FUNDAMENTALS OF NURSING

Outline of review for the boards

History of Nursing- World and Philippines
The Nursing theories
Concepts of Health and Illness
Human Basic Needs
Stress and Adaptation
ASSESSING HEALTH STATUS
VITAL SIGNS
PHYSICAL ASSESSMENT
CLIENT CARE
ASEPSIS
SAFETY
HYGIENE
MEDICATIONS
SKIN INTEGRITY
TERMINAL CARE
HEATH PROMOTION AND DISEASE PREVENTION
ACTIVITY and EXERCISE
REST and SLEEP
PAIN management
NUTRITION
FECAL ELIMINATION
URINARY ELIMINATION
OXYGENATION
CIRCULATION
Fluids and Electrolytes
History of Nursing

Intuitive Nursing

Apprentice Nursing

Dark Period of Nursing

Educated Nursing

Contemporary Nursing

Intuitive Nursing
Primitive and untaught
Code of HAMMURABI
Moses- Father of Sanitation
Hippocrates- Developed standards for client care, medical standards and need for nurses
Educated Nursing
Florence Nightingale- born May 12, 1820 in Florence ITALY
Trained: Germany at Kaiserswerth School

Founded the St. Thomas School of Nursing in England

Teachers are devoted clinical instructors solely for teaching
The first nurse to exert political pressure on government

Nursing in the PHILIPPINES

First School of Nursing= ILOILO MISSION hospital school of nursing
Anastacia Giron-Tupas= Founder of the PNA
Rosario Delgado= first PNA president
NURSING THEORIES
Theories in Nursing
Four concepts Central to Nursing:
P-E-H-N
Person
Environment
Health
Nursing
ENVIRONMENTAL THEORY
Relate nature with the bird- Nightingale
The act of utilizing the environment of the patient to assist him in his recovery
INTER-PERSONAL RELATIONS Model
Remember PEP talk
Hildegard PEPLAU
Therapeutic relationship:
Orientation= assist client to understand problem
Identification= Client dependence, inde and inter he recognizes his problems in this
phase
Exploitation/Exploration= Derives full value ini-exploit!!
Resolution= old and new goals put aside

Nature of Nursing- Definition of Nursing

The meaning of Nursing is VIRGIN
Recall the 14 needs!!!!!
Associate 14 virgin HENS
Virginia HENDERSON
She believes that clients need to express their emotions, remain independent,
autonomous
They must work in such a way that they feel a sense of accomplishment

21 nursing problems
Faid 21
Faye Abdellah

GENERAL THEORY OF NURSING- SELF- CARE

Associate Self care to ORAL care or per orem
Dorothea OREM
1. WHOLLY compensatory= unable to control
2. PARTLY compensatory= unable to perform SOME self care
3. SUPPORTIVE- EDUCATIVE= who needs to learn and needs assistance

BEHAVIORAL SYSTEM MODEL

Associate behavior with John (in John and Marsha)

kaya JOHN(son) magsumikap ka
Dorothy Johnson
Conservation Theory
the Divine is Conservative
Levin levine, divine

GOAL ATTAINMENT
Recall that the KING of the land has a GOAL to attain for his kingdom

IMOGENE KING!
Her theory is applicable to the child bearing women and their families

UNITARY BEING: Man as the CENTRAL Focus

Roger , Roger, let us unite our Man in the center of the battlefield
The whole is greater than its parts
Martha ROGERS
She believes in the use of the principles of NON CONTACT therapeutic touch

HEALTH CARE SYSTEMS model

Betty NEUMAN
Stresses, reactions to stress and adaptation to stressors
After overcoming the stresses you will become a NEW- Man
Intrapersonal stressor= illness
Extrapersonal stressors= financial concerns, community resources
Interpersonal stressor= unrealistic role expectations

ADAPTATION MODEL
Individual is a BIOPSYCHOSOCIAL ADAPTIVE system with input and output
associate this with a Nun
SISTER ROY= nag a adopt ng mga bata
Her theory supports the unity between the client and God

CULTURAL CARE DIVERSITY

Transcultural Nursing
Madeleine LEININGER

Nursing Process theory and CARE, CORE and CURE

The nurse who coined the word nursing process and stated I care, I core and I cure
Hall of Fame award!!!
LYDIA HALL

DYNAMIC NURSE-PATIENT Relationship

Associate dynamic action to the team of ORLANDO
Ida Jean ORLANDO!!!
Go Orlando, the dynamic team!!!!!

HUMAN BECOMING THEORY

Remember to become a rose per se , you must be a bud first!!!!!!!!!!!!
Rosemarie Parse
Her theory emphasizes that clients are the AUTHORITY figures and decision
makers for their personal health

HUMAN CARING THEORY

What is caring?
Jean WATSON
Caring for clients during their end-of-life experiences
Patricia Benners Stages of nursing expertise (NACPE)

Stage 1 = novice

No experience, performance is limited, inflexible

Stage 2= advanced
Beginner

Demonstrates MARGINALLY acceptable

performance, recognizes the meaningful aspects of
a real situation

Stage 3= competent

Has 2-3 years experience, demonstrates

ORGANIZATIONAL and planning abilities

Stage 4= proficient

Has 3-5 years of experience, perceives situations as

whole, has HOLISTIC understanding of patient

Stage 5= expert

Performance is FLUID, flexible and HIGHLY

Proficient, No longer requires rules, maxims
Demonstrates HIGHLY skilled intuitive and
analytic ability

HEALTH AND ILLNESS CONCEPTS

Health Definition

A state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity
WHO, 1948

Wellness
State of well-being
Seven Components- seven wishing WELL
Physical= carry out task
Social= interact with people
Emotional= express feelings
Intellectual= learn and use info
Spiritual= belief in supernatural
Occupational= leisure and work
Environmental= standard of living in community
Health Theories

CLINICAL

Health is absence of disease

ROLE PERFORMANCE
Health is ability to fulfill societal functions
ADAPTIVE
Heath is a creative process of adaptation
EUDEMONISTIC
Health is a condition of self-actualization
ECOLOGIC
Health is interaction of three elements:
Agent
Host
Environment

Health-Illness Continua

Dunn

Travis

Health Theories

Dunn

doon, dito, dine and dire

Four quadrants
HIGH level Wellness is functioning at the BEST possible level

Illness and Disease

DISEASE
Alteration in body functions
ILLNESS
A state of physical, social, emotional, intellectual, developmental or spiritual
functioning is DIMINISHED

Stages of Illness: S-A-M-D-R

SYMPTOM experiences
Client believe something is wrong
ASSUMPTION of the sick role
Excuse form work and family role
MEDICAL care contact
DEPENDENT CLIENT role
RECOVERY or REHABILITATION

HUMAN NEEDS
Abraham Maslows Hierarchy of needs

Physiologic needs- oxygen, water, food

Safety and security
Love and belonginess
Self esteem
Self actualization

Safety and security

Physical safety
Psychological safety
Shelter from harm
Love and belonginess
Need to love
Need to belong
Need for affection
Self esteem
Self-worth
Self-identity
Self-respect
Self-image
Self actualization
Self-fulfillment
Spiritual fulfillmen
Man and His needs

SelfActualizati
on
Self-Esteem

Love and Belongingness

Safety and Security

Physiologic Needs
Mans Need

Need is something desirable and useful

Needs are UNIVERSAL
Needs are MET in different WAYS
Needs are influenced by different FACTORS
Priorities may be CHANGED
Needs may be POSTPONED
Needs are INTER-RELATED

Need is something desirable and useful

Prioritization of needs mat be dictated by the clients perception

Nursing goal is this area is to:

Meet the PHYSIOLOGICAL needs of the patient
Assess the patient's perception of his other needs
Employ nursing Interventions according to the PERCEIVED NEEDS of the patient
NOT of the nurse

Evaluation Parameters of nursing care

The nurse checks if the desired criteria dictated by patients needs are achieved
Check which interventions were helpful
Revise the plan as needed

Man achieves self-actualization

(Udan)
A self-actualized person is basically a MENTALLY healthy person
And self-actualization is the essence of mental Health

MAN AND NATURE OF NURSING

Man
A Bio-Psycho-Social-Spiritual being

As a BIOLOGIC and SPIRITUAL BEING

Like ALL other man
As a SOCIAL BEING
Like SOME other man
As a PSYCHOLOGIC BEING
Like NO OTHER MAN

THE PRACTICE OF NURSING

Nursing Defined

act of utilizing environment of the patient to assist him in his recovery

CNA: a dynamic, caring, helping relationship in which the nurse assists the client to achieve
and obtain optimal health

Nursing Practice Scope

 Involves four areas (KOZIER)

1. Promoting health and wellness
2. Preventing illness
3. Restoring health
4. Care of the dying
Professional Nursing in the Phil

1.
2.
3.

Personal and professional qualities

Interest and willingness to work and learn with individuals in a variety of settings
Warm personality and concern for people
Competence, initiative and capacity to work

Professional Behaviors (Venzon)

Caring behaviors
Ability to practice legal, ETHICO-moral, social responsibilities
Critical and creative thinking
Skill in practicing K-S-A for promotion of health, prevention of illness, restoration of health,
alleviation of suffering and assisting clients to face death with dignity
The Standard of Nursing Practice
The purpose of standards of Nursing practice is to describe the responsibilities for which nurses
are accountable
Profession

An occupation, or calling requiring advanced training and experience in some specific body
of knowledge which PROVIDES SERVICE to society or that special field

Professional Nurse

Is a person who has completed a basic nursing education program and is licensed in his/her
country or state to practice professional nursing

Professional Goal of Nursing

As independent practitioners, nurses are primarily responsible for the promotion of

health/wellness and prevention of illness

Health Promotion

Helping people develop resources to maintain or enhance their health and well-being

1.
2.
3.

Health promotion programs

Information dissemination
Health Appraisal
Wellness assessment program

TRANSCULTURAL NURSING
Cultural care nursing

It is the provision of nursing care across cultural boundaries and takes into account the
context in which the client lives

It is professional nursing that is culturally sensitive, culturally appropriate, and culturally

competent

The suggested steps for culture care are:

1. Become aware of ones own culture heritage
2. Become aware of the clients heritage and health tradition
3. Identify clients preference in health practices, diet, hygiene, etc. These will affect their health
practices
4. Formulate a culture care plan
Prevention of illness

Employing activities that will hinder the occurrence of disease

Ex: Asepsis techniques, isolation

STRESS
Stress and Adaptation

STRESS
A condition in which the person responds to changes in the normal balanced state
Selye: non specific response of the body to any kind of demand made upon it

STRESSOR
Any event or stimulus that causes an individual to experience stress

1.
2.
3.
4.

SOURCES OF STRESS
Internal
External
Developmental
Situational

Physiological indicators of stress: Sympathetic response

Dilated pupils
Diaphoresis
Tachycardia, tachypnea, HYPERTENSION, increased blood flow to the muscles
Increased blood clotting
Bronchodilation
Skin pallor
Water retention, Sodium retention
Oliguria
Dry mouth, decrease peristalsis
Hyperglycemia

1.

Models of Stress
STIMULUS based models

1.

RESPONSE based models

1.

TRANSACTION based models

SELYES General Adaptation Theory

A-R-E

ALARM: sympathetic system is mobilized!

RESISTANCE: adaptation takes place
EXHAUSTION: adaptation cannot be maintained
ANXIETY
CATEGORY

MILD

MODERATE

SEVERE

PANIC

Perception and
attention

Increased
arousal

Narrowed focus

Inability to focus Distorted

perception

Communication

Increased
questioning

Voice tremors
Focus on
particular object

Difficult to
Trembling
understand
unpredictable
Easily distracted response

VS changes

NONE

Slight Increase

Tachycardia,
Palpitation,
Hyperventilation choking, chest
pain

Anxiety versus fear

ANXIETY

FEAR

State of mental uneasiness

Emotion of apprehension

Source may not be identifiable

Source is identifiable

Related to the future

Related to the present

Vague

Definite

Result of psychologic or emotional conflict Result of discrete physical or psychological

entity, definite and concrete events

VITAL SIGNS
VS

T
P
R

BP

TEMPERATURE

Reflects the balance between the heat produced and the heat lost from the body
CORE TEMPRATURE: deep tissues of body

Temperature Monitoring
Oral- accessible and convenient
Rectal- very accurate
Axillary- preferred for newborns
Tympanic- reflects core temperature
Body temperature has a diurnal variation

POINT of Highest body temperature is BETWEEN 8 pm to 12 midnight

POINT of Lowest body temperature is BETWEEN 4 am to 6 am
Temperature Alteration
FEVER, PYREXIA, HYPERTHERMIA
1. Intermittent: Periods of fever and normal temp
2. Remittent: Fever fluctuates BUT above normal
3. Relapsing: Fever for few days, then normal for few days
4. Constant: ALWAYS above normal, minimal fluctuation
Heat loss
Mechanism

Description

Conduction

Transfer of heat form one object to another by direct contact

Convection

Movement of air and heat by air current

Evaporation

Loss of heat through evaporation of water/sweat

Radiation

Transfer of heat from warm objects to cool objects in the

form of electromagnetic waves

Pulse

A wave of blood created by contraction of the left ventricle of the heart

Normal range: 60-100 BPM

Pulse pressure:
Systolic pressure MINUS diastolic pressure
Pulse deficit
Apical pulse MINUS peripheral pulse
Pulsus paradoxus

Systolic pressure falls by more than 15 mmHg during INHALATION

Pulsus alternans
Alternating strong and weak pulses

Respiratory rate

Normal range: 12 to 21 BPM

Respiratory pattern
Cheyne-Stokes
Kussmaul
Biot
Agoral

Blood Pressure

Measure of the pressure exerted by the blood as it flows though the arteries

Systolic and Diastolic

Average is 120/80 mmHg
Taking BP
Width of the BP bladder should be 40% of the circumference
Identify the FIVE phases of Korotkoffs sounds
K1= systolic, K5=diastolic
Error of BP reading
1. Too Narrow cuff
Falsely HIGH reading

2. Too wide cuff

Flasely LOW reading

NURSING FUNDAMENTALS IN RANDOM

Friends and Enemas

What is an ENEMA?
A solution introduced into the rectum and large intestine for the purposes of:
To relieve constipation
To relieve flatulence
To administer medication
To evacuate feces in diagnostics or surgery

Enema types
1.

Cleansing Enema= intended to remove feces to prevent escape during surgery, for
visualization procedure and constipation
Purposes To
1. Prevent escape of feces during surgery
2. Prepare intestines for diagnostics and surgery
3. Remove feces in constipation/impaction

Carminative enema= to expel flatus, 60-80 mL of fluids instilled

3. Retention enema= oil or medication is instilled to treat infection

4. Return flow enema= also to expel flatus, repeated 6 times

Enema Solutions
Hypertonic

Draws water into the colon

SE: Retention of sodium

Hypotonic

Distends colon, softens feces SE: F and E imbalance, water

intoxication

Isotonic

Distends colon

SE: possible sodium retention

Soap suds

Irritates colon

SE: May damage mucosa

Oil enema

Lubricates feces

The Height of the ENEMAS

During MOST enemas

For HIGH enema

No higher than 30 cm above rectum

Up to 45 cm above rectum

The TIME of the ENEMAS

Cleansing Enema

For Oil retention enema

5-10 minutes

30 minutes

The Length of the ENEMA tube insertion

The rectal tube is inserted 3 to 4 inches

KVO
Intravenous Infusion: 10 gtts/min
Blood Transfusion: 10 gtt/min (Udan) and 20 gtt/min (Kozier)
DIET ANOTHER DAY
Liquid Diet Vs Soft diet

Clear liquid

Full liquid

Soft diet

Coffee
Tea
Carbonated drink
Bouillon
Clear fruit juice
Popsicle
Gelatin
Hard candy

Clear liquid PLUS:

Milk/Milk prod
Vegetable juices
Cream, butter
Yogurt
Puddings
Custard
Ice cream and sherbet

All CL and FL plus:

Meat
Vegetables
Fruits
Breads and cereals
Pureed foods

LEVELS OF PREVENTION

Primary Prevention

Education, Exercise, Diet and

Nutrition, Immunization

Secondary Prevention

Physical Examination, Paps smear, BSE, TSE

Sputum AFB, DRE
Providing medication and treatment

Tertiary Prevention

Physical therapy, Self-monitoring of DM,

Speech therapy

Levels of Prevention
PRIMARY LEVEL OF PREVENTION
1. Family Planning and marriage counseling
SECONDARY LEVEL OF PREVENTION
1.
2.

ENCOURAGING MEDICAL CONSULTATIONS AND DENTAL CHECK-UPS

Assessing growth and development of children for nutritional evaluation

TERTIARY LEVEL OF PREVENTION

Teaching a client with diabetes self-monitoring of glucose level
ASEPSIS CONCEPTS
Hand-washing
The single most important measure to prevent infection

For routine care, it is required that vigorous hand washing with soap under a stream of
water for
At least 10 seconds (CDC, Kozier)
At least 15-30 seconds (Udan)

The chain of infection

Etiologic agent
Reservoir
Portal of exit from reservoir
Method of transmission
Portal of entry to the susceptible host
Susceptible host

Types of Immunity
Type

Antigen or antibody source

duration

Active Immuity

Antibodies are produced by the body in

response to an antigen

long

Natural
active

Antibodies are formed in the presence of active lifelong

infection

Artificial
active

Antigens (vaccines/toxoids) are injected to

stimulate antibody production

Many years

Antibodies are produced by another source

Short
About 6 months
to 1 year

Passive Immunity

Natural
passive

Antibodies are transferred naturally from an

immune mother to her baby through the
PLACENTA or BREAST FEEDING

Artificial
passive

Immune serum (antibodies) comes from another 2 to 3 weeks

source (humans/animals) injected to another
human

Immunity
Immunity

examples

ACTIVE natural

Infectious disease

ACTIVE artificial

Immunization with vaccines and

toxoids

PASSIVE natural

Placenta and Breastfeeding

PASIVE artificial

Injection of Immune serum, anti-toxins

Surgical Asepsis (Udan)

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

Required in these situations:

Surgical procedures
All procedures that invade bloodstream
Procedures that cause break in the skin
Complex dressing changes and wound care
Insertion of tubes, catheters into sterile body cavities like Urinary bladder
Care for HIGH risk groups: AIDS, cancer, burn pt

Principles and Practices of Surgical Asepsis (Kozier)

1.
2.
3.

All objects used in the sterile field must be sterile

Sterile objects become unsterile when touched by unsterile objects
Sterile items that are out of vision or below the waist level of the nurse are considered
unsterile
4. Sterile objects can become unsterile by prolonged exposure to airborne microorganisms
5. Fluids flow in the direction of gravity
6. Moisture that passes through sterile objects draws microorganisms form unsterile surfaces above
or below to the sterile surface by capillary action
7. The edges of a sterile field are considered unsterile
8. The skin cannot be sterilized
9. Conscientiousness, alertness and honesty are essential qualities in maintaining asepsis
Sterile objects are kept in view
Only the front part of the sterile gown of sterile
2 inches above the elbows to the cuff of the sleeves is sterile
Utilize sterile forceps to handle sterile items
A 1-inch margin at each edge of drapes is considered unsterile
Place sterile objects MORE than 1 inch inside the edges of the sterile field
Hospital Techniques
(Udan)
These precaution techniques like standard precaution and protective isolation are used to
prevent or limit the spread of infection
Standard precaution

1.
2.
3.
4.
5.

blood-borne and moist body substance pathogens

Wearing Intended to prevent transmission of of clean gloves
Performing hand washing immediately
Wear mask, eye shield during procedures that generate splashes
Wear gown if splashes, sprays, secretions cause soiling
Prevent injuries from needle & sharp objects

Precaution
Standard Precaution

Used in care of ALL hospitalized persons- applies to blood, all

body fluids, secretions, excretions

TRANSMISSION-based Airborne, Droplet and Contact

precaution
AIRBORNE
Measles, varicella and TB
Airborne droplet Private room, negative air pressure and N95 respirator when
nuclei less than t entering room
microns
DROPLET
Diphtheria, pneumonia, pertussis, mumps, German measles
Particles greater
than 5 microns

Contact

GIT, Respi, Skin and wound infection easily transmitted by

direct client contact or contact with client items

inflammation
A response of a living vascularized tissue to injury
It is also an example of LOCAL Adaptation to stress

1.
2.
3.
4.
5.

Cardinal Signs of inflammation:

Rubor= redness (initial change)
Calor= heat
Tumor= swelling
Dolor= pain
Functio laesa= loss of function

Stages: V-C-R
Vascular Response
Cellular formation
Repair
Nursing Interventions
Reduce inflammatory process
Minimize swelling
Relieve pain
Provide adequate nutrition: high calorie, high protein, high vitamin C
Promote rest
Administer prescribed medications
BODY MECHANICS
The efficient, coordinated and safe use of the body to produce motion and maintain balance during
the activity

The major purpose is :

To facilitate the safe and efficient use of appropriate muscle groups to maintain
balance, reduce the energy required, reduce fatigue and decrease the risk for injury

Two positions that should be avoided by the nurse because they cause back Injury

Twisting
Stooping

How to enhance body balance

1.

Widen the base of support

1.

Lower the center of gravity by bringing it closer to the base of support- FLEX the hip and
knees


1.
2.
3.
4.
5.

Principles of Body mechanics

Plan the movement and obtain assistance
Adjust working area to waist level
ELEVATE THE BED and LOWER SIDE RAILS
Face the direction of movement
Widen stance and contract gluteal , abdominal, leg and arm muscles BEFORE moving an
object

In all positions, it is important to maintain a distance of at least 12 inches between the feet
(Kozier)

Temperatures in Boards
Hot water Bag

SITZ BATH

Cooling Sponge Bath Alcohol Sponge Bath

Adult and more than 40-43 C

2 years-old:
46-52 C

18-32 C

Less than 2:
40-46 C

Tepid sponge bath:

37 C (Craven)

27-37 C

80-98 F (Udan)

PHYSICAL HEALTH ASSESSMENT

Physical Assessment: 4 methods
1.
2.
3.
4.

Inspection: visual examination

Palpation: touch
Percussion: act of striking the body surface
Auscultation: listening to sounds with stethoscope

Assessing The Respiratory System

NORMAL BREATHING PATTERN
The normal breathing pattern is smooth, even and regular
A description of the patients breathing pattern should include information about the rate,
rhythm, effort and quality.
Normal quiet breathing at rest occurs at the rate of 12 to 21 breaths per minute in adult.
Assessing The Respiratory System
NORMAL BREATHING PATTERN
The rhythm is steady. All breaths are evenly spaced, with an equal interval between each
breath. Exhalation is normally TWICE as long as inspiration.
Each breath is about the same size. The chest of the normal adult who is breathing will be
seen to rise and fall the same amount from breath to breath.

 Effort is nearly effortless. Little muscular work is required to move air through the lungs. No
sounds are associated with it.
Assessment of respiratory system
1. Nursing History
Relevant data in the history which focuses on the respiratory system include current and
past respiratory disorders, lifestyle, presence of cough, pain, medications for breathing and
assessment of risk factors.
2. Physical Examination
The techniques of Inspection, Palpation, Percussion and Auscultation are employed.
The rate, rhythm, depth and quality of respiration are observed.
Note for the color, consistency, and amount of sputum
UTILIZE THE diaphragm of the stet to hear breath sounds
Adventitious sounds

Crackles/Rales: Crackling sound BEST heard during inhalation

Rhonchi: Coarse, gurgling, vibrations heard during breathing with moaning or snoring
quality

Friction rub: creaking sound

Wheeze: Squeaky musical sound

Sound

Cause

Crackles/Rales
Rhonchi

Air passing through fluid or mucus

Air passing through narrowed air passageway as a result of
thick secretions, swelling, tumor

Wheeze

Air passing through a constricted bronchus/ bronchioles as a

result of secretions, swelling

Friction rub

Rubbing together of inflamed pleural surfaces

Abdominal Assessment

The sequence is always ask in the exam!=

Inspection
Auscultation
Percussion
Palpation

Auscultate with the use of the diaphragm in all four quadrants

The usual sequence is RIGHT LOWER quadrant RIGHT UPPER quadrant
LEFT UPPER quadrant LEFT LOWER quadrant
Normal bowel sounds: high pitched GURGLING occurring every 5 to 20 SECONDS

THE NURSING PROCESS

Assessment: gathering of data, validate and document data

Nursing diagnosis: analyze data, identify problems and formulate diagnostic statements
Planning: prioritizing problems, formulate goals and select nursing interventions
Implementation: carrying out the nursing measures, supervising, delegating, reassessing and
documenting activities
Evaluation: Compare evaluated data withy outcome criteria, continue, modify or terminate
client care

Characteristics of the Nursing process

Open and flexible

Cyclic and dynamic
Client centered
Individualized
Planned
Goal directed
Permits creativity
Emphasizes feedbacks
Universally accepted

ANA Standard of Clinical Nursing

Standard I
Assessment

The nurse collects data

Standard II
Diagnosis

The nurse analyzes the assessment data

determining diagnosis

Standard III
Outcome identification

The nurse identifies expected outcomes

Standard IV
Implementation

The nurse develops a plan of care,

prescribes interventions to attain
expected outcome

Standard V
Evaluation

The nurse evaluates the clients progress

toward attainment of outcomes

The Nursing assessment

First step

1.
2.
3.
4.

Components:
Collect data
Organize data
Validate data
Document data

A method of information collection for the establishment of data base

Types of Data

 SUBJECTIVE data
Symptoms reported by the patient
OBJECTIVE data
Signs and manifestations that are gathered by the nurse through Inspection, palpation,
percussion and auscultation
Diagnosing
2nd step

The process which results to a diagnostic statement

Clinical act of identifying problems
Analysis of assessment information to derive meaning from the analysis

The nursing Diagnosis

A statement of clients potential or actual alteration of health status
The nurse writes a summary statement that NANDA has developed
Activities in this step are:
Analyze data
Identify health problems, risks and strengths
Formulate diagnostic statements

1.
2.
3.

Writing Nursing Diagnosis

Different Nursing Diagnoses
Actual Nursing diagnosis
Risk nursing diagnosis
Wellness diagnosis
Syndrome diagnosis
Possible nursing diagnosis
Collaborative problems
ACTUAL Nursing Diagnosis
1. Utilize the P-r/t-E format
Problem related to etiology
2. Utilize the P-E-S
Problem-Etiology-Signs and Symptoms
P-r/t-E format
Ineffective airway clearance related to weak cough effort
P-E-S format

Ineffective airway clearance related to tracheobronchial infection as manifested by copious

sputum production and adventitious breath sounds

Guidelines in writing ND
1.
2.
3.

Prioritize according to clients needs

Write in terms of persons response rather than need
Use related to to connect the two parts of the statement
Avoid the terms due to and because of or secondary to
4. Write in legally advisable term

5. Write without judgment value

6. Be sure the two parts do not mean the same thing
7. Express problems and factors in terms that can be changed
PLANNING 3rd step
Designing a care plan
Activities in planning:
1. Formulate desired outcomes with client-based nursing diagnosis
2. Choose nursing interventions that can achieve the desired outcomes
Guidelines for formulating Nursing Objective
Goals are written with the end goal of reversal of nursing problem
Outcome criteria are similar to objectives
Objectives or OC are written to achieve the goals
They are related to human responses and centered on the patient, determined by the nurse
and patient
Writing Nursing Interventions
Precise actions to achieve desired outcomes
Consistent with plan of care
Define who/what/where/when/how and how often identified activities will take place
Individualized
Modifications of standard therapy as applicable
IMPLEMENTATION 4th step

The step concerned with doing, delegating and documenting client responses
The nurse MUST re-assess the client BEFORE employing nursing measures to be able to
determine if the interventions are still needed or are still safe\

1.

We carry out two interventions

Independent interventions

2.

Dependent interventions, Interdependent or Collaborative

EVALUATION 5th step

THE final step in the nursing process that involves collecting data and comparing the data
with the outcome criteria to determine goal attainment
THE nurse will either:
Revise the Care plan
Continue the care plan
Make a new care plan for a new problem

DOCUMENTATION and REPORTING

Documentation
Permanent record of client information and care

REPORTING
Takes place when two or more people share information about client care either face to face or
by telephone (Udan)
Purposes of Client record
Communication
Legal Documentation
Research
Statistics
Education
Audit
Planning care and reimbursement
Types of Records
Traditional client record
Problem oriented medical record
Kardex- series of cards with entries written in pencil
Characteristics of good recording
1.
2.
3.
4.
5.
6.
7.

Brevity
Use of INK
Accuracy
Appropriateness
Complete and timely organized
Use standard terminology
SIGNED

Reporting
1. Endorsements
Reporting done for continuity of care
Based on the health care needs of patient to be handled by the next shift nurses
Endorsements shall be as objective as possible related to client needs and care
2. Telephone reports
. Telephone orders
4. Transfer reports
Nursing Management
Staffing is the process of determining and providing the acceptable NUMBER and MIX of
nursing personnel to produce a desired level of care and to meet the patient demand for care
Steps in Staffing
1. Selection of personnel
2. Staff development

3.
4.

System assignment
Scheduling

Steps in STAFFING: SELECTION of PERSONNEL (RSIO)

1.
2.
3.
4.

Recruitment
Screening
Interview
Orientation

Steps in STAFFING: Staff development

Steps in STAFFING: System assignment
Steps in STAFFING: Scheduling
Recruitment
Advertising= most common method
Word of mouth
Recommendation
Screening
Screen out applicants who DO NOT fit the image of the agency
Try to fit the job to a promising applicant
Try to fit the applicant to the job
Usually the recruiter will ask about Work experience, personal history, educational history and biographic
data
Interview
To obtain further information about the applicant and to determine of the applicant is qualified for the
position
Orientation
Process of becoming familiar with a new environment and adapting well to it
SYSTEMS OF ASSIGNMENT
1.
2.
3.
4.
5.

Case Method
Functional Method
Team Method
Primary Method
Modular Method

CASE SYSTEM
Oldest method of delivering care
ONE nurse is assigned to give TOTAL nursing care to ONE client while ON DUTY!
Usually used for ICU patients and for assigning pts to nursing students
FUNCTIONAL SYSTEM
Most frequently used
Division of labor

 Nurses are assigned a specific task

Nurses tend to become highly competent only with the task repeatedly done
TASK-focused and Not Client-focused
TEAM NURSING
TEAM provides total nursing care to specific client or patient
Individualized patient care
A leader, the senior professional nurse in the unit, will do the coordination, supervision and
gather cooperation of all staff in delivery of patient care
Registered nurses and assistive personnel are given client assignments rather than TASK
Lack of continuity of care
Undefined role of RN an assistive personnel
Lack of time the leader can spread with clients
PRIMARY NURSING
Recent method- HOLISTIC approach in care
A PRIMARY nurse is responsible to give total nursing care to 4 to 6 patients 24 HOURS a
day from hospitalization to discharge
An associate nurse usually substitute the nurse when off duty, but the plan of care made by
the primary nurse is IMPLEMENTED
Nurses have AUTONOMY and AUTHORITY for patient care
Scheduling

1.
2.
3.
4.

To assign working days and day-offs to staff nurses in order to:

Provide adequate patient care while avoiding overstaffing
Achieve a desirable distribution of days off
Treat individual staff nurse fairly
Allow the staff to know in advance what their schedules are

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

Balance the need of employee and employer

Distribute fairly good and bad days off to all
Make sure they adhere to schedule. Request and exception must be in Writing
Advance posting of schedules
Be consistent in scheduling
Make sure that schedules conform with labor laws and hospital policy
Prepare for emergency changes

The NURSE MANAGER

The nurse manager PLANS, gives direction, develops staff, monitors operations, gives fair rewards
and represents BOTH staff members and administration as needed
Nursing Jurisprudence
The Philippine Nursing Act of 2002 (RA 9173) IS THE BEST GUIDE THE NURSE CAN UTILIZE
as it defines the scope of nursing practice
Intentional Wrongs= TORTS
Tort is a legal wrong committed against a person or property independent of a contract which
renders the person who commits it liable for damages in civil action

Examples of TORTS
1. Assault= attempt to touch another person, imminent threat of harmful or offensive bodily
contact
2. Battery = intentional, unconsented touching of another person
3. False imprisonment= unjustifiable detention of a person without a legal warrant
4. Invasion of Privacy and breach of confidentiality
5. Libel= written
6. Slander= spoken
Professional Negligence

NEGLIGENCE
Commission or omission of an act pursuant to a duty, that a reasonably prudent
person in the same or similar circumstance would do or would not do and the acting
or the non-acting of which is the proximate cause of injury to another person or
property

Elements of Negligence
1.
2.
3.
4.

Existence of a duty on the part of the person

Failure to meet the standards of due care
The forseability of harm resulting from failure to meet standard
The breach of the standard resulted in an injury to the plaintiff

Examples of Negligence
1. Failure to report observation to the physician
2. Failure to exercise the degree of diligence
3. Mistaken identity
4. Wrong medicine, wrong calculation, wrong route and wrong doses
5. Defects in the equipment such as stretchers and wheelchairs that may lead to falls
6. Errors due to family assistance
7. Administration of medicine without a doctors prescription
Res ipsa loquitur

1.
2.
3.

Three conditions are required to establish a negligence WITHOUT proving specific conduct
That the injury was of such nature that it would not normally occur unless there was a
negligent act
That the injury was caused by an agency within control of the defendant
That the complainant himself did not engage in any manner that would tend to bring about
the injury

MALPRACTICE

IMPROPER or unskillful care of a patient by a nurse

Stepping beyond ones authority with serious consequences
NEGLIGENCE or carelessness of a professional personnel
Negligent act committed in the course of professional performance

Consent

free and rational act that presupposes knowledge of the thing to which consent is being given
by a person who is legally capable of giving consent

Informed consent

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

Elements:
The diagnosis and explanation of the condition
Fair explanation of the procedures and consequences
Description of alternative treatments
Description of benefits to be expected
Material rights
The prognosis, if refused

Sleep
REST- a state of calmness, relaxation without emotional stress, and freedom from anxiety
SLEEP- an altered state of consciousness in which the individuals perception of and
reaction to the environment are decreased.

This can be discussed simply by considering the three basic research approaches:
ELECTROPHYSIOLOGIC
HORMONAL and
NEURAL

TYPES OF SLEEP
There are two types of sleep identified:
The NREM sleep (or the non-REM sleep) and
The REM sleep ( rapid eye movement sleep)
1. THE NREM SLEEP
Also referred to as the SLOW wave sleep, because the brain waves of the client are slower
than the alpha and beta waves of an awake or alert person.
It is a deep, restful sleep
There is a decreased physiologic functions
All metabolic processes are reduced
It is divided into FOUR stages:1-4
STAGE 1- the stage of very light sleep, sleeper can readily be awakened, lasts for a few minutes. The
eyes tend to roll slowly from side to side, and muscle tension remains absent.
STAGE 2- the stage of light sleep, body processes continues to slow down, and lasts about 10-15
minutes. Constitutes 40-45% of TOTAL sleep!
STAGE 3-refers to a medium-depth sleep where vital signs and metabolic processes slow further
because of the PARASYMPATHETIC nervous system influence. The sleeper is difficult to arouse.
STAGE 4-this is the deepest sleep or delta sleep. It is the stage where the heart rate and respiratory
rate drop 20-30% below those exhibited during waking hours. This stage is thought to restore the
body physically. Some dreaming may occur here. This stage may be absent in the elderly.
REM Sleep
THE REM SLEEP
This sleep type usually recurs about every 90 minutes and lasts 5 to 30 minutes.
Other name: PARADOXICAL Sleep
The EEG pattern resembles that of the awake state.
This is not as restful as NREM sleep

 Most dreams take place during this period and the dreams are usually remembered or
consolidated to memory
The brain is highly active with metabolic rate increasing as much as 20%
The sleeper may be very difficult to arouse
There are rapid conjugate eye movements, muscle tone is depressed, but gastric secretions
increase, HR and RR are increased and IRREGULAR
This sleep period becomes longer as the night progresses.
NREM versus REM
NREM

REM

Slow eye movement

Rapid Eye movement

Restful sleep

NOT restful

Decreased metabolism

Increased metabolism

Vital signs LOW

Muscle tone maintained
NO vivid dreams

Vital signs Irregular

Muscle tone depressed
Dreams occur

Sleep Cycle
All of us undergoes around 5t cycles of sleep of NREM to REM
We begin with STAGE 1234 32REM

Sleep cycle
AWAKE
Stage 1

REM

Stage 2

Stage 2

Stage 3

Stage 3
Stage 4

Stage 2
Stage 3
Stage 4

Sleep Variations
For NEONATES- newborns sleep for 16-18 hours divided into 7 sleep periods. They have
two sleep states- QUIET sleep (their NREM sleep) is characterized by closed eyes, regular
respirations and absence of eye/body movements; ACTIVE sleep is characterized by eye
movements observable through the closed eyelids, with body movements and irregular
respirations.
For INFANTS- some infants sleep for 22 hours, while the average is 12-14 hours. Their sleep cycle is
shorter (about 50-60 minutes). The REM sleep is 20-30% (which decreases as the infant grows and
will stabilize at 20% until late in adulthood). About 50% of the sleep is spent during LIGHT sleep
(Stage 1).
For TODDLERS- the sleep requirement is 10-12 hours a day. The same 20-30% of sleep is
REM. The normal sleep wake pattern is established at age 2-3.
Bedtime rituals often develop and assume great importance in providing nighttime security.
For PRESCHOLERS- they usually require 11-12 hours of sleep per night. The REM sleep is
still 20-30%. Many of the preschoolers resist going to sleep
Remember that the preschoolers have fear of the dark that nurses must anticipate to guide the
mothers
For PRESCHOLERS Suggested Measures by Pilliteri:
1. Read bedtime stories until patient sleeps

2.
3.

Reassure that child is Safe

Monitor environmental stimuli such as television and noise

Nursing Interventions
Assessment relative to a clients sleep includes a sleep history, sleep diary, physical
examination, and a review of laboratory studies
The single most important criterion for adequacy of sleep/rest is the patients statement.
1. CLIENT HEALTH TEACHING- nurses should teach the client about the importance of
rest and sleep.
The following are needed to be taught- the conditions that promote sleep, the safe use of
sleep medications, the effects of meds on sleep and the effects of the diseased states in their
sleep.
2. SUPPORTING BEDTIME RITUALS
Nurses can promote sleep by supporting the rituals like an evening stroll, music, TV, bath
and prayer.
Children should promote pre-sleep routines like bedtime stories, holding the favorite toys,
drinking warm milk etc.
3. CREATING A RESTFUL ENVIRONMENT darkened room or dim-lit room can be provided for the patients.
Noise should be reduced to a minimum
environmental distractions should be eliminated.
SAFETY: placing beds in low positions, using night-lights and placing call beds
within easy reach.
People with impaired physical mobility should be assisted with voiding before
retiring.
Fluids may need to be restricted in the evening
4. PROVIDING COMFORT AND RELAXATION- comfort measures are essential to help
the client to fall asleep and stay asleep.
providing loose-fitting nightwear, hygienic routines
providing clean dry linens
offering back massages
positioning patients in a comfortable position, correct medication administration to
avoid sleep interruptions, etc.
5. ENHANCING SLEEP WITH MEDICATIONS- sleep medications are prescribed on a
PRN basis for clients.
Medications include- sedatives, hypnotics, anti-anxiety drugs, and tranquilizers.
Hypnotics may be used as a short term intervention during situational induced sleep
pattern disturbance
Sleep deprivation
A prolonged disturbance in amount, quality and consistency of sleep
Restlessness, irritability, withdrawal, speech deterioration
NREM versus REM
Dream:
Associate DREM
Pain

 Pain is an unpleasant sensory and emotional experience associated with actual or potential
tissue damage.
It is sometimes referred to as the FIFTH vital sign

PAIN
ACUTE pain
Mild to severe
Sudden
Sympathetic system

CHRONIC pain
Prolonged
Persisting 6 months or longer
Parasympathetic responses

Pain Theory: Gate control

Melzack and Wall developed gate control theory in 1965. The theory proposes that the substantia
gelatinosa (SG) in the spinal cord acts as a gating mechanism to permit or inhibit passage of pain

impulses. The gate can be closed (so that the contact is not made, thus interrupting the pain
impulse) by nerve impulses from the large non-nociceptive A-beta and A-alpha fibers or from the
descending pathways
Impulses conducted over large fibers not only close the gate but also are sent immediately to the
cortex for rapid identification, evaluation, and modification of the sensory inputs
Impulses sent to the brainstem, the center for motivational-affective and sensorydiscriminative actions, can influence cognition or evaluation in the cortex. Impulses are then
sent from the cortex back to the SG via corticospinal pathways to inhibit or permit passage
of pain impulses.

Catheterization (Kozier)

Explain procedure
Wash hands
Drape areas except perineum
Open the sterile catheterization kit
Apply sterile Gloves
Lubricate catheter
Cleanse the meatus
Insert catheter

Grasp 2-3 inches from the catheter tip and insert

Advance the catheter 2 inches further after the urine begins to flow
Male: Insert around 6-9 inches

 Female: insert around 3-4 inches

DEATH and DYING
Loss and grieving

LOSS= something valuable is gone

GRIEF= total response to emotional experience related to loss
BEREAVEMENT= Subjective response by loved-ones
MOURNING= behavioral response

Stages of Grieving (Kubler-Ross)

DABDA
DENIAL= refusal to believe
ANGER= hostility
BARGAINING= feeling of guilt, fear of punishment
DEPRESSION= withdrawn behavior
ACCEPTANCE= comes to terms with loss
Loss and grieving

Stages

Behaviors

Refuses to believe that loss is happening

A
B

Retaliation

Laments over what has happened

Begins to plan like wills, prosthesis

Feelings of guilt, punishment for sins

Death and Dying (Kozier)

AGE

Beliefs

Infancy to 5 years old

NO clear concept of Death

It is Reversible, temporary sleep

5 to 9 years

Understands DEATH is FINAL but can be AVOIDED

9-12 years

Death is INEVITABLE, everyone will die someday

Understands own mortality

12-18 years

Fears a lingering Death

18-45

Attitude is influenced by religion

45-65 years

Experiences peak of death anxiety

65 and above

Death as multiple meanings

Nursing responsibilities In Death and dying

Nurses need to take time to analyze their own feelings about death before they can effectively help
others with terminal illness

1.
2.
3.

The major goals for the dying clients are:

To maintain PHYSIOLOGIC and PSYCHOLOGIC support
To Achieve a dignified and peaceful death
To maintain personal control

Death and Dying RESPONSIBILITIES

Provide Relief from loneliness, fear and depression

Help clients maintain sense of security
Help clients accept losses
Provide physical comfort

The fowlers

LOW fowlers= 15 to 30 degrees

SEMI fowlers= 30-45 degrees

FOWLERs= 45-60 degrees

HIGH Fowlers= 60-90 degrees

Car safety

Infants up to 9 kilograms or 20 pounds should FACE the REAR

Children greater than 9 kilograms or 20 pounds should be in the FORWARD facing position
in the BACK seat of the car

PAIN

Highly unpleasant personal sensation

Most acceptable theory: GATE CONTROL THEORY
PQRST
Quality: Tell me what your pain feels like

Potassium

Banana (small)= 9.5 mEq/L

Orange= 9.5 mEq/L

Potato (medium)= 12.5 mEq/L

Watermelon (1/2 slice)= 15.3

Clear liquid diet

Lacks calories
Permitted fluids:
Coffee
Tea
Carbonates drinks
Fat-free broth
Clear fruit juices
GELATIN
popsicles

Full liquid

All foods in clear liquid

Milk and Milk drinks

Pudding , custards
Ice cream
Cream, butter, margarine
Yogurt
Vegetable juices

Food Guide pyramid

Bread, cereals, rice and pasta= 6-11 servings

Fruit and vegetables
Meat, poultry, fish, dry beans, eggs
Milk, yogurt, cheese
Fats, oils and sweets

The definitions of A
ANOMIA= inability to NAME object
AGNOSIA= inability to RECOGNIZE things
APRAXIA= inability to PERFORM previously learned movements/behavior
ATAXIA= lack of COORDINATION in movement
APHASIA= lack of power to express oneself by speech, writing or signs, lack of power to understand
spoken/written language