TABLE OF CONTENTS

Fundamental in Nursing Practice

Fundamentals in Nursing Practice Q&A
Nutrition

Nursing Research
Bioethics in Nursing Practice
Communicable Disease Nursing
Table on Hepatitis
Table on Helminthes
Community Health Nursing
Precede-Proceed
Sustainable Development Goals (2016 Update)
Leadership & Management
Maternal & Child Nursing
Pediatrics
Obstetrics & Gynecology
Nursing Pharmacology
Mental Health & Psychiatric Nursing
Perioperative Nursing
Medical Surgical Nursing
MS 1 Board Reviewer
MS 2 Board Reviewer
MS 3 Board Reviewer

DISCLAIMER

Greetings in the name of St. Thomas!
Congratulations for reaching this far fellow Thomasian! You are in the
next phase of your professional life as a Thomasian Nurse.

Take note that all of the information compiled in this module is the
intellectual property of the University of Santo Tomas – College of
Nursing. The aim of this module is solely to share the knowledge that
our dear mentors have thought us. This is in hopes of keeping the
standards of excellence that the college bestowed on us. So please,
share this responsibly.

CREATED BY THOMASIANS FOR THOMASIANS.

FJCP 2017


α USER: ______________________
#SLAYPNLE

X O X O, F J C P
 FUNDAMENTALS OF NURSING PRACTICE

‘NUTRIX’: Nurturing NURSING THEORIES & MODELS

- Nursing in all these concepts: ENVIRONMENTAL MODEL
1. Art/ Science - FLORENCE NIGHTINGALE: (May 12 1820 –
2. Total Patient August 13 1910): Also named what Nursing is..
3. Environment - Act of utilizing the environment of the patient to
4. Individual, Family, Community assist him in his recovery.
- Environmental sanitation
- 4 MAJOR PARADIGMS/ CONCEPTS: Man,
Health, Environment & Nursing PSYCHODYNAMIC NURSING
- Hildegard Peplau (1909-1999)
CONCEPTS OF MAN - INTERPERSONAL RELATIONS IN NURSING
- Man is a bio-psychosocial and spiritual being who is - 4 PHASES
in constant contact with the environment. 1. Orientation
- Man is an open system in constant interaction with a 2. Identification
changing environment. 3. Exploitation
- Man is a unified whole composed of parts, which are 4. Resolution
interdependent and interrelated with each other. - Nursing: Interpersonal and therapeutic process
- Man is composed of parts, which are greater than and
different from the sum of all his parts. 14 FUNDAMENTAL NEEDS
• Simply saying, you cannot remove 1 system from - Virginia Henderson (1897-1996)
man.
- Man is composed of subsystems and suprasystems. TYPOLOGY OF THE 21 NURSING PROBLEMS
• Subsystem (within) Example: biological, - Faye Abdellah (March 31, 1919-)
psychological, emotional. - Patient-centered approach: the client’s needs are the
• Suprasystem (outside) Example: Family, basis of the nursing problems
community, population
• An integration of the physical or physiological, THE CORE CARE CURE
emotional, social, cultural and spiritual. - Lydia Hall (1926-1969)
• ABRAHAM MASLOW (Hierarchy of Needs, 1. Core (therapeutic use of self) – Patient
walang kamatayan arghh…; Last level or 6th level 2. Care (nursing function) – Nurse
is TRANSCENDENCE); Could be rearranged by 3. Cure (medical) – Doctor
your needs ex. Food Vs. Needing to study; O2 after
3-5 minutes, irreversible brain damage HUMAN CARING THEORY
- Jean Watson (1940)
CONCEPTS OF NURSING - 10 Clinical Carital Processes
1. ANA (AMERICAN NURSES ASSOCIATION): - Caring is an innate characteristic of every nurse.
Nursing is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury, INTERPERSONAL/ DYNAMIC
alleviation of suffering through the diagnosis and - Ida Jean Orlando (August 23, 1926)
advocacy in the care of individuals, families,
communities, and populations (2003). TRANSCULTURAL NURSING
2. ABRAHAM MASLOW’S HIERARCHY OF NEEDS Madeleine Leigninger
- Self-actualization
- Self-esteem 4 PRINCIPLES OF CONSERVATION
- Love and belongingness Myra Levin
- Safety and Security – 4 Principles of Conservation
• Being free from harm or danger 1. Conservation of energy
• 2 FORMS: Physical safety (free from physical 2. Conservation of structural integrity of the body
harm) and Psychological safety (explaining the 3. Conservation of personal integrity
procedure to the patient) 4. Conservation of social integrity
- Physiologic (priority)
ADAPTATION MODEL
• If all the needs are within the physiologic level
- Sister Callista Roy (1939-)
• HIGH PRIORITY NEEDS – (life threatening
- Theoretical system of knowledge that prescribes a
needs) Airway, Breathing, Circulation
process of analysis and action related to the care of
• MEDIUM PRIORITY NEEDS – (Health
the ill person.
threatening needs) Elimination, Nutrition, Comfort,
- Individuals cope through biophysical social
• LOW PRIORITY NEEDS – (Person’s adaptation
developmental needs)
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 FUNDAMENTALS OF NURSING PRACTICE

- 4 MODES: • Emphasizes how individual choose and bear

• PHYSIOLOGICAL responsibility for patters of personal health
• SELF-CONCEPT • Spec:
• INTERDEPENDENCE • Illuminating, synchronizing, mobilizing

SELF CARE MODEL NOVICE TO EXPERT THEORY

- Dorothea Orem (1914-2007) - Patricia Benner
- Universal self-care requirement (nutrition, - Skills acquisition
oxygenation), developmental self-care requirement - STAGES:
(developmental tasks), health care deviation self-care • STAGE 1: Novice
requirement • STAGE 2: Advanced Beginner
- Health deviation mediation care development • STAGE 3: Competent
- Helping or assisting service to persons who are • STAGE 4: Proficient
wholly or • STAGE 5: The Expert
- partly dependent, when they, their parents and
guardians, or other adults responsible for their care HUMAN TO HUMAN RELATIONSHIP MODEL
are no longer able to give or supervise their care. - Joyce Travelbee (1926-1973)
- LEVELS: Wholly, partial compensatory, supportive
educative CLINICAL NURSING: AS A CLINICAL ART
- Ernestine Weidenbach (1900-1998)
7 SUBSYSTEMS OF MAN’S BEHEVAIORAL SYSTEMS
- Dorothy Johnsons (1919-1990) HEALTH PROMOTION MODEL
- Man is composed of subsystems and these systems - Nola Pender
exist in dynamic stability.
FILIPINO CONCEPTUAL MODELS IN NURSING
MAN AS A UNITARY BEING PREPARE ME Intervention
- Martha Rogers (1914-1994) - CHAIRWOMAN OF THE BON: Carmencita M.
- Nursing is a humanistic science dedicated to the Abaquin
compassionate concern with maintaining and - To improve use PREPARE ME:
promoting health and preventing illness and caring • Presence: therapeutic communication and touch
for and rehabilitating the sick and disabled. • Be there: reminiscence: good memories from
- Unitary man is an energy field in constant interaction the past; a therapy
with the environment.
• Prayer: Religion
- Levels of prevention
• Relaxation
• PRIMARY: Health promotion and disease
• Meditation
prevention
• SECONDARY: Treatment, curative 5 Cs: TRANSFORMATIVE LEADERSHIP BEHAVIOR;
• TERTIARY: Rehabilitation THE CASAGRA TRANSFOR MATIVE LEADERSHIP
BEHAVIOR
GOAL ATTAINMENT THEORY OF NURSING - Sister Carol S. Agravante
- Imogene King (1923-2007) 1. Creativeness
- Interacting systems framework 2. Caring attitude
- Nurses purposefully interact with the patient and 3. Critical Thinking
mutually set the goal, explore, and agree to means to 4. Contemplative
achieve the goals. 5. Collegial
TOTAL PERSON MODEL FOR NURSING ADVANCE NURSE PRACTICIONERS’ COMPOSURE
- Betty Neuman (1924-) BEHAVIOR AND PATEINT’S WELLNESS OUTCOME
- 3 types of stressors: intra-personal, extra personal, - Carmelita Devina Gracia
interpersonal - COMPONENTS:
- Primary, secondary & tertiary Levels of Prevention • COMpetence
(used the levels in her theory but not created) • Presence and Prayer
- The goal of nursing is to assist individual families
• Open-mindedness
and groups in attaining and maintaining a maximal
• Stimulation
level of total wellness by purposeful interventions.
• Understanding
THEORY OF HUMAN BECOMING • Respect
- Parse • Relaxation

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 FUNDAMENTALS OF NURSING PRACTICE
• Empathy
CONCEPTUAL MODEL ON CORE COMPETENCY
DEVELOPMENT
- Milia Delia M. Llanes
THE EFEECTS OF ENHANCING SELD-ESTEEM
ENHANCING (NurSe) PROGRAM TO THE SELF
ESTEEM OF FILIPINO ABUSED WOMEN
- Ma. Irma C. Bustamante
RETIREMENT AND ROLE DISCONTINUITY
- Letty Kua
*St. Elizabeth of Hungary: Patroness of nurses
*St. Catherine of Siena: The 1st lady with the lamp
*Clara Barton: Founder of American Red Cross
*Fabiola: Wealthy Matron who donated her wealth to build a
hospital the Christian world
*T. Fliedner: Founder of the first organized school of nursing
*Rose Nicolet: Helped establish the first school of nursing in
the Philippines
*Lilian Wald: Founder of Public Health Nursing
HISTORICAL DEVELOPMENT OF NURSING
1. INTUITIVE NURSING: or the sake of doing good;
all in instinct; for compassion: mostly Women; Evil
spirits invade the human body; Charms, dances;
Medicine men: Shamans to drive the spirits away;
TREPHINING: to drill into the skull without
anesthesia;
2. APPRENTICE: Volunteer nursing through
experience of elder nurses; The elder nurse knew
what they knew due to trial and error; War;
Volunteers came from religious orders; greater
demand than supply due to the WW1; Some
volunteers were poor people but they used bribes for
healing; DARK PERIOD OF NURSING: death in the
area, no sanitation and air; SAIREY GAMP,
BETSY PROG (Titles of the nurses before, since
they used alcohol to deter pain); DECONESS
SCHOOL OF NURSING (instituted by the T.
Fliedner; Found at KAISSERWERTH; Education at
6 MONTHS);
*Trephining: boring a hole into a skull without anesthesia to
release evil spirits
*Egyptians: art of embalming, anatomy and physiology
*Moses: Father of Sanitation, asepsis, art of circumcision
*China: material medica – book of pharmacology
*Babylonians: Bill of Rights, Code of Hammurabi (made by
King Hammurabi which include freedom to refuse treatment),
medical fee
*India: Shushurutu: list of function of the nurse –
combination of masseur, caregiver
*Romans: Fabiola – a rich matron who contributed her home
to serve as first hospital
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 3
3. EDUCATED NURSING:
FLORENCE NIGHTINGALE
- FIRST NURSE THEORIST
- Mother of modern nursing and nursing research
- Lady with a lamp
- CRIMEAN WAR: the royalty, the queen, 4500
pounds was given by her; SUPERINTENDENT:
given title by the royal office;
- She developed her own nursing education: THE
NURSING EDUCATION SYSTEM: correlation
theory to practice, self supporting school for nursing
(the school and the hospital were one since it was the
practice where apprentice learn), a place of nurses in
the hospital (THE NURSE STATION), a decent
quarter for nurses, Nurse educations
- 1860: ST THOMAS HOSPITAL NURSING
SCHOOL
- changed the image of nursing
- TWO BOOKS:
1. NOTES ON NURSING: what it is what it is
not.
2. NOTES ON HOSPITAL
- She did not believe that microorganisms could be
removed; Believed in MEDICAL ASEPSIS not in
SURGICAL ASEPSIS; Since curing for her is simply
manipulating the environment
- No standardization of nursing practice: this will
curtail the development of nursing; she prompted the
thought of giving the students options
4. COMTEMPORARY NURSING: the healthy and
the sick; preventive and promotion of health
HISTORY OF NURSING IN HE PHILIPPINES
1. PRE COLONIAL: Herbelaryo
2. SPANISH: Education and Catholicism; Built the first
hospital: 1577 HOSPITAL REAL DE MANILA –
Francisco Salve (Creator; used government funding;
for the Spanish regime); 1578 SAN LAZARO
HOSPITAL the oldest existing hospital (meant for
mental and leprosy cases); 1906 ILO ILO MISSION
HOSPITAL SCHOOL OF NURSING (6 mos.
training), the first nursing school; 1879 – ESCUELA
DE PRACTECANDES (A 6 month nursing course
at UST; however not the first due to lack of
evidence); 1907 PGH, ST PAUL HOPSPITAL, ST
LUKES, MARY JOHNSTON [SCHOOL OF
NURSING] (all except the MJH, they used the same
curriculum and use the NORMAL HALL at the
Philippine Normal University; USING the
CENTRAL SCHOOL IDEA by fusing all these
school since they were only 15 students at most); GN
Graduate Nursing Course
3. AFTER WWII:
4. 1920 first Board Examination
*1959 ACT 2493 – The first law that affected the Nursing
practice but it was a medical law; Medical Act 7&8 - for you
 FUNDAMENTALS OF NURSING PRACTICE
to practice in the Philippines must have a license certificate
must be given
*1919 ACT 2808- The First True Nursing Law; Considered
because it is exclusively for nurses;
5. BEN Board of Examiners for Nurses (then became
BON): A doctor was the commissioner: Juan
Cabarus and 2 nurses: Anastacia Geron Tupas
6. Anna Dohlgen: First nursing Top Notcher
7. February 8, 1946: UST offered the First BSN
Curriculum (4 year program)
*1953 RA 877 – BEN with academic qualification of A BSN
DEGREE HOLDER with 5 years nursing practice; the GN had
4 years then the BSN had 5 years
- 1966 RA 4704 (increase the BED from 3 to 5; BEN
must be Master’s Degree Holder)
- RA 6136 (IV push and insertion, only if supervised
by doctors)– amended the RA 877 [this was still in
act until 1992, the nurse only prepared and primed
and the Doctors gave the medication]; There are
principles that were stepped on: AUTONOMY &
DRUG ADMIN (who prepared the medication,
he/she will give it)
1976 – GN program was discontinued; BSN was made
into a 4 year program (MARCOS proposed and enacted
this); The RNs before that were not BSN must take the 4
year of the curriculum for them to work as RN, even if
they took the board exam.
1980 – overlap of the BSN 4 year and 5 year program
(There was NO surplus of Nurses in the Philippines)
*1991 RA 7162: IV Training fro ANSAP (Association of
Nursing Services and Administration of the Philippines);
SUPERCEDED other Nursing Laws
*RA 9173: repealed RA 7162 (just edited some sections)
CONCEPTS OF HEALTH
- WHO: Defined as the merely the absence or presence
of disease or infirmity. WHO defined health as a state
of complete physical, mental, and social well-being
and not just merely the absence of disease or
infirmity.
- HEALTH MODELS:
1. CLINICAL MODEL OF HEALTHL: JUDITH
SMITH: The absence of signs and symptoms of a
disease; Narrow
2. ROLE PERFORMACE: Able to perform jobs
3. ADAPTIVE MODEL:
4. EUDAEMONISTIC MODEL: Self Actualization;
Individual is able to achieve the apex of Maslow’s
Hierarchy of needs (self-actualization); Maximization
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 4
of potential and mission in life: Fulfillment of his
purpose in life
5. ECOLOGICAL MODEL OF HEALTH: Leavell
Clark; Agent, Host and Environment
(Epidemiological Triangle or Triad refers to the
triangle not the model); Must be in balance
6. MULTIPLE CAUSATION THEORY: Cannot
trace the true cause of the disease
7. ROSENSTOCK-BECKER: HEALTH BELIEF
MODEL: Health belief motivates and your actions to
health; Individual perception affect modifying factors
which may influence likelihood of action
8. TRAVIS ILLNESS WELLNESS CONTINUUM:
High-level wellness or Pre-Mature Death; Health is
in a spectrum which moves into polarity of
directions; Premature of death à Disability/Disease
à Symptoms à Signs à Awareness à Education
à Growth à High level wellness
9. HUBERT DUNN HIGH-LEVEL WELLNESS
GRID: Peak wellness or Death [HEALTH AXIS] &
Very favorable Environment or Very unfavorable
environment [ENVIRONMENTAL AXIS];
10. SCHUMANN’S STAGES OF ILLNESS
BEHAVIORS
10.1 Symptom experience
10.2 Assumption of sick role
10.3 Medical care contact
10.4 Dependent client role
10.5 Convalescence/ Rehabilitation
CONCEPTS OF ILLNESS
* ANTOMYM OF HEALTH IS ILLNESS
1. DISEASE: for physical; for problems of Anatomy &
Physiology; Malfunctioning of the body system
2. ILLNESS: all other holistic problems (emotional and
other aspects); It is a state wherein the person’s
physical, emotional, and social well-being is thought
to be diminishing. Felt by the patient. It is highly
SUBJECTIVE.
2.1 SUCHMANN’s Stages if Illness Behavior
2.1.1 SYMPTOM EXPERIENCE (You
recognize the symptoms or you don’t)
2.1.2 ASSUMPTION OF THE SICK
ROLE
2.1.3 MEDICAL CARE CONTACT
2.1.4 DEPENDENT CLIENT ROLE
2.1.5 CONVALESCENT/
REHABILITATION
2.2 TYPES
2.2.1 ACUTE: Sudden onset, short duration,
may or may not require immediate
intervention.
2.2.2 CHRONIC: Gradual/slow onset, long
duration, lessen complications or
debilitating effects of the condition for
the client to be able to function given
the limitations of the condition.
 FUNDAMENTALS OF NURSING PRACTICE

3. WELLNESS: OBJECTIVE, Can be seen or 2. EMOTIONAL/ PSYCHOLOGICAL: EGO

measurable; This can be Physical Wellness with DEFENSE MECHANISMS
parameters to check; 3. SOCIO-CULTURAL
4. WELLBEING: SUBJECTIVE, Feeling of harmony 4. TECHNOLOGICAL
and vitality 5. SPIRITUAL
5. REMISSION AND EXACERBATION - HOMEOSTASIS: The internal balance; Walter B.
Canon
6. STAGES OF HEALTH BEAHAVIOR CHANGE
6.1 Pre-contemplation Phase - PRINCIPLES OF HOMEOSTATIC
6.2 Contemplation Phase MECHANISMS
6.3 Preparation Phase • Automatic, self-regulatory
6.4 Action Phase • Compensatory
6.5 Maintenance Phase • Negative feedback, except for uterine contraction
6.6 Termination Phase during labor
• Has limits
*Health should be seen as a means not as a state • One physiologic error is corrected by several
homeostatic mechanisms
STRESS
1. STIMULUS BASED MODEL OF STRESS STRESS REPONSE
(SELYE): life went or life change; Non-specific 1. SPIRITUAL RESPONSE
response of the body to any demand made upon it 2. EMOTIONAL RESPONSE: Mild, Moderate & Severe
2. TRANSACTION BASED: Cognitive process, 3. PHYSICAL OR PHYSIOLOGICAL RESPONSE
psychological changes HANS SELYE:
3. RESPONSE BASED MODEL: Physiological 3.1 GENERAL ADAPTATION SYNDROME
changes 3.1.1 ALARM: Awareness of stressor; React; Fight
or Flight from reaction; Vital Sign increase;
*ADAPTATION MODEL: was removed in the latest edition Mobilization of Defenses; increased Hormonal
of KOZIER since anxiety provoking, which was its definition, level; If Failure, Decreased Body resistance
was too vague.
ALARM RESPONSE:
*CRISIS: it is not only psychological but also a physiological 3.1.1.1 SYMPATHOADRENO-MEDULLARY
such as SHOCK; Defenses are working unfavorably; RESPONSE
spontaneous resolution is 6 weeks; grieving process: 4 years - SNS & Adrenal Medulla (EPI & NOR EPI): Increase
in physiological activities [Improve VISUAL
*STRESS: is part of life and normal response PERCEPTION, Increased CO, Increased brain
- TYPES OF STRESS: perfusion, Increased VS, Bronchodilation for better
1. EUTSRESS: Needed stress breathing; decreased Peristalsis, decreased motility or
2. DISTRESS: constipation or Tympanism, Decreased Renal
- TYPES OF CRISIS: perfusion, RAAS system, Decreased urine output,
1. SITUATIONAL: Acts of God or accidental GLYCOGENOLYSIS (Breakdown of
2. MATURATIONAL: Changes in the body or in carbohydrates for energy), Anterior pituitary/
life events Adenohypophysis: ACTH - Cortisol and
Aldosterone: Sodium resorption causing oliguria
ADAPTATION: changes in you and yet you remain the same with increased blood volume, these will sustain the
with the stresses of the environment energy of the body; CATABOLISM/
GLUCONEOGENOLYSIS: breakdown of other
*MALADAPTIVE: Disease; When abused; (fat and protein) sources of food or energy]

3.1.1.2 NEUROHYPOPHYSEAL RESPONSE/

- MODES OF ADAPTATION: PITUITARY:
1. BIOLOGICAL/ PHYSIOLOGICAL: - Posterior Pituitary Gland: Sodium reabsorption with
HOMEOSTATIC MECHANISMS decreased urine output and increased blood volume
1.1 Self regulatory with increased BP & OXYTOCIN: menstruation will
1.2 Compensatory in Nature (Overcoming the decrease and this also plays a role in ejaculation
needs) 3.2.1 RESISTANACE: Repel of the stressor,
1.3 Negative Feedback Normalization of the VS and body resistance
1.4 Positive Feedback: ONLY UTERINE back to Normal; If failure
CONTRACTION

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 FUNDAMENTALS OF NURSING PRACTICE

3.2.2 EXHAUSTION: decreased energy, failure surgically created wound; this can be done with
of feedback, decreased physiological stitches, staples, etc.
functions, organ or tissue damage, 2. SECONDARY INTENTION: Wound edges are not
Exaggerated manifestation of illnesses well approximated, moderate to extensive tissue
damage and edges can’t be brought together i.e.
3.2 LOCAL ADAPTATION SYNDROME: Decubitus ulcer
3.2.1 INFLAMMATORY PHASE: 3. TERTIARY INTENTION: “Delated primary
3.2.1.1 VASCULAR: intention”, suturing or closing of the wound is
- Vasoconstriction: contain the area of damage; delayed i.e. due to poor circulation in the area
Chemical mediators: Kinins; Cellular activity
increases with WBCs; Increased warmth; then NURSING PROCESS (ADPIE)
vasoconstriction; Increase blood supply WARMTH - Use the nursing process to deliver Quality patient care
(CALOR), REDNESS (RUBOR), increase capillary - PATIENT ORIENTED
Permeability; SWELLING (TUMOR); PAIN - There can be overlapping: CYCLING PROCESS
(DOLOR); Temporary Loss of function (FUNCTIO
LAESA) 1. ASSESSMENT
1.1 DATA COLLECTION:
3.2.1.1.2 Prostaglandin 1.1.1 Objective/ Overt/ Sign/ Cue
3.2.1.1.3 Bradykinin 1.1.2 Subjective/ Covert/ Symptoms/ Clue
1.1.3 Sources of Data: Primary or Secondary
3.2.1.2 CELLULAR PHASE 1.1.4 Methods of Collecting Data: Interview;
3.2.1.2.1 Movement of WBC/ Chemotaxis: History Taking (Medical or Nursing =
1. MARGINATION/ PAVEMENTATION Health History); Observation; Physical
2. DIAPEDESIS exam (IPPA)
3. EMIGRATION 1.2 Data Analysis or Validation/ interpretation/ Data
synthesis
*NEUTROPHILS: first to appear 1.3 Therapeutic and non-communication Health history
*EOSINOPHIL 1.3.1 MEDICAL HISTORY: disease focused
*BASOPHIL: Histamine (physiological)
*MACROPHAGE: can ingest large amount of infectious 1.3.2 NURSING HISTORY: needs, psychosocial
agents but not as motile as neutrophils dimension, Spiritual aspects
*Not all inflammation is caused by infection 1.4 PERSONAL SPACE
*Not all forms of injury through inflammation: An example is 1.4.1 INTIMATE SPACE: 1 1⁄2 foot
Cancer 1.4.2 PERSONAL SPACE: 1 1⁄2 - 4 feet
1.4.3 SOCIAL SPACE: 4 –12 feet
3.2.1.3 EXUDATIVE PHASE 1.4.4 PUBLIC SPACE: 12–15 feet
3.2.1.3.1 Types of Exudate 1.5 Observation: Use of senses to gather data; Clinical
1. Serous: PLASMA eye – comes with practice and experience
2. Sanguineous: BLOOD
3. Purulent: PUS 2. DIAGNOSIS
4. Catarrhal: MUCIN
5. Fibrinous: FIBRIN FIBERS *COMPOSITION: Problem + etiology +defining symptoms
*Guided by the NANDA
3.2.1.4
REPARATIVE: Phagocytosis: ingestion
of foreign substances Macrophages à 2.1 PRIORITIZATION:
Monocytes; Chemotaxis – movement of 2.1.1 AIRWAY, BREATHING,
substances to a chemical signal CIRCULATION
1. Primary 2.1.2 ELECTROLYTE
2. Secondary 2.1.3 NUTRITION
3. Tertiary 2.1.4 ELIMINATION
TO DETER STRESS 2.2 TYPES:
1. BENSON RELAXATION TECHNIQUE 2.2.1 ACTUAL: what you see
2. RECREATIONAL 2.2.2 RISK: the problem is yet to occur
3. MASSAGE 2.2.3 WELLNESS: No problems but for a
4. MUSIC THERAPY higher level of functioning
2.2.4 SYNDROME: these are cluster of nursing
TYPES OF WOUND HEALING diagnosis; e.g. RAPE TRAUMA
1. PRIMARY INTENTION: Wound edges are well SYNDROME
approximated (closed), minimal tissue damage i.e.
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 FUNDAMENTALS OF NURSING PRACTICE

2.2.5 POSSIBLE – vague/ unclear – 2.1 DATABASE: all the initial information of
possible/probable the patient; baseline data.
2.2 PROBLEM LIST: A list of problems
*PROBABLE: cannot be seen in newest version of KOZIER; identifies.
unclear and vague 2.3 PLAN OF CARE: All the management that
has been prepared for the patient; Includes
*Knowledge deficit: kulang sa kaisipan both the medical and nursing management;
*Knowledge deficiency: kulang sa kaalaman (preferred) NURSING ORDERS;
*Self-care deficit: acceptable 2.4 PROGRESS NOTES: (1) narrative notes
(observation, care given to the patient and
3. PLANNING: SMART; SHORT & LONG TERM; evaluation; FDAR; before was SOAPIE), (2)
Planning into writing is called a care pan flow sheet (monitor in a specific amount of
3.1 Classify as dependent, interdependent, and time) and (3) discharge notes (health
collaborative instructions; METHODS)
2.5 COMPUTER ASSISSTED RECORDING
4. IMPLEMENTATION 2.6 FLOW CHART: pre-structured assessment
4.1 STEPS parameters
4.1.1 REASSESS 2.7 CHARTING BY EXCEPTION: chart only
4.1.2 Assess if needing Assistance: (1) Patient important or changes in the patient’s health;
may be heavy, (2) still novice needing NO NEED TO CHART STATUS QUO (no
guidance, (3) If the nurse is knowledgeable change in the patient’s condition)
regarding the procedure (4) Check if 2.8 CASE MANAGEMENT THROUGH
effective CLINICAL PATHWAY: done with a
4.1.3 PROCESS OF IMPLEMENTING: particular algorithm, with a checklist
Reassess client à Determine nurses’ needs checking through variance per day so you
for assistance à Implementing nursing may be able to know the how many days the
interventions à Supervising the delegated patient will be staying.
care à Documenting nursing activities
STAT: now OU: both
5. EVALUATION: check if probable problem is still Adlib: as desired AD: right ear
available. PRN: as required AS: left ear
5.1 PROCESSES OF EVALUATION: To determine OD: right eye/once a day AU: both ears
the: OS: left eye Ss: half
5.1.1 Client’s progress or lack of progress ERROR: draw a straight line, signature, initials
5.1.2 Overall quality of care provided
5.1.3 Promote nursing accountability POSITIONING
5.2 Guidelines for evaluation 1. Fowler’s: sitting for chest expansion and upper
5.2.1 Systemic process extremities
5.2.2 On-going basis 2. Supine/ Back Lying/ Dorsal/ Horizontal
5.2.3 Revision of the plan of care when needed Recumbent
5.2.4 Involve the client, significant others, and 3. FLAT ON BED: meaning that they cannot place
other members of the health team pillows
5.2.5 Must be documented 4. Dorsal Recumbent: for abdomen
- Emergency Assessment 5. Erect/ Standing: Contour or Curvature of the
- Ongoing Assessment Spine
6. Sim’s/ Side Lying/ Lateral: Anal exam at the left:
*Process: Nurse sigmoid colon; For easier insertion of fingers for
*Structure: System DRE, enema and suppository.
*Outcome: Patient 7. Knee Chest Position/ Genupectoral: also used for
Rectal Exam; for inverted uterus inspection
8. Dorsal Lithotomy: NEEDS STIRRUPS for Pelvic
DOCUMENTATION / CHARTING Exam; IE
- PRIMARY PURPOSE: for Communication 9. Trendelenburg: head lower than the body
- KINDS: 10. Reverse Trendelenburg
1. SOURCE ORIENTED RECORDING: Each 11. Modified Trendelenburg: The Legs are only
department or healthcare profession has a section elevated and the body and head are the same; This
in the chart is done for SHOCK positioning since they also
2. PROBLEM ORIENTED RECORDING: have increased ICP.

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 FUNDAMENTALS OF NURSING PRACTICE

12. KRAASKE Position: Proctosigmoidoscopy; 2. PALPATION (Touch)

Similar to knee chest however much more - Edema (leaves with a mark: Pitting; Ascites:
exaggerated with a device in the middle to Abdomen; Anasarca: generalize edema; pedal
facilitate position. Edema; Periorbital Edema; GRADING: 1234 on
2,4,8,12 cm); IE; DRE; Chest expansion; Tactile
PROTECTIVE POSITIONING Fremitus
- To prevent respiratory and MSK injuries 2.1 Finger tips: Tactile discrimination
- With immobility problems 2.2 Dorsum: temperature
2.3 Heeves (edges of the hands): vibratory signs
PHYSICAL EXAM (PLAN ORDER)
1. INSPECTION *TRAINING FOR IE: MCNAP, without antenatal bleeding
2. PALPATION
3. PERCUSION 3. PERCUSSION
4. AUSCULTATION 3.1 Indirect Palpation
- PRIVACY 3.1.1 Flexor: Hitting
- Symmetrical check 3.1.2 Pleximeter: Receiving
- Use all sense even common sense 3.2 Added instruments
3.2.1 Audiometry: machine for hearing
*ABDOMEN: Inspection, Auscultation, Percussion and acuity (Pure tone Audiometry and
Palpation (Alters bowel sounds; comfortable to least Voice)
comfortable) 3.2.2 Rinne’s Test: On the mastoid test;
Conduction
*Incident report or variance Report 3.2.3 Weber’s test: Lateralization
3.2.4 Schwabach test: to determine hearing
PHYSICAL EXAM TECHNIQUES acuity; Place the tuning fork on the
1. INSPECTION: examiner’s ear
1.1 General Appearance 3.3 SOUNDS:
1.1.1 Lordosis, Kyphosis and Scoliosis 3.3.1 Resonance: posterior chest
1.2 Skin Color: Icteric Sclera: Yellowish 3.3.2 Hyperresonance: Emphysema,
Discoloration; Cyanosis: Blue, Late sign of O2 3.3.3 Dull Resonance: hydrothorax; organ
deprivation; Vitiligo: Hypopigmentation; Black: 3.3.4 Tympani: percussion of the epigastric
necrosis region
1.3 Symmetry 3.3.5 Tympanism: Drum like sound with
1.4 EXAMINATION FINDINGS pain; ‘kabag’
CHEST 3.4 DTR: +2 normal; Strike on the tendon
• Pectus excavatum: funnel chest (congenital); 3.5 SHIFTING DULLNESS: Ascites
compression of heart and breathing 3.6 FLUID SHIFT
• Pectus carinatum: pigeon chest; deformity for
rickets (Vit D deficiency); AP diameter 4.
AUSCULTATION
decreased 4.1 Lung Sounds
POSTURE 4.1.1 Vesicular: Soft intensity, low pitched;
• Kyphosis T5 onward; Peripheral lung, base of the
• Lordosis lung;
• Scoliosis – lateral 4.1.2 Bronchovesicular: Moderate intensity,
NAIL BEDS moderate pitch; T3-T5; Between
scapulae lateral to the sternum
• Capillary Refill Test: n. 1-2 seconds
4.1.3 Bronchial: High pitch, loud harsh
• Clubbing: Beyond 180 degrees due to
sounds; T1-T3; Anteriorly over the
decrease oxygen
trachea
• Koilonychia: Spoon shaped nail due to iron
4.1.4 TRANSMITTED SOUNDS: when
deficiency anemia
speaking and should be muffled but
• Onycholysis/Oncolysis: separation of nail BRONCHOPHONY if heard;
• Paronychia: severe inflammation of nail EGOPHONY if you hear the word E;
• Unguis incartatus: ingrown toenail WHIPER PERTERILOQUY
ICTERIC SCLERA 4.1.5 Adventious breath sounds
CYANOSIS: late sign of oxygen deprivation 4.1.5.1 Crackles/ Rales: Hair is rubbing
VITILIGO together
• Erythema 4.1.5.2 Gurggles/ Ronchi: sounds of
• Pallor Cellophane
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 8
 FUNDAMENTALS OF NURSING PRACTICE

4.1.5.3 Wheezes: the narrowing of airway; • Initial catch is considered ‘dirty’ since there is
4.1.5.4 Friction rub: Superficial grating or bacterial or other microorganisms; use MID-
creaking sounds CATCH;
4.1.5.5 Vocal (tactile) fremitus: Faintly • In ONE HOUR, send immediately, it is only
perceptible vibration felt through fresh at that time
the chest wall when the client • CLAMP through kinking in a 2 way indwelling
speaks catheter; most ideal means to collect urine;
4.1.5.6 Stridor: noisy breathing Unclamp after collecting
4.1.5.7 Stertor: laryngeal spasm • Epithelial cells are a sign of dirty catch since it
4.2 Bowel Sounds can be seen in the top most layer of urethra
4.2.1 Normoactive: 5-30 bowel sounds per • Only a few cc needed for urinalysis and C&S
minute; Wait 3-5 mins before
concluding that bowel sounds are absent 2. URINE CUTURE AND SENSITIVITY:
4.2.2 Hyperactive: Borborygmus specify the strain of bacteria or other
4.2.3 Hypoactive: Paralytic ileus – paralysis microorganisms and in its amount; The result is
after surgery only available in 5-7 days, even if the
microorganisms have popped up in earlier time.
HEART SOUNDS: Some reagents take a few days like 5 days for
5th ICS Left Mid-clavicular line other microorganisms to grow; Sterile containers
are used;
LLLLLL Pulmonic L 2nd ICS
RRRRR Aortic R 2nd ICS 3. 24 HOUR COLLECTION or 6 HOUR
FRACTIONAL COLLECTION: Urinary
Three three Right lobe has three HCG, Urinary Amylase, Urinary 17
ketosteroid, Urinary Catecholamines, Urinary
Rararapid : Humlin R – Fast acting Uric Acid, Urinary Creatinine; DISCARD THE
N-termediate: NPH FIRST URINE SPECIMENT for the collection,
REMEMBER that you label the second as the
LABORATORY EXAMS first time started since the contents of the bladder
- Nursing responsibility: send immediately, label it at the first hour is the urine collected or created
properly at a previous time so this will create a wrong
1. URINALYSIS: The physical characteristics of result. Start when the bladder is empty meaning
the urine this will show the created urine at that time and
1.1 COLOR: Straw because of collect everything since this will count the
UROBILINOGEN contents of the urine being test (eg if U.HCG:
1.2 ODOR: Ammoniacle (decomposed urine – amount of HCG in the urine); Remember to
board exam); Usually odorless refrigerate the urine sample; Now, if the urine
1.3 pH: below 7 acidic was passed the 24 or 6 hr period yet the last urine
1.4 SPECIFIC GRAVITY: 1.01 to 1.025 (at collected was just few hours prior and the patient
1.025 or higher indicates dehydration; the urinated a few minutes after, still collect this
opposite may indicate over hydration) since it is in the collection time.
1.5 MICROSCOPIC: Amorphous phosphate or
urate are normal; 4. CHEMICAL TEST FOR URINE: not used
1.5.1 GLYCOSURIA (glucose in the anymore; OBSOLETE
urine; however best indicator of 4.1 Clinitest: urine before meals; way to
blood sugar is in the blood since determine sugar in urine (glycosuria)
before spilling the sugar will be in 4.2 BENDEDICT’s TEST: Blue in appearance,
the blood); Heat 5cc Benedict’s Solution, 3-10 drops
1.5.2 HEMATURIA (UTI, Calculi or and add the urine, NEG: Blue, Positive:
stones, BPH); GREEN (+1), YELLOW(+2), ORANGE or
1.5.3 ALBIMUNURIA or BRICK RED (+3)
PROTEINURIA (Pre-Ecclampsia 4.3 HEAT & ACETIC ACID: crude way to
and ecclapmsia; nephrotic find ALBUMINURIA; 1/3 Vinegar and 2/3
syndrome) urine then heat, in the PRESENCE OF
1.5.4 PYURIA; TURBIDITY or CLOUDINESS means
1.5.5 CYLINDRURIA (calculi or stones; positive; Principle: Heats coagulate proteins;
cylinders in the urine); If heating only the urine, crystallizes the
1.5.6 KETONURIA Amorphous urates

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 FUNDAMENTALS OF NURSING PRACTICE
5. FECALYISIS
5.1 COLOR: STERCOBILIN makes the color
of the
5.1. Clay colored: acholic stool; biliary track
obstruction
5.2. Hematochezia: red; lower GI bleeding
5.3. Melena: blood; upper GI bleeding
5.4. Steatorrhea: fat; gall bladder problem
5.5. Foul smelling: indole and skatole
5.6. Soft/formed
5.2 ODOR: foul smelling due to Indol and
Scatol
5.3 SHAPE: Cylindrical; Soft and Formed
5.4 MICROSCOPE
5.4.1 Dead bacteria, fibers, amorphous
phosphates: normal
5.4.2 Live bacteria: abnormal
*Do not collect whole amount in a CLEAN container; Send
when warm since ova can still be seen at this temperature; DO
NOT COLLECT URINE WITH STOOL
*After 1 hour, the stool cannot be used for fecalysis
*Collect abnormal looking feces, not the one which is well
formed
6. STOOL CULTURE & SENSITIVITY: not
used commonly due to expensive reagents;
STERILE: since the microorganisms may come
from the bottle; Determining exact
microorganism; Result also final after 5-7 days
7. GUIAC TEST: TEST FOR OCCULT BLOOD
TEST; MAJOR RESPONSIBILITY: no meat or
highly colored, no iron containing food!; used for
DENGUE; No meat, highly colored food, iron
preparation, Vit. C in diet; 3 days occult blood
sample
* HEMOGLOBIN FREE DIET: No protein diet
8. SPUTUM EXAM: collect the sputum not the
saliva; Done in early morning since secretions
already pooled; If unconscious, suction may be
done: mucus trap
8.1 SPUTUM Culture & Sensitivity: Specific
microorganism
8.2 SPUTUM ACID FAST BACILI (AFP):
Tuberculosis test taken at the morning; 3
consecutive days
8.3 SPUTUM CYTOLOGY: for cancer cells
8.4 SPUTUM EOSINOPHIL: Hypersensitivity
state; to determine allergic reaction
• NO ORAL HYGIENE prior to the sputum test
• SPUTUM C&S may have oral hygiene! (evidence
based practice)
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 10
9. BLOOD EXAM:
9.1 FASTING: (Triglyceride [1-12 hours],
BUN [6-8 hours], HDL, LDL, FBS, Total
Protein, Albumin Globulin ration, uric acid)
9.2 NO FASTING: Crea, Na, K, Ca, CBG (but
pre meals; mostly before meals; prick at the
side since low blood vessels)
10. BODY FLUIDS: Aspirated
10.1 PLEURAL FLUID: Thoracentesis with
guided UTZ from the pleural space;
ORTHOPNIC POSTION; Prior CXR is
done before the procedure to determine the
location and amount of fluid; PLEURAL
SPACE: 7-8 or 9th rib posterior axillary line
in fluid; 2nd or 4th rib for air; Ruptured
Bullae or Lymphoma; remain immobile;
BOTTLE should be lower than the organ
being drained; POST-OP: UNAFFECTED
SIDE is position
*Thoracostomy: to return to negative pressure
10.2 PERITONEAL FLUID: Abdominal
Paracentesis; SITTING or FOWLER’S;
INSERTION: Midway symphysis pubis and
umbilicus (Tenkoff same area of insertion);
Prior: let the patient void since this may be
punctured; During Draining: Check for sign
of HYPOVELIMIC SHOCK so check BP,
remember to clamp or stop drain if there are
signs of shock, ONLY STOP never remove
since the one who inserted has the rite; use
two liter bottles
10.3 CEREBROSPINAL FLUID: SPINAL
TAP; L3-L5; SC ends at T 12; Shrimp
position or Fetal Position; SPINAL
MANOMETER: measures the opening
pressure, CHIN TOWARD CHEST AND
LEGS TOWARD THE BODY but for
measuring the pressure remember to
straighten legs (false negative result); 3
WAY STOPCOCK: for low; May use band
aide for the area of puncture; POST: place in
a FOB or spinal headache Test tube: 4 since
every test tube has a specimen:
10.3.1 Cell count
10.3.2 Glucose
10.3.3 Eosinophil count
*Xanthochromic: hemolyzed blood; yellowish discoloration
* EVIDENCE BASED PRACTICE: If small bore needle
gauge 25, this will ensure no spinal leak, may place pillow
however, if we could not determine the gauge place FOB
*10 to 12hrs FOB but LUMBAR 4-6 hrs
DIAGNOSTIC EXAMS: Visualization
1. ENDOSCOPY: DIRECT Visualization of the organ
1.1 OPTHALMOSCOPY: Red-orange reflex:
intact lens and no opacity; Used in determining
cataract; Dim the light and focus light of
 FUNDAMENTALS OF NURSING PRACTICE
opthalmoscope in the eye; Fundoscopy may be
determined
1.2 FUNDOSCOPY: if the fundus is seen in the
eye; not in uterus only
1.3 OTOSCOPY: electronic otoscopy: has a screen
that the patient and the doctor can see through a
monitor; ADULT EAR: UP & BACK; PEDIA
EAR: DOWN & BACK (3 & below); To check
impacted cerumen, eardrum problems; A cannula
is inserted in the external auditory canal; No
need for written consent
1.4 RHINOSCOPY: septal problems
1.5 PARYNGOSCOPY
1.6 BRONCHOSCOPY: SEMI FOWLER’S
POSITION, inserted through nostrils
1.7 LARYNGOSOPY: INDIRECT
LARYNGOSOPY Laryngeal Mirror (the mirror
for dentists) is used to visualized the larynx so
please prepare a glass of water to return the
moisture of the larynx
1.8 ESOPHASCOSPY
1.9 GASTROSCOPY
1.10 DUODENOSCOPY
1.11 ESOPHAGOGASTRODUODENOSCOPY
(EGD OR UPPER GI ENDOSCOPY): May be
nose or mouth, oral hygiene, remove dentures,
consent, under local anesthesia spray to remove
the gag reflex; as the patient swallows, insertion
follows; Neoplasms, bleeding, Erosions, Fistula;
MAJOR RESPONSIBILITY POST: CHECK
GAG REFLEX before eating food or fluids
1.12 ANASCOPY
1.13 SIGMOIDOSCOPY
1.14 PROCTOSCOPY
1.15 PROCTOSIGMOIDOSCOPY
1.16 COLONOSCOPY: until Ileocelcal valve area;
Preparation: consent, NPO to prevent fecal
formation, BOWEL PREP depending on the site
(SIGMOID: 60 cc castor oil with orange juice
per orem; COLON: through enema clean until
clear water is seen; FLEET PHOSPHOSODA:
commercially prepared solution that is salty
mixed with soda like 7 up and must be in
CLEAR LIQUID DIET given once or twice)
1.17 URETHROSCOPY
1.18 CYSTOSCOPY: Preparation: consent, NO
VOIDING since there is a sterile water positive
pressure through cystoclysis; TURP; MAJOR
RESPONSIBILITY POST: FORCE FLUIDS 3
LITERS to dilute urine since concentrated urine
will cause pain in urination.
1.19 CULPOSCOPY: directed light to the cervix;
SHEROD KAR: the tightens cervix for
incompetence cervix; Preparation: Empty
bladder; POST: Perineal Care
2. XRAY/ ROENTENGENOGRAPHY; AMT XRAY
radiation of new machines are now lower so
teratogenic effects are minimized.
2.1 CXR: lung fields and size of the heart
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 11
2.2 MAMMOGRAPHY
2.3 UPPER GI SERIES: CONTRAST; until
duodenum; Prepare: light meal at night with
laxative, NPO, given DYE per orem (BARIUM
SWALLOW) to outline the stomach portion of
duodenum , consent; POST: increase fluids since
the barium costing constipation, doctors will also
give laxative
2.4 LOWER GI SERIES: large intestines; Prepare:
CLEANSING ENEMA UNTIL CLEAN;
BARIUM ENEMA given before procedure;
POST: enema is also use once or twice a day,
evacuate or may cause FECAL IMPACTION
2.5 INTRAVENOUS PYELOGRAPHY
(EXCRETORY UROGRAPHY): DYE given
per IV; Contrast: HYPAQUE made of iodine;
Skin test may be done; IV push but preferred
given per IV; If with kidney function do not use
this, Anatomic problems
2.6 RETROGRADE PYELOGRAPHY:
introduced through the urethra to bladder to
ureter to the kidneys
2.7 ORAL CHOLECYSTOGRAPHY: Contrast:
IAPANOIC ACID (TELEPAQUE) with 6
tablets taken every 5-10 minutes (can be given in
double dose) with LOW FAT MEALS since the
gallbladder will contract in presence of the fat,
also given laxative on NPO; TELEPAQUE does
not need to have an order.
*FEW NO CONTRAST: CXR, Skeletal
3. TRANSFORMED VIZUALIZATION
3.1 ULTRASOUND/ SONOGRAM
- no special preparation except UTZ of the
bladder/ Pelvic: must be full bladder with 6-8
Glasses
3.1.1 UTZ OF THE BRAIN
3.1.2 2D ECHO: UTZ of the heart; no
special prep
3.1.3 UTZ OF THE ABDOMEN
3.1.4 SONOMAMMOGRAPHY
3.1.5 UTZ OF THE LUNGS
3.1.6 UTZ OF THE PELVIS: If pregnant at
3rd Trimester, no fluids needed
3.1.7 TRANSVAGINAL SOSNOGRAM:
for BPS of the FETUS; Can be through
TRANSRECTAL
3.1.8 TRANSRECTAL SONOGRAM: for
prostate; Preparation: empty bladder
(even transvaginal)
3.2 ELECTROENCEPHALOGRAPHY (EEG):
Pre: remember to shampoo since it may cause
trouble attaching and may affect result, HOLD
THE ANTICONVULSANT MEDS, may alter
but depends on the doctor’s order; POST: also
shampoo since the gel must be removed plus
comfort; 32 electrodes are attached at specific
regions of the cranium.
 FUNDAMENTALS OF NURSING PRACTICE
3.3 ELECTROCARDIOGRAPHY (ECG): 12
LEEDS; Movement may cause changes in the
reading
3.4 ELECTROMYOGRAPHY: Tonicity and other
parameters of the muscle by placing wires
inserting into muscles; Remember to place
pressure on the sites of insertion
3.5 MAGNETIC RESONACE IMAGING (MRI):
CONTRAST HAS NPO if non, no need for
NPO; CONTRAST must check the creatinine for
kidney functioning; GADOLINIUM; Post:
increase fluids to flush the contrast; Non-
invasive but has consent due to the expense
involved; ABDOMEN: give laxative and in NPO
3.6 COMPUTED TOMOGRAPHY/
COMPUTERIZED TOMOGRAPHY SCAN
(CT or CAT scan): CONTRAST with NPO
3.7 POSITRON EMISSION TOMOGRAPHY
(PET Scan): RADIOACTIVE GLUCOSE: CA
cells like glucose and where it is absorbed
3.8 THYROID SCAN
*MYELO: Spinal Canal
*SBAR: SITUATION, BACKGROUND, ASSESSMENT &
RECOMMENDATION
ADMISSION
1. BED MAKING
- Body mechanics
- Aesthetic value: a wrinkle free, well stretched linen
- Aseptic to Clean technique: Do not place soiled linen
unto the floor just since the this is the dirtiest place in
the room
- TOP SHEET: Excess to the FOOT;
- BOTTOM SHEET: Excess to the HEAD PART
1.1 TYPES:
1.1.1 CLOSE
1.1.2 OPEN
1.1.3 POST OP
RECOVERY
1.1.4 ANESTHETIC
1.1.5 OCCUPIED
2. CHANGING GOWN: Remove with free arm first in
changing gown; If both with contraption, any arm
3. ORIENTING THE CLIENT:
3.1 Assessment
3.2 History Taking
3.3 Physical Exam
3.4 Vital Signs
3.5 Document
4. CHARTING: ADMISSION CHARTING: Chief
Complain must be paced into the charting
5. DISCHARGE PLAN: Must start in admission by
telling the most probable number of days of stay;
may be against medical advice (DAMA) but it needs
doctor’s order; health instruction; Illegal detention
(false imprisonment)
6. WARD: must introduce the ward
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 12
VITAL SIGN/ CARDINAL SIGNS
- BP, PR, RR, TEMP. PAIN
- 3 years and old below: RR then HR then Temp; BP
only if the client has precaution
- Monitor if client is table: Q4 HOURS
- Monitor if unstable: Q15 minutes, however
temperature 30 minutes to 1 hour since it takes the
Hypothalamus takes a awhile for temp to readjust.
1. TEMPERATURE:
Temperature conversion
CàF multiply 1.8 + 32
FàC subtract 32/ 1.8
1.1 FACTORS AFFECTING BODY
TEMPERATURE:
1.1.1 Age
1.1.2 Ovulation
• POIKILOTHERMIA: same as the environment
• HOMEOTHERMIA: different from the
environment
1.2 TYPES
1.2.1 CORE: Inside the body; more important;
can’t be affected by environment
1.2.2 SURFACE: Skin; more important in children
since hypothalamus not yet developed
1.3 ROUTES
1.3.1 ORAL: 7 years and below do not take by this
area; CONTRAINDICATED TO brain
damage, Mental illness, retarded, Problems in
the oral cavity like palate, Contraptions like
NGT, O2 Mask, stupor coma, tooth extraction
1.3.2 RECTAL: CONTRAINIDICATED in:
Hemorrhoid, Diarrhea Hurshprung, Tumors
or CA, Cardiac disease (Vagal nerve
stimulation causing bradycardia), Increased
ICP; not used to babies due to risk of Rectal
perforation
1.3.3 AXILLARY: hollow aspect of the axilla,
make sure that its dry;
CONTRAINDICATION: Lymphadenopathy;
LEAST ACCURATE
1.3.4 TYPAMNIC: CONTRAINDICATED:
impacted cerumen, otitis media; Use
technique
1.3.5 TEMPORAL ARTERY
*Unexpected Situation and Associated Interventions:
During rectal temperature assessment, the patient reports
feeling lightheaded or passes out; Remove the thermometer
immediately. Quickly assess the patient’s BP and HR. Notify
 FUNDAMENTALS OF NURSING PRACTICE

physician. Do not attempt to take another rectal temperature 1.7.5 Oral hygiene
on this patient. 1.7.6 Tepid Sponge Bath – increase heat loss
(conduction, convection, evaporation)
*Temperature can be checked every 30 mins since
hypothalamus can only fluctuate the temperature every 30 *TRANSFER OF HEAT: Conduction, Convection, Radiation,
mins
1.8 HYPOTHERMIA
1.4 DEVICES
1.4.1 SPOT VITAL SIGNS: Gets all VS; plus O2 *38: Febrile; 37.9 could be discovered
Saturation *Best method to determine Perforate Rectum: pass meconium
1.4.2 MERCURIAL in 24 hours
1.4.3 DIGITAL: could be axilla and rectal route *Minimum number of wash cloth for TSB: 4
1.4.4 THERMOPACIFIER: for infants
1.4.5 TYPANIC SCANNER 2. PULSES: Left ventricle of the heart created;
1.4.6 ELECTRONIC: similar to digital; larger; No MEDULLA controlled
longer manufactured 2.1 SITES
1.4.7 PLASTIC STRIP: make sure that all dots 2.1.1 Posterior tibial pulse: same side of the great
are lined black to determine true temperature toe
if only half its 0.5 2.1.2 RADIAL: THUMB
2.1.3 BRACHIAL
1.5 FEVER 2.1.4 CAROTID: for heart disease
2.1.5 TEMPORAL
* TSB must be given when temp is 38, if it is lower do not 2.1.6 FEMORAL: for heart disease if carotid not
render since it may just be rising effervescence available
2.1.7 POPLITEAL
Average: 36 ̊ - 38 ̊ degrees 2.1.8 DOSALIS PEDIS
Hypothermia: 36 ̊ degrees below 2.1.9 APICAL: FOR BABY
Death: 34 ̊ degrees
*PEDAL PULSE: Dorsalis pedis, Pedal Pulse, radial; All for
1.5.1 EFFERVESCENSE: increasing temperature peripheral circulation and perfusion
1.5.2 FASTIGIUM/ STADUM: Highest
temperature 2.2 FACTORS AFFECTING PULSE RATE:
1.5.3 DEFERVESCENCE 2.2.1 Age
1.5.4 RESOLUTION BY CRISIS: Sudden 2.2.2 Activity
decrease temperature 2.2.3 Stress: SNS
1.5.5 RESOLUTION BY LYSIS: gradual 2.2.4 DRUGS:
lowering of temperature
*Anticholinergics, Sympathomimetics/ adrenergic (do not give
1.6 TYPES OF FEVER 90pm and above);
1.6.1 INTERMITTENT: fluctuates from febrile to *Beta blockers, Digitalis (Do not give if 60bpm and below)
afebrile
1.6.2 REMITTENT: febrile, temperature 2.3 PULSE RYTHYM:
fluctuation is minimal 2.3.1 REGULAR:
1.6.3 RELAPSING: Several days; fluctuates in +1 Thready or collapsing pulse
days +2 normal pulse volume
1.6.4 CONSTANT/ CONTINUOUS: fluctuating +3 Full Volume
but not more than 0.2 +4 Bounding
2.3.2 ARYTHMIA/ DYSRYTHMIA (referring
1.6.5 HEAT STROKE: depletion of fluid, that they are not regular rhythms)
hypothalamus does not regulate 2.3.2.1 BIGEMINAL: 2 beats then longer than
1.6.6 HYPOTHERMIA: induced (surgery), usual
extreme temperature 2.3.2.2 TRIGENIMAL: 3 beats then longer
1.7 NX MGMT: FEVER than usual
1.7.1 Feels chilled: provide extra blankets 2.3.2.3 QUADRIGENIMAL: 4 beats then
1.7.2 Feels warm: remove excess blankets; loosen longer than usual
clothing 2.3.2.4 CORRIGAN/ WATER HAMMER:
1.7.3 Adequate nutrition and fluids thread pulse with full expansion then
1.7.4 Reduce physical activity sudden collapse

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 FUNDAMENTALS OF NURSING PRACTICE

*Unexpected Situations and Associated Interventions 3.3 HYPOVENTILATION

The pulse is irregular; Monitor the pulse for a full minute. If
the pulse is difficult to assess, validate pulse measurement by *if given the choice for RR 12-20 / 16-20: choose 12-20 but
taking the apical pulse for 1 minute. If this is a change for the choose 16, if ever any problems is suspected
patient, notify the physician.
4. BLOOD PRESSURE: Force left ventricle and
* Unexpected Situations and Associated Interventions pressure on the arterial walls
You cannot palpate a pulse, Use a portable ultrasound Doppler • Using Sphygmomanometer
to assess the pulse. If this is a change in assessment or if you • 1-2 minutes if taking the BP again
cannot find the pulse using an ultrasound Doppler, notify the • if with movement or activity, wait 30 minutes
physician.
3. RESPIRATION: Better taken asleep; MEDULLA/ KOROTFOFF SOUNDS
Pons controlled
PHASES SOUND
• As the elevation increases = decreased O2
Phase 1 sharp tapping (systolic)
saturation; Increased
Phase 2 swishing or wooshing sound
• Opiate Agonist: decreases RR; so check RR if 12
Phase 3 thump softer than the tapping in phase 1
or below. Do not give if lower
softer blowing muffled sound that fades
• MEPERIDINE HCL (Demerol): Withhold if the Phase 4
(END = diastolic)
respiration is also 12
Phase 5 silence
• 12-20: ADULT;
3.1 PROCESSES
3.1.1 VENTILATION: the breathing in and 4.1 FACTORS AFFECTING
breathing out; Intact CNS; Clear airway; 4.1.1 Age, Gender
Intact thoracic cavity; Compliance and recoil 4.1.2 Activity
3.1.2 DIFFUSION: movement of gases from 4.1.3 Time of the day: Lowest at the morning
higher to lower concentration; Adequate 4.2 METHODS
concentration of gases; Normal lung tissue 4.2.1 DIRECT: Invasive using CENTRAL
VENOUS PRESSURE (CVP) at the Right
3.1.3 PERFUSION: circulation of the oxygenated
Atrium
blood to the different tissues of the body
4.2.2 INDIRECT: external
3.1.4 Inhalation / Inspiration – 1 to 1.5 seconds
4.3 ROUTES
Exhalation / Expiration – 2 to 3 seconds
4.3.1 PALPATORY: feel the pulse using Brachial
3.2 ALTERATIONS IN BREATHING PATTERN
or Medial ; Dorsalis Pedis (Calf) or Posterior
3.2.1 RATE
3.2.1.1 EUPNEA: normal Popliteal (Thigh)
3.2.1.2 TACHYPNEA/ POLYPNEA: 27 4.3.2 AUSCULTATORY
3.2.1.3 APNEA: no breathing
3.2.1.4 BRADYPNEA: slowed breathing PULSE PRESSURE: Systolic minus Diastolic;
3.2.2 EASE OF COMFORT Normal 40
3.2.2.1 ORTHOPNEA: can’t breathe supine PULSE DEFICIT: HR minus PR; * normal deficit
down; BEST POSITION for patient
*If there is a deficit higher than 8: recheck and refer, a heart
with orthopnea: SITTING
block might be the reason
3.2.2.2 PLATYPNEA: difficulty breathing
while sitting
4.4 EQUIPMENT
3.2.2.3 DYSPNEA: Diff breathing
3.2.2.4 TREPOPNEAL: difficulty breathing 4.4.1 ELECTRONIC SPHYMOMANOMETER
Side-lying
3.2.2.5 HYPERPNEA: increased rate and OPTIMAL BP: 110/70
depth of respiration
3.2.3 PATHOLOGICAL CAUSE FOR HTN Diagnosis
3.2.3.1 CHYNE STOKES: hyperpnea with 1. Age 18 and above
2. No diagnosis HTN or any related disorder
gradual increase and gradual decrease
3. Monitor BP 1-2 weeks
and apnea
4. On two HTN categories: the one with the higher
3.2.3.2 BIOT: hypernea then apnea
reading, take the higher
3.2.3.3 KUSSMAULS: Hyperventilation
(increased ventilation or gas HTN CLASSIFICATIONS
exchange); in increased Arterial blood BP Lifestyle
SBP DBP
gas will be affected; Blowing off the CLASS Modification
CO2; Optimal <120 And < 80 Encouraged
PreHTN 120-139 80-89 Yes
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 14
 FUNDAMENTALS OF NURSING PRACTICE

HTN St 1 140-159 90-99 Yes 1.4 PARTIAL REBREATHER: (approx. 60-80%);

HTN St 2 >or equal 160 >or Equal 100 Yes 6-10L/min = up to 80%
HTN St 3 >or equal 180 >or equal 110 Yes 1.4.1 NX MGMT: Set flow rate so that mask
remains two-thirds full during
SOURCES OF ERROR IS BP ASSESSMENT inspiration; Keep reservoir bag free of
HIGH BP READING twists or kinks.
• Bladder cuff too narrow
• Arms unsupported 1.5 TENT / VENT
1.6 NON-REBREATHER: 10L/min = 80-100%
• Insufficient rest before the assessment
1.6.1 NX MGMT: Maintain flow rate so
• Repeating reassessment too quickly
reservoir bag collapses only slightly
• Deflating cuff too slowly during inspiration; Check that valved and
• Assessing immediately after a meal or while client rubber flaps are functioning properly
smokes or has pain (open during expiration and closed
LOW BP READING during inhalation); Monitor SaO2 with
• Bladder cuff too wide pulse oximeter.
• Deflating cuff too quickly
• Arm above the level of the heart 1.7 VENTURI: most accurate and precise oxygen
• Failure to identify auscultatory gap concentration delivery

OXYGENATION VENTURI MASK 02

• Safety precautions: “NO SMOKNG” and “O2 IN 4L/min = 24%
USE” signs at the door 4L/mins = 28%
1. TYPES: 6L/min = 31%
1.1 NASAL CANNULA: only dislodged into placed 8L/min = 35%
with prongs 8L/min = 40%
10L/min = 50%
NASAL CANNULA 02
(approx. 20-40% of oxygen) - PRIORITY: SAFETY, moisten using humidifying
1L/min = 24% agent, check for patency and saturation; Check
2L/min = 28% breaths sounds for Copious (plenty) or Tenacious
3L/min = 32% (thick)
4L/min = 36% -
5L/min = 40% * OXYGEN CONCENTRATION FOR CHILDREN: for not
6L/min = 40% more than 40% concentration may cause RETROLENTAL
FIBROLASIA or BLINDNESS
1.1.1 NX MGMT: Check frequently that both * COPD: hypoxic drive will decrease, if O2 is increased: 1-2
prongs are in the patient’s nares; or 3 lpm
Encourage the patient to breathe through
the nose, with mouth closed. * Increase fluid to decrease the tenacious and copious
secretion; but for other methods, using mucolytic in either
1.2 CATHETER: Tip of nose to the earlobe: 40% syrup or inhalation
behind uvula
*Unexpected Situations and Associated Interventions:
1.3 SIMPLE FACE MASK 60 % Oxygen Tent
• Child refuses to stay in the tent; Parent may play
SIMPLE FACE MASK 02 games in the tent with child. Alternative methods of
(approx. 40-60%) O2 delivery may need to be considered if child still
5-6L/min = 40% refuses to stay in tent.
7-8L/min = 50% • It is difficult to maintain an O2 level above 40% in
10L/min = 60% the tent; Ensure that the flap is closed and edges of
1.3.1 NX MGMT: Monitor patient frequently tent are tucked under blanket. Check O2 delivery unit
to check the placement of the mask; to ensure that rate has not been changed.
Support patient if claustrophobia is a • Patient was confined on O2 delivered by nasal
concern.; Secure physician’s order to cannula but now is cyanotic, and the pulse oximeter
replace mask with nasal; cannula during reading is less than 05%; Check to see that O2 tubing
meal time is still connected to the flow meter.

UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 15

 FUNDAMENTALS OF NURSING PRACTICE
• When dozing, patient begins to breathe through the
mouth. Temporarily place the nasal cannula near the
mouth. If this does not raise the pulse oximetry
reading, you may need to obtain an order to switch
the patient to a mask while sleeping.
2. INHALATION: STEAM/ AEROSOL
INHALATION: not found in the hospital due to risk
for burns, but it still can be used. NEVER GIVE
STEAM TO INFANTS; NEBULIZATIONS ARE
MOST PREFERRED; Saline or NSS is the cheapest
means; Mucosulvant is the chemical means; After
liquefying, CPT from base to apex, Coughing
Exercises (most practical) and Postural Drainage 15
to 20 mins after changing or moving.
2.1 MOIST INHALATION: Steam inhalation = 12-
18 inches; 15 – 20 mins.
2.2 DRY INHALATION: Metered dose inhaler =
use of spacer; hold breath; for 10 seconds with 5
minutes interval
2.3 CHEST PHYSIOTHERAPY
2.3.1 POSTURAL DRAINAGE: Done
during morning time; at bedtime: 30
minutes – 1 hour before or 1-2 hours
after meal; Each position = assumed for
10 – 15 minutes; Entire treatment should
last only for 30 minutes
2.3.2 PERCUSSION: Rhythmical force
provided by clapping the nurse’s cupped
hands against the client’s thorax; Over
affected segment for 1-2 minutes
2.3.3 VIBRATION: Perform by contracting
all the muscles in the nurse’s upper
extremities to cause vibration while
applying pressure to the client’s chest
wall; One hand over the other
2.4 Positioning à percussion à vibration à
removal of secretions by coughing or suction
2.5 CONTRAINDICATIONS FOR CPT: ICP more
than 20mmHg, head and neck injury, active
hemorrhage, recent spinal surgery, active
hemoptysis, pulmonary edema, confused or
anxious patients, rib fracture
*CONTRAINDICATED for CPT: TB
3. SUCTIONING: substitute for effecting coughing;
suction pressure checked when sucking water; 10
seconds for each suction; Introduce positive then
move out through negative suction; Ideally sterile
technique, when clean on the other hand, wash with
soap and water then dry, then place in another
container; RESPONSIBILITY: hyperventilate or
Hyperoxygenate for 15-30 Seconds (use this time
especially when there is Pulse Oximeter), checking
O2 saturation of 100%, Also check after breath
sounds to determine effectiveness; IF CLIENT
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 16
COUGHS IN THE MIDDLE OF PROCEDURE,
stop, don’t suction, remove then oxygenate and
repeat.
FRENCH SIZES
Adult: Fr 12-18
Child: Fr 8-10
Infant: Fr 5-8
LENGTH
AREAS MEASUREMENT
Tip of nose to earlobe 5 Inches
Nasopharyngeal 5-6 Inches
Oropharyngeal 3-4 Inches
Nasotracheal 8-9 Inches
ET Length of ET + 1
Tracheostomy Length of Trachea +1cm
3.1 OROPHARYNGEAL AIRWAY: Prevents
tongue from falling back against the posterior
pharynx; Measurement: from opening of the
mouth to the ear (back angle of the jaw); Check
for loose teeth, food and dentures
*Unexpected Situations and Associated Interventions:
Oropharyngeal Airway
• The patient awakens; Remove the oral airway
• The tongue is sliding back into the posterior pharynx,
causing respiratory difficulties; Put on disposable
gloves and remove airway. Make sure airway is the
most appropriate size for the patient.
• Patient vomits as oropharyngeal airway is inserted;
Quickly position patient onto his side to prevent
aspiration
3.2 NASOPHARYNGEAL AIRWAY / NASAL
TRUMPETS: Indications Clenched teeth,
enlarged tongue, need for frequent nasal
suctioning; Measurement: from the tragus of the
ear to the nostrils plus one inch; Proper
lubrication for easy insertion
3.3 ENDOTRACHEAL: INDICATIONS: route
for mechanical ventilation, easy access for
secretion removal, artificial airway to relieve
mechanical airway obstruction.
3.3.1 Care for patients with ET:
3.3.1 Repositioned at least every 24-48
hours
3.3.2 Depth and length during insertion
should be maintained
3.3.3 Level of tube: gumline / biteline
3.3.4 Maintain cuff pressure of 20-25
mmHg
3.3.5 Check lips for cracks and irritation
*Unexpected Situations and Associated Interventions: ET
TUBE
• Patient is accidentally extubated during suctioning;
Remain with the patient. Instruct assistant to notify
 FUNDAMENTALS OF NURSING PRACTICE
physician. Assess patient’s vital signs, ability to
breathe without assistance and O2 saturation. Be
ready to administer assisted breaths with a bag-valve
mask or administer O2. Anticipate need for
reintubation.
• Oxygen saturation decreases after suctioning;
Hyperoxygenate patient.
• Patient develops signs of intolerance to suctioning;
O2 saturation level decreases and remains low after
hyperoxygenating, patient becomes cyanotic or
patient becomes bradycardic; Stop suctioning.
Auscultate lung sounds. Consider hyperventilating
patient with manual resuscitation device. Remain
with patient.
• Patient is biting on ET; Obtain a bite block. With the
help of an assistant, place the bite block around the
ET or in patient’s mouth.
• Lung sounds are greater on one side; Check the depth
of the ET. If the tube has been advanced, the lung
sounds will appear greater on one side on which the
tube is further down. Remove the tape and move tube
so that it is placed properly.
3.4 TRACHEOSTOMY: To maintain patent
airway and prevent infection of respiratory
tract.
3.4.1 NX MGMT: Sterile technique:
acute phase; Clean technique: home
care; 1st 24 hours: tracheostomy
care every 4 hours; Prevent
aspiration
* Unexpected Situations and Associated Interventions:
Tracheostomy
• Patient coughs hard enough to dislodge
tracheostomy; Keep a spare tracheostomy and
obturator at the bedside. Insert obturator into
tracheostomy tube and insert tracheostomy into
stoma. Remove obturator. Secure ties and auscultate
lung sounds.
* Unexpected Situations and Associated Interventions:
SUCTIONING
• Patient vomits during suctioning; If patient gags or
becomes nauseated, remove the catheter; it has
probably entered the esophagus inadvertently. If the
patient needs to be suctioned again, change suction
tip then oxygenate and suction.
• Secretion appear to be stomach content; Ask the
patient to extend the neck slightly. This helps to
prevent the tube from passing into the esophagus.
• Epistaxis noted with continued suctioning; Notify
the physician and anticipate the need for a nasal
trumpet.
4. SPIROMETER: INHALE to INCREASE DEEP
BREATHING; It is not the height of the ball but the
ability of the patient to sustain the balls; A breathing
device that provides visual feedback that encourages
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 17
patient to sustain deep voluntary breathing and
maximum inspiration; 10 times every 1 to 2 hours
5. ABDOMINAL (DIAPHRAGMATIC) AND
PURSE-LIP BREATHING: Semi / high fowlers
position; Slow deep breath, hold for a count of 3 then
slowly exhale à through mouth and pursed lip;
FREQUENCY: 5 – 10 slow deep breaths every 2
hours on waking hours
6. COUGHING EXERCISE: Upright position;
CONTRAINDICATED: post brain, spinal or eye
surgery (increased ICP & IOP, respectively); Take
two slow deep breaths; on the third breath, hold for
dew seconds, cough twice without inhaling in
between; May splint surgical incisions; Every 2
hours while awake
7. PULSE OXYMETRY: Purpose: measure arterial
blood O2 by external sensor (non-invasive)
7.1 PLACEMENT
7.1.1 Adult: usually on the finger
7.1.2 Pedia: usually on the big toe
7.1.3 Other sites: earlobes, nose, hand and feet
NUTRITION
WATER
- Males have more fluids than females
- Females have more adipose
- 70-90% CHILD
- 50-70 % ADULT
PRINCIPLES IN THE PROMOTION OF GOOD
NUTRITION
- The body requires food to:
• Provide energy for organ function, movement,
• and work.
• Provide raw materials for enzyme function,
growth, replacement of cells and repair.
- The process of digestion, absorption, and metabolism
work together to provide all body cells with energy
and nutrients.
- Man’s energy requirement vary and is influenced by
many factors: Age, body size, activity, occupation,
climate, sleep, physiological stress, pathological
disorders, lifestyle, and gender.
- Foods are described according to the density of their
nutrients. NUTRIENT DENSITY: the proportion of
essential nutrients to the number of kilocalories.
• MACRONUTRIENTS: Give off calories for
energy [Fat soluble vitamins: Vit. A, D, E, and
K]
• MICRONUTRIENTS – No calories, vitamins
and nutrients [Water soluble vitamins: Vit. C,
B1, B2, B3, B6, B9, and B12
• CALORIE (KCAL): unit of energy
measurement; amount of heat required to raise
the temperature of 1kg of water to 1°C
 FUNDAMENTALS OF NURSING PRACTICE
- NUTRIENTS:
• CHO – 4 calories/gm; first to be burned
• FATS – 9 calories/gm; stored as adipose tissue
CHON – 4 calories/gm; meat
• Alcohol – 7 calories/gm
*EGG Yolk: RDA Vitamin A
VITAMINS
- FAT SOLUBLE: ADEK; not needed everyday
- WATER SOLUBLE: B complex, C; must be
supplemented daily
- Macrominerals :100 mg or more;
- Microminerals: Less than 100 mg; Zinc, iron, iodine
*Potato: highest in potassium
*The tip of the banana has the highest amount of potassium
- IODINE: prevent cretinism
- ZINC: to improve appetite
- IRON: corrects anemia
- Hypervitaminosis – increase in vitamins intake;
occurs commonly in fat soluble
• No hypervitaminosis in water soluble since it is
easily eliminated in urine
- OVERWEIGHT: increase in macronutrients; may
progress to obese
- MARASMUS (Calorie Deficiency)
• Old man facie, intercostal and subcostal
retractions
- KWASHIORKOR (Protein Deficiency)
• Moon face, Globular abdomen, edema
• PROTEIN Deficiency: causes delayed brain
development; KWASHORKOR IS A BIGGER
PROBLEM VS MARASMUS
- MINERALS
• 100 mg Ca, P, (Inverse relationship for Ca and P)
• Na, Cl (Partners)
• K
FAT SOLUBLE
1. Vitamin A: Deficiency: Xeropthalmia (S/sx Night
Blindness, Bitot’s Spots), SEVERE: Keratomalacia
(irreversible blindness)
*NICTALOPYA: Night Blindness Scientific Term
2. VITAMIN D (CALCIFEROL): Enhances Calcium
and Phosphorus absorption; Deficiency Ricketts
(Children); SEVERE: Osteomalacia (Adults)
• GENOVARUM: Bow legged
• GENOVALGUM: Knock Knee
• RACHITIC ROSARY: bending of the Rib cage
• HARRISON’S GROOVE/ PIGEON’S CHEST
• SPINAL DEFORMITY
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 18
• Stunted growth
* You can store calcium until age 31
3. VITAMIN E (TOCOPHEROL): To enhance RBC
MATURATION; Deficiency: Anemia; Antioxidant;
Not exceeding 400iu or it it will cause PRO-
OXIDATION
4. VITAMIN K (MENADIONE): Anti-Hemorrhagic or
Coagulant/ Promotes clotting; deficiency:
hemorrhage., bleeding;
*Nasal Box Plexus/ Kaesselbach’s plexus: most sensitive area
to bleed in the nose
5. B1 THIAMINE: Beri Beri, Wernicke-Korsakoff
Syndrome: with CNS involvement wwith memory
loss and dementia; EDEMA
6. B2 RIBOFLAVING: Deficiency Ariboflavinosis
(Children) & Cheilosis (Adult) – Skin Leisures;
Angular stomatitis: corner of the mouth
7. B3 NIACIN: Deficiency: Pellagra (darkness and
Butterfly sign; CASAL COLLAR) Diarrhea
8. B6 PYRIDOXINE: Deficiency: Neuritis (Flicking
eyelid unvoluntarily)
9. B9 FOLIC ACID: Megaloblastoc Anemia
10. B12 (CYANOCOBALAMINE): Pernicious Anemia,
Neuritis
11. B5 PANTOTHENIC ACID: Deficiency: Alopecia;
Food: Turnips (sinkamas), raddish (labanos)
12. VITAMIN C ASCORBIC ACID: Enhances iron
absorption, immunity; Deficiency: Scurvy
(Parafullicular hemorrhage: red spots or hemorrhage
in skin without trauma)
DIETS
1. Regular
1.1 Has all essentials, no restrictions
1.2 No special diet needed
2. Clear liquid
2.1 “see-through foods” like broth, tea, strained
juices, gelatin
2.2 Recovery from surgery or very ill
3. Full liquid
3.1 Clear liquids plus milk products, eggs
3.2 Transition from clear to regular diet
4. Soft diet
4.1 Soft consistency and mild spice
4.2 Difficulty swallowing
5. Mechanically soft
5.1 Regular diet but chopped or ground
5.2 Difficulty chewing
6. Bland
6.1 Chemically and mechanically non stimulating,
no spicy food
6.2 Ulcers or colitis
7. Low residue
 FUNDAMENTALS OF NURSING PRACTICE

7.1 No bulky foods, apples or nuts, fiber, foods 4. JEJUNOSTOMY: ELEMENTAL FEEDING; End
having skins and seeds of digestion area; May likely have dumping
7.2 Rectal disease syndrome; Preventive trough Supine, no danger of
8. High calorie aspiration and delay the movement; HIGH PROTEIN
8.1 High protein, vitamin and fat HIGH FATE (both are hard to digest) with less fluids
8.2 Malnourished given in between meals; SFF! ; Observe stomach air
9. Low calorie
9.1 Decreased fat, no whole milk, cream, eggs, 5. TPN/ IV HYPERAILENMENTATION: CHON&
complex CHO CHO; good for only 24 hours; CAMBIVENT,
9.2 Obese NUTRIVENT; 7700 pesos one bag; No digestion;
10. Diabetic Large Bore needle; I&O is needed; Watch out for
10.1 Balance of protein, CHO and fat Glycosuria: the CHO Not low as 30 % sugar for
10.2 Insulin-food imbalance TPN; Insulin may be injected to facilitate transport.
11. High protein
11.1 Meat, fish, milk, cheese, poultry, eggs 6. GAVAGE
11.2 Tissue repair and underweight 6.1 Position: sitting
12. Low fat 6.2 Gastric aspirate: >1000mL: withhold feeding;
12.1 Little butter, cream, whole milk or eggs put back the residue
12.2 Gallbladder, liver or heart disease 6.3 If with medication and is not gastric irritant: 20-
13. Low cholesterol 30cc; flushing à meds à feeding à 20-30cc
13.1 Little meat or cheese flushing
13.2 Need to decrease fat intake
14. Low sodium 7. LAVAGE
14.1 No salt added during cooking 7.1 To irrigate the stomach in case of gastric
14.2 Heart or renal disease bleeding, food poisoning or ingestion; if
corrosive substance: do not irrigate
NUTRITIONAL PROBLEM (ABCD) 7.2 Position: sitting
1. ANTHROPOMETRIC MEASUREMENT 7.3 Gastric aspirate: discard
BMI: 18-24 Asia NORMAL 7.4 Amount of irrigating solution: 750mL – 1L
Wt (kg)/ht (m2)
2. Biochemical Assay *200 calories dextrose and other IVs available
3. Clinical Signs
4. Dietary History: food habits; Comprehensive about
client’s nutrition *Unexpected Situations and Associated Interventions:
NGT
EXTRA-ORAL FEEDING • Tube found not to be in the stomach or intestines;
1. LEVINE’S/ NGT: Adult: French 12-18; May use to Replace the tube
LAVAGE: feeding; DRAINING through gravity or • Patient complains of nausea after tube feeding;
SUCTION MACHINE (Decompression); HCL for Ensure that the head of the bed remains elevated
analysis; INSERTING NGT: Described as GASTRIC and that suction equipment is at bedside; Check
INTUBATION; Distance Tip of nose to ear to medication record to see if any anti-emetics is
Xiphoid Process; Sip water as you insert tube; ordered.
Immerse, auscultate, aspirate; CXR most reliable; pH • When attempting to aspirate contents, the nurse
of 6 and below to give the feeding to check; notes that tube is clogged; Try using warm water
INTRODUCE H20 first; Coffee ground, please do and gentle pressure to remove the clog; Never use
not give feeding; a stylet to unclog the tubes; Tube may have to be
replaced.
2. GASTROSTOMY: into the stomach; no need to
check anymore; Check the area for signs of infection; 8. GASTROSTOMY / JEJUNOSTOMY FEEDING
POSITION is semi-sitting because still causes 8.1 Long term nutritional support, more than 6 – 8
aspiration; flushing still needed; DO NOT MIX weeks
MEDS WITH FOOD; Check for Stomach air; BARD 8.2 Place in high fowler’s position
BUTTON GASTROSTOMY: 5-7 years for 8.3 Check the patency of the tube: Pour 15-30 cc of
permanent water
8.4 Check for residual feeding
3. DUODENOSTOMY: Rare, Not as safe as the 8.5 Hold asepto-syringe 3-6 inches above ostomy
Jejunum feeding
8.6 Frequently assess for skin breakdown

UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 19

 FUNDAMENTALS OF NURSING PRACTICE
*Unexpected Situations and Associated Interventions:
Gastrostomy
• Gastrostomy tube is leaking large amount of
drainage; Check tension of the tube; Apply gentle
pressure to tube while pressing the external bumper
closer to the skin; If tube has an internal balloon
holding it in place, check to make sure that the
balloon is inflated properly.
• Skin irritation around the insertion site; Stop the
leakage, as prescribed previously and apply a skin
barrier.
• Site appears erythematous and patient complains of
pain at the site; Notify physician, patient could be
developing cellulitis at the site.
URINE/ MICTURATION
- 1200 – 1500cc/day
- Normal output: 30ml/hour
- Urge to urinate: 300-500ml
1. POLLAKURIA: frequent scanty urine
2. URGENCY: Feeling of urinating without pee
coming-out
*TENESMUS: Feeling of pooping with hilab but nothing
came out
3. URINARY RETENTION: Stimulate warm and cold,
sound of water; if those actions don’t work,
CATHETERIZATION: irrigation, eliminate, measure
CATHETER SIZE
Children: Fr 8-10
Female Adult: Fr 14-16; Fr 12 for young girls
Male Adult: Fr 16-18
1. STRAIGHT/ SINGLE: used once to get catch
2. INDWELLING: anchored using balloon
2.1 2 way
2.2 3 way: Nurses cannot insert needing 20 cc for
anchoring in BPH (UROLOGIST), Given with
KY and Lidocaine
2.3 FEMALES: Dorsal Recumbent; French 12 – 14;
3-4 inches insert; 1.5-2.5 FEMALE
URETHREA; Anchor at the INNER THIGH
2.4 MALE: Supine; 5.5-6.5 inches; urethra and S
shaped; Perpendicular insertion; Anchor at the
Lower Abdomen or Upper Thigh
*After removal of the Catheter: Urinate after 4-6 hours
2.5 CONDOMCATH: if the condom cannot grasp
penis, refer to the doctor for changing; Not used
due to ascending infection; PURPOSE IS ONLY
FOR MALE INCONTINENCE; must be secured
through a belt
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 20
*NORMAL: 30-60 cc/hr
*ANURIA: 10cc/hr
*Unexpected Situations and Associated Interventions:
Catherization
• No urine flow is obtained and you note that catheter
is in vaginal office; Leave catheter in place as a
marker; Obtain new sterile gloves and catheter set;
Once new catheter is correctly in place, remove the
catheter in vaginal orifice.
• Patient complains of extreme pain when you are
inflating the balloon; Stop inflation of balloon;
Withdraw solution from the balloon.
BLADDER IRRIGATION
1. OPEN SYSTEM (intermittent): For installation of
medications or irrigation of catheter
2. CLOSED SYSTEM (Intermittent or Continuous): For
those who had genitourinary surgery & for
instillation of medications, promoting homeostasis,
flushing of clots or debris
*NEVER INFLATE THE BALLOON UNLESS URINE
FLOWS
* Catheter can be placed in one month as long as no signs of
infection
*FIDES’ MANEUVER: application of pressure in the
bladder to stimulate urine
BOWEL ELIMINATION
- Inspection – Auscultation – Percussion – Palpation
approach
- Bowel sound (4 quadrants)
• ACTIVE: every 5-20 seconds
• HYPOACTIVE: 1 per minute
• HYPERACTIVE: every 3 seconds
• ABSENT: None heard in 3-5 minutes
- FECALYSIS: an inch of formed stool, 15-30 mL of
liquid stool
- Fecal occult blood testing / GUIAC TEST
1. DIARRHEA: given oral hydration therapy
2. CONSTIPATION: Exercise, Roughage; Bulk
former is safest form of laxative; Castor oil only
irritates the intestines
3. FECAL IMPACTION: Passage of watery stools,
prolonged stool; ONLY DIGITAL MANUAL
EXTRACTION, DANGER: VAGAL
STIMULATION
4. FLATULENCE: Cola, cauliflower;
CARMINATIVE ENEMA: to remove; if
carminative does not work: RECTAL INSERTION:
TUBE is inserted with KY jelly, 1 inch and inserted
for only 20 minutes and damage is created if placed
longer and other side is inserted into water which
forms big bubble that are aromatic;
5. ENEMA:
 FUNDAMENTALS OF NURSING PRACTICE

5.1 RETENTION: COLON until purpose is 2.2 HYPOTONIC: Distends colon, stimulates,
achieved softens (Tap water)
5.2 NON RETENTION: Removed after inserted 2.3 ISOTONIC: Distends colon, stimulates, softens
like cleaning, soap suds, hypotonic or isotonic (Normal saline)
enema 2.4 SOAP SUDS: Irritates mucosa, distends colon
(3-5 mL soap to 1L of water)
ENEMA 2.5 OIL: Lubricates feces (Mineral, olive,
APPROPRIATE SIZE cottonseed)
Adult: Fr 22-30
Child: Fr 12-18 Correct Volume *Unexpected Situations and Associated Interventions:
Adult: 750 – 1,000 mL Enema
Adolescent: 500 – 750 mL • Solution does not flow into the rectum; Reposition
School-aged: 300 – 500 mL rectal tube, if solution will still not flow, remove tube
Toddler: 250 – 350 mL and check for any fecal contents.
Infant: 150 – 250 mL • Patient cannot retain enema solution for adequate
LENGTH OF INSERTION amount of time; Patient needs to be placed on bedpan
Adult: 3-4 inches in the supine position
Child: 2-3 inches • Patient cannot tolerate large amounts of enema
Infant: 1 – 1 1⁄2 inches solution; mount and length of administration may
have to be modified if the patient begins to complain
*18 inches at high pressure; 12 inches at low pressure at Left of pain
sided Sim’s • Patient complains of severe cramping with
*If retained: reposition if not, may use SYPHONING introduction of enema solution; Lower solution
ENEMA through RIGHT SIDE LYING POSITION by container and check temperature and flow rate; If the
inserting 100 cc of water and connecting the water retained solution is too cold, or too fast, severe cramping may
and use a something to suck the fluid occur.
LAXATIVES SITZ BATH: 110-150 Celsius; Cerebral hypoxia if not given
1. BULK FORMING: Increases fluid, gaseous or solid ICE CAP; Rectal pack is submerged into the water
bulk (Metamucil, Citrucel)
2. EMOLIENT / STOOL SOFTENER: Softens and COLOSTOMY
delays drying of feces (Colace) - Size of stoma will be stabilized within 6-8weeks
3. STIMULANT / IRRITANT: Irritates / stimulates - Effluent: Foul smelling and irritating to the skin =
(Dulcolax, Senokot, Castor Oil) Ileostomy
4. LUBRICANT: Lubricates (Mineral Oil) 1. Guidelines for Ostomy Care
5. SALINE / OSMOTIC: Draws water into intestine 1.1 Keep patients as free of odors as possible.
(Epsom salts, Milk of Magnesia) 1.2 Empty ostomy appliance frequently.
1.3 Inspect stoma frequently
ENEMA 1.4 Normal color of stoma, pinkish-red, moist. Pale
1. TYPES or bluish indicates cyanosis or decreased
1.1 CLEANSING ENEMA circulation in the tissue
1.1.1 Prior to diagnostic test, surgery 1.5 Note the side of the stoma
1.1.2 In cases of constipation and impaction 1.6 Keep skin around the peristomal area clean and
1.1.3 Either be: High enema (12-18 in.) or dry
Low enema (12 in.) 1.7 Intake and output
1.2 CARMINATIVE ENEMA
1.2.1 To expel flatus *Unexpected Situations and Associated Interventions:
1.2.2 60 – 80 mL of fluid Colostomy
1.3 RETENTION ENEMA • Peristomal skin is excoriated or irritated; Make sure
1.3.1 Solution retained for 1-3 hours appliance is not cut too large; Assess for presence of
1.3.2 Oil enema, antibiotic enema, anti- fungal skin infection; Thoroughly cleanse skin and
helminthic enema, nutritive enema apply skin barrier; Allow to dry completely; Reapply
1.4 RETURN-FLOW ENEMA pouch
1.4.1 To expel flatus
• Patient continues to notice odor; Check system for
1.4.2 Alternating flow of 100-200 mL of fluid
any leaks or poor adhesion; Thoroughly empty pouc
in and out of the rectum
MEDICATION
2. COMMONLY USED ENEMA SOLUTIONS
1. PARENTERAL
2.1 HYPERTONIC: Draws water into colon
1.1 INTRADERMAL
(Sodium phosphate solution)
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 21
 FUNDAMENTALS OF NURSING PRACTICE

1.1.1 Gauge 25 -25 3.1 Hot water bags temperature: 110-125 degrees F
1.1.2 Insert only the bevel; zero to 15-degree 3.2 Disposable hot packs
angle 3.3 Floor lamp / gooseneck lamp / heat cradle
1.1.3 Epidermal 3.3.1 Bulb: 25 watts
1.1.4 Sensitivity test 3.3.2 Distance: 12-14 inches

1.2 SUBCUTANEOUS 4. DRY COLD APPLICATION

1.2.1 Stretch if fat, pinch if thin 4.1 Ice cap
1.2.2 Adipose layer of the buttocks, arms 4.2 Compress
1.2.3 Best site is abdomen, below the 4.3 After 15 mins
umbilicus!
1.2.4 Gauge 23-25, 5/8 inch inserted 5. TEPID SPONGE BATH
1.2.5 If long needle, insert 5/8; if short 90 5.1 Do anterior first
degree 5.2 Use 1 washcloths
1.3 INTRAMUSCULAR
1.3.1 Must be strictly 90 percent 6. SITZ BATH
1.3.2 1-1.5 inch 6.1 immersion of 110-115 degrees Fahrenheit
1.3.3 Gauge 22-23 6.2 do not remove rectal pack, remove rectal
dressing
1.4 Z-TRACK TECHNIQUE 6.3 may have cerebral hypoxia – put ice cap on
1.4.1 Deep IM forehead
1.4.2 Prevent leakage of solution to tissue
WOUND MANAGEMENT
*NO INSERTION IN GLUTEUS MAXIMUS, BUT ON - No gauze since it can stick to skin Center to outer
MINIMUS AND MEDIUS when cleaning
- Jackson Pratt
2. INTRAVENOUS • keep in negative pressure; remove drainage
2.1 IV Push: check backflow, if none do not insert • in head injury, can have JP but not on negative
2.2 IV infusion pump: for more accurate drip pressure since it can interfere with ICP
2.3 SOLUSET: chamber up to 100cc; microset
calibration HYGIENIC MEASURES
1. PERINEAL CARE
3. OPTHALMIC SOLUTION: lower conjunctival 1.1 Female: Dorsal recumbent; front to back
site; 1-2 drops at maximum 1.2 Male: Supine; circular; one stroke, one direction
4. RECTAL SUPPOSITORY: go beyond the anal 2. ORAL CARE
sphincter Inhaler; may use spacer 2.1 Brushing: circular technique
2.2 Lemon-glycerine swab, mineral oil
*DO NOT USE INHALER IN STEROIDS TO PREVENT 3. ORAL HYGIENE FOR UNCONSCIOUS
MOUTH SORES! 3.1 supine, head turned to one side
3.2 antiseptic solution
HEAT AND COLD APPLICATION 4. BED BATH
- Do not prolong more than 20mins, because of 4.1 Water temperature: 43-46 C or 110-115F
rebound 4.2 Arms: Long, firm strokes, distal to proximal
1. HEAT 4.3 Breasts: Female – circular; Male – Longitudinal
1.1 Vasodilation
Increase capillary permeability EXERCISE AND ACTIVITY
1.2 Increase cellular metabolism 1. ACTIVE-ASSITIVE: one side help the affected side
1.3 Increase inflammation 2. ISOTONIC: jogging; change in length
1.4 Sedative effect 3. ISOMETRIC: muscle tension no change in length
2. COLD 4. ISOKINETIC: weights
2.1 Vasoconstriction 5. AEROBIC: exceed oxygen needs
2.2 Decrease capillary permeability 6. ANEROBIC: does not exceed oxygen needs
2.3 Decrease cellular metabolism
2.4 Decrease inflammation
2.5 Local anesthetic effect MASSAGES
*INFLAMMATION: first 24 hours = cold then heat Pain – 1. EFFLEURAGE – smooth, long gliding stroke
cold; to block nerve 2. PETRISSAGE – large pinch of skin; “kneading”

3. DRY HEAT
UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 22
 FUNDAMENTALS OF NURSING PRACTICE

3. TAPOTEMENT – side of each hand, sharp hacking 2.1 INSOMNIA: difficulty falling asleep; avoid
movement caffeine, chocolates coffee; Non narcotic
sedative: MELATONIN
IMMOBILITY 2.2 PARASOMNIA: periods of waking up while
- Thrombus formation asleep
- Edema 2.3 SOMABULISM: walking
- Constipation 2.4 SOMNAMLOQUISM: Talking
- Urinary stasis: stones, calculi 2.5 NUCTURNAL EMISIS: BED WETTING
- Atrophy; Disuse syndrome 2.6 BRIXISM: grinding of teeth
- Trochanter roll to prevent external rotation of femur 2.7 HYPERSOMNIA: Excessive sleeping
1. PRESSURE ULCER 2.8 NARCOLEPSY: Uncontrollable desire to sleep;
1.1 Decubitus ulcer/ bed sore Amphetamines given
1.2 Prone in bony surfaces
1.3 SCORING: PAIN
1.3.1 1 – non blanchable erythema - SUBJECTIVE
1.3.2 2 – open lesion - May have psychogenic pain as well
1.3.3 3- with fat exposed - ACUTE: less than 6 months
1.3.4 4 – exposed muscles and bones - CHRONIC: more than 6 months
2. DRESSING - INTRACTABLE: not relieved
2.1 Transparent barrier - WONG AND BAKER SCALE: 1-10 rating
2.2 Gauze not used Phantom pain – pain from amputated limb
2.3 To absorb exudates - GATE THEORY OF PAIN: Substantia gelatinosa
2.4 Hydrocolloid - PAIN THRESHOLD:
SLEEP • May be psychological/ physiological o Heat
- REST: State of calmness; relaxation without and cold
emotional stress or freedom from anxiety. • Imagery and distraction
- SLEEP: State of consciousness in which the
individual’s perception and reaction to the THANATOLOGY: scientific study of death, includiong its
environment are decreased. etiology and digagmnosis
- PHYSIOLOGY OF SLEEP CYONICS: freezing body
• RETICULAR ACTIVATING SYSTEM POST MORTEM CRARE:
(RAS): responsible in keeping you awake and 1. Rigor: stiffening
alert 2. Algor: drop in temp
• BULBAR SYNCHRONIZING REGION 3. Livor: Discoloration of the body
(BSR): causes sleep
1. TYPES OF SLEEP\
1.1 NREM (Non-Rapid Eye Movement/ deep,
restful sleep / slow-wave sleep)
1.1.1 STAGE I: very light; drowsy; α
relaxed, eyes roll from side-to-side;
lasting a few mins.
1.1.2 STAGE II: light sleep; body
processes slow further (decrease
PR/RR), eyes are still; lasts about
10-20 mins.
1.1.3 STAGE III: domination of the
PNS; difficult to arouse; not
disturbed by sensory stimuli;
snoring; muscles totally relaxed.
1.1.4 STAGE IV: delta sleep; deep
slow-wave sleep
1.2 REM (Rapid Eye Movement): Where most
dreams take place; Brain is highly active,
hence, paradoxical sleep

2. COMMON SLEEP DISORDERS

UNIVERSITY OF SANTO TOMAS – COLLEGE OF NURSING | FJCP 2017 |α NOTES 23


2017

FJCP