYPEROXYGENATE the patient
o During intervals, HYPEROXYGENATE the patient
For ET, Tracheostomy, ET Tube
o Nursing Alert!
During insertion, if you encounter resistance, withdraw the catheter about one
centimeter (1 cm) before applying suction
o Rationale: To avoid trauma on the mucous membrane
Do suctioning intermittently
Suctioning should not be continuous
Rotate the catheter (between the thumb and the index finger) as you withdraw
Apply suction only when you are ready to withdraw (i.e. keep finger away from
suction port if you are still not ready)
VITAL SIGNS
TEMPERATURE
o Oral
Axillary
Rectal
Oral Method
Most convenient Most accessible
Nursing Alert!
o Applicability is for children aged six (6) years and above
o Not applicable for children below six (6) years old
Contraindicated in patients with:
o Oral surgery o Mouth breathers
o History of convulsive seizures
o Unconscious
48
o Incoherent
o Irrational
o Mentally disrupted
o Insane
Procedure o Nothing Per Orem for about thirty (30) minutes before taking temperature
o No food intake o No drinks o No smoking o No chewing gum o No whistling
o No gargling
Rationale:
o Any of the above would alter the result
Placement:
o Under the tongue, beside the frenulum (right or left)
Total Time:
o Two (2) to three (3) minutes
Axillary Method
Least realiable Safest method
Nursing Alert!
o During application, be sure that axilla is dry
o Dry using a patting motion Nursing Alert!
o Do NOT RUB!!!
Rationale:
o This increases heat due to friction
o Rubbing increases blood supply to the area
o Therefore, there will be increase in temperature reading
o Rubbing provides a false-positive elevation of temperature reading Duration:
o In adults – nine (9) minutes
o In children – five (5) minutes
Rectal Method
Most reliable (except for tympanic thermometer)
Most accurate (except for tympanic thermometer)
Concept!
o If tympanic method is used using a tympanic thermometer, the rectal method is
only second most reliable and second most accurate Disadvantage:
o Placement on a different site yields a different reading
o Therefore, ensure that the bulb of the rectal thermometer rests on the mucous
membrane
Contraindications:
o Hemorrhoids
o Rectal Surgery
o Certain Cardiac ailments due to stimulation of the vagus nerve;
valsalva maneuver leads to arrhythmias
Position of Patient when taking the reading:
o Sim’s left position
o Sim’s right position
o For Newborn, lift up ankles to keep buttocks up
o In Toddlers, set on prone position on adult’s lap
Duration: Two (2) minutes
Conversion of Centigrade to Fahrenheit
49
Centigrade = (5/9)F – 32
Centigrade = (F/1.8) – 32
Concepts!!!
Peak body temperature occurs at 12NN to 3PM or 4PM
Lowest body temperature occurs in the early morning hours of the day
FEVER
Normally, the hypothalamus is able to adjust body temperatures between 37°C to 40°C
But due to the presence of pyrogenic materials like the following:
o Pathogenic microorganisms
o Toxins o Foreign substances o Any substance capable of increasing body
temperature
Creates a deficiency of -3°C, making a person enter the FIRST STAGE OF FEVER
50
Also called Coarse Stage of Fever o Peak Stage of Fever
Key Concept!
o Patient does not feel hot or cold
o Skin is warm to touch
o Skin is flushed
o Fever blisters are present
Herpetic lesions o Absence of shivering o Possible dehydration
Important Concept!!!
o For every increase of temperature, there is a corresponding increase in pulse rate
Rationale:
o Increase in temperature results in an increase in pulse rate due to increased
metabolic rate
o Increased metabolic rate increases oxygen demand
o Due to increased oxygen demand of susceptible brain cells,
CONVULSIVE
SEIZURES may occur. These may also be due to irritation of nerve cells –
FEBRILE CONVULSIONS
Increased oxygen demand also leads to an increase in respiratory rate
Patient complains of:
o Loss of appetite
o Myalgia or muscle pains due to increased catabolism
Nursing Management
51
A fever that is alternated at regular intervals by periods of normal and subnormal
temperature
2. Remittent Fever
Fever alternated by wide range of fluctuations in temperature, all of them are ABOVE
NORMAL.
Duration is within a 24hour period
3. Relapsing Fever
Short periods of febrile episodes alternated by one (1) to two (2) days of normal
temperature
4. Constant Fever
Minimal fluctuations of temperature, all of which are ABOVE NORMAL
Concepts!
If pulse is regular, count or monitor pulse for thirty (30) seconds and multiply by
two (2). This is legal!
If pulse is irregular, count or monitor the pulse for one (1) FULL minute
BLOOD PRESURE
Systolic
Produced by ventricular contraction
Pressure on blood vessels during depolarization or ventricular contraction
Diastolic
Pressure that remains in the walls of the blood vessels during relaxation
or repolarization or resting
Broadly two (2) types:
52
Direct o By insertion of a catheter
Indirect Method o Auscultatory method o Palpatory method o Flush Method
Auscultatory Method
Uses Korotkoff sound o A popping sound o NOT the heart beat
o It is a phenomenon – an unknown phenomenon!
Concepts!!!
Take systolic on loudest sound if patient is an adult
If patient is pediatric or up to ten (10) years old, take the first sound, whether it is faint or
loud
If, for example, first sound is at 190 mmHg and there is silence up to 140 mmHg and then
there is a sound at 130 mmHg down to 80 mmHg then…
Use the PALPATORY
METHOD in combination with the AUSCULTATORY
METHOD because there is an auscultatory gap
Repeat using:
Auscultatory method
Palpatory method
Flush Method
53
Represents the mean blood pressure
Represents the average of the systolic and diastolic pressures
When done:
o When you have a BP
apparatus without a stethoscope
o Used for pediatric patients
How done:
o Inflate up to the point where extremity
becomes pale
o Deflate slowly and look for a REBOUND FLUSH – when extremity becomes red
again
This is the true reading!!
Note that there is only ONE reading!!!
SKIN INTEGRITY
Decubitus ulcers are caused by:
o Unrelieved, sustained pressure
o Localized ischemia o Shearing force o Pressure plus friction
Predisposing Factors: o Unconsciousness o Incontinence o Loss of Sensation o
Hypoproteinemia
Decreased lean muscle mass
Increase in fluid shifting leads to
edema
Dependent
position is the skin attached to or facing the bed o Emaciation
Stage 2
Partial Thickness Skin Loss
Involves epidermis and dermis
Manifestation o Blister formation o Shallow craters
o Shallow abrasion and ulceration
Stage 3
Full Thickness Skin Loss
Ulceration
There is skin loss already
Involves necrosis of the skin and subcutaneous tissues EXTENDING TO but NOT
THROUGH the underlying
54
fascia
Stage 4
Formations and manifestations of Stage 3 plus…
o Involvement of bones, supporting structures (tendons), joint capsules
o Massive damage
EDEMA
Caused by shifting of fluid into the interstitial tissues
Management of Edema
1. Elevation of the edematous part
Nursing Alert!
If edema is due to Congestive Heart Failure (Right Sided),
NEVER ELEVATE THE LOWER EXTREMITIES
Rationale:
This increases the workload of the right side of the heart
Concept!
If edema is due to prolonged standing, DO THE ELEVATION
2. Wear elastic stockings
Assessment of Edema
Induration
1+ - 1 cm induration
2+ - 2 cm induration
3+ - 3 cm induration 4+ - 4 cm induration
5+ - 5 cm induration
PAIN MANAGEMENT
Pain
55
A noxious stimulation of actual or threatened / potential tissue
damage
Pain Tolerance
Maximum amount of pain and duration that a person is willing to endure
Concepts!
At the dorsal horn of the spinal cord is a gate.
This gate is called the SUBSTANCIA GELATINOSA
A series of nerves pass through this gate
Small diameter nerve fibers pass through the substancia gelatinosa
o Pain signals are carried to the spinal cord by the small diameter nerve
fibers
56
Large diameter nerve fibers also pass through the substancia gelatinosa
o Large diameter nerve fibers close the gate – prevents the transmission of impulses
through the spinal cord
o Therefore, when LARGE DIAMETER NERVE FIBERS ARE
STIMULATED, THE GATE IS CLOSED
Pain management operates on the principle of how to stimulate the Large Diameter Nerve
Fibers to close the gate.
Pharmacologic Methods
Narcotics
NSAIDs
Adjuvants or Co-analgesics
Non-Pharmacologic Methods
Physical Interventions
Cognitive/ Behavioral Interventions
Non-Pharmacologic Physical Interventions
1. Cutaneous Stimulation
Massage
o Effleurage o Soft massage o Gentle stroking Petrissage
o Hard massage
Large and quick pinches
o Also done by striking
Application of Counter-Irritant o Bengay o Menthol o Omega Pain Killer o Flax Seeds o
Poultices
Heat and Cold Application o Nursing Alert!
o Rebound Phenomenon
When you apply heat (usually done for 20
minutes), vasodilation is produced
If heat is applied for more than 20
minutes, there is vasoconstriction
This is an inherent defense mechanism from burning of tissues
Cold Application o Maximum
vasoconstriction is reached when skin reaches 15°C
o If there is further drom in temperature, there is vasodilation (skin becomes reddish)
o This is the inherent defense mechanism from being frozen
Accupressure o Pressure on certain points of the body
o Stimulates release of endorphins, which have natural analgesic
effects
o This started in Ancient China
Accupuncture
o Insertion of long slender needles on certain chemical pathways
o Origin is also Ancient china
Contralateral Stimulation
o Example: Injury on left side and massage is done on the right side
57
Useful when patient cannot be accessed:
For patients in a cast
For patients with burns
For patients with phantom pain
2. Immobilization
Application of splints
4.Administration of a Placebo
Relieves pain because of its intent and not because of physical or chemical
properties
4.Guided Imagery
Imagine that you are walking along a peaceful shore
Eyes are closed and suggestions are given
5.Hypnosis
The success of hypnosis depends on the ability of the patient to concentrate and the
capacity of the hypnotist to suggest
Based on suggestion
58
Progressive relaxation
URINARY ELIMINATION
Oliguria
Renal output of less than 500 ml per day
Anuria
Renal output of less than 100 ml per day
Retention
Positive for distended bladder
May also occur in the absence of bladder distention
Enuresis
Common among pediatric patients
Age 4 – 5 years old child has adequate bladder control
Primary Enuresis o Never had a dry period
Secondary Enuresis o Acquired enuresis
o At age 7, bladder control is present for at least one year
o Then, enuresis comes back
o Urinating could NOT be controlled again
Incontinence
Involuntary passage of urine
Types of Incontinence
1.Functional Incontinence
Involuntary passage
Unpredictable time
2.Reflex Incontinence
Occurs at somewhat predictable times when specific bladder volume is reached
No awareness of bladder filling
No urge to void
It may be related to neurologic impairment
3.Stress Incontinence
Loss of urine is less than 50 ml occurring with increased intra-abdominal pressure o Occurs
when laughing o Occurs when sneezing o Occurs when smiling
4. Total Incontinence
Continuous flow of urine
No bladder distention
59
No bladder spasm
No awareness of bladder filling
5. Urge Incontinence
Urine flows as soon as a strong sense of feeling to void occurs
Strong bladder spasm
Management of Incontinence
1.Kegel’s Exercises
Also called:
o Pubococcygeal Muscle Exercises
o Pelvic Floor Muscle Exercises
Applicable for:
o Functional Incontinence
o Stress Incontinence
How done:
o Advise patient to stand with legs slightly apart
o Concentrate on perineum
o Draw perineum upward slowly
Alternative way:
o When urinating, try to stop in the middle of flow or try to stop diarrhea from flowing
o Advantage of Kegel’s Exercises o Increases muscle tone of the pelvis
o Increases muscle control
60
MIDSTREAM CLEAN CATCH
URINE SPECIMEN
How is this done?
If patient is a MalE, Clean the penis
o Do this from the meatus down to the shaft
o Let the patient urinate
o Discard the first or the initial urine
o Collect midstream urine o Purpose is to attain sterile specimen for urine culture
and sensitivity testing
If patient is a Female…
o Let patient wash genitals
o Dry the genitals o Get to bed
Place patient in semi-Fowler’s position when she is ready to void
Clean and spread labia with two fingers
Remain holding labia
Then let patient urinate
Let go of first flow
Collect next flow
CATHETERIZATION
Concepts!!!
See to it that penis is perpendicular to body to straighten up the urethra to bladder
While inserting the catheter, ask the patient to breathe through the mouth
Cleanse the penis before insertion
Grasp penis firmly to avoid stimulating erections
Where to tape catheter? Tape it upward on the abdomen
Rationale:
o To avoid scrotal excoriation
o Tape on the inner thigh (with penis sideways either on left or right and follow the
normal contour of the penis
Length of Catheter -40 centimeters
Depth of Insertion
o While inserting, the point at which urine starts to flow, insert further by five (5)
centimeters and then inflate the balloon –
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o Insert up to a the Y point, retract after inflating (this method is more prone
to infection
For females
o Insert at female Urethra
o Length of Catheter - 22 centimeters
o Depth of Insertion - Point at which urine starts to flow, insert further by five
(5) centimeter before inflating balloon
Wellness Teachings
Fluid intake of at least 2,000 ml per day
Regular exercise
High fiber diet
Avoid ignoring the urge to defecate
Do not abuse laxatives
Concepts!
For Flatulence
o Avoid carbonated drinks
o Do not use straw
o Avoid chewing gum
o Avoid gas-forming foods:
Camote, Cabbage,Cauliflower, Onions
For Constipation:
Increase fluid intake
Prune juice
Papaya
Increase fiber in the diet
Use METAMUCIL (natural fiber) instead of laxatives
1.Guiac Test
To determine the presence of occult blood
Concepts!!!
o Have a meat-less diet three (3) days before examination
o Withhold oral iron supplements
o Injectible iron is allowed
o Avoid any food that discolors the stool.
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o To offset the risk of constipation
o Inform patient that the color of the stool will be WHITE
Lower GI Series – Barium Enema
Done at the radiology department
Nursing Concern:
o Elimination of Barium
How:
o Cleansing enema may be needed after barium enema
1. Cleansing Enema
Soap suds enema Alkaline solution
Nursing Alert!
o Contraindicated in patients with liver cirrhosis and with increased ammonia in the
blood
o Rationale:
• Alkaline solution facilitates transfer of ammonia from the GI tract to the
bloodstream, Therefore, use lemon juice or dilute vinegar instead!!!
Nursing Alert!
o Also contraindicated in possible appendicitis or appendicitis patients
Rationale:
o Can lead to rupture of he appendix
2. Carminative Enema
Used to expel out flatus
Burned sugar
Now commercially available
Positions in Enema
Cleansing Enema
High Cleansing Enema o Clean as much of the colon as possible
o On introduction, Sim’s Left position facilitates flow of enema to sigmoid
colon
o Then, assume Dorsal Recumbent position to facilitate flow of enema to transverse
colon
o Then, Right Side-Lying position to facilitate flow of enema to the descending colon
Low Cleansing Enema o For cleaning of rectum and colon only
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