FUNDAMENTALS OF NURSING

Vital Reparative Process

Man  By Florence Nightingale
 Forms the foundation of  Man is passive in influencing
Nursing the nurse or the environment

Four Components or Attributes of Man is a whole. Man is complete

Man  By Virginia Henderson
 Capacity to think on an  Man has fourteen (14)
Abstract Level fundamental needs
 Establish a family
 Establish a territory Human Needs
 Ability to use verbal symbols  Needs are physiologic and
as language psychologic
 Both these needs must be
Concept: met in order to maintain well-
 Animals form a family by being.
instinct
 Via hormonal scents Key Concept:
 Basic Human Needs are
Nursing Concepts of Man equivalent to COMMON
Biopsychosocial Spiritual Being NEEDS
 By Sister Calista Roy
 Man interacts with the Characteristics of Human Needs
environment  Universal
 Interrelated
Open System  One need is related to another
 By Martha Rogers need
 Man interacts with the  May be stimulated by internal
environment or external factors
 Exchanges matter with energy  May be deferred (but not
 Exchanges energy with indefinitely)
environment
Maslow’s Hierarchy of Needs
Unified Whole
 By Martha Rogers Why do we study this?
 Man is composed of certain  In order to prioritize nursing
parts actions
 Total of those parts is more
than the sum of all parts 1. Physiologic needs
 This is because man has  Food, maintenance of
attributes homeostasis
2. Safety and security
3. Love and belongingness
4. Self-Esteem

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  Feeling good about one’s self  Open to new ideas
 Two factors affecting Self- o Not adopts new ideas
esteem o Not one track mind
o Yourself  Highly creative and flexible
 Sense of  Does not need fame
adequacy  Problem-centered rather than
 Accomplishment self-centered
o Others
 Appreciation Concept:
 Recognition  Self-Actualization is very
 Admiration difficult to attain
 Belongingness  It is impossible to attain
5. Self-Actualization  New needs come after getting
 Able to fulfill needs and one need
ambitions
 Maximizing one’s full potential Illness
6. Aesthetics  Highly subjective feeling of
 Beauty being sick or ill

Two Additional Needs by Maslow Two types of Illness:

 Need to know Acute Illness
 Need to understand  Sudden in onset (most of the
time, but not always)
Richard Kalish  Less than six (6) months
 Man needs stimulation
 Needs to explore Chronic Illness
o Sex  Gradual in onset (most of the
o Activity time, but not always)
o Novelty  Types of Chronic Illness
o Exacerbation
 Stimulator
 Period
 Desire to come
characterized by
up with
active signs and
something of
symptoms of the
your own
illness
o Remission
Characteristics of Self-Actualized
Persons  Periods where
 Judges people correctly no signs and
symptoms are
 Superior perception
present
 Decisive
o Capable of making
Disease
decisions
 Objective pathologic process
 Clear notion as to what is right
and wrong Concepts:

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  Illness without disease is
possible Walter Cannon
 Disease without illness is  Ability to maintain
possible homeostasis
 Illness may or may not be  A dynamic equilibrium
related to a disease  A state of balance of the
 One can have a disease internal environment while
without necessarily feeling ill external environment is
changing
Deviance
 Any behavior that goes Florence Nightingale
against social norms  Health is using one’s power to
 Shortens life span the fullest
 Results to disrupted family  Being well
and community  Can be maintained by
manipulating the environment
Concept:
 Deviant behavior can be Virginia Henderson
considered a disease  Viewed in terms of ability to
perform the fourteen (14)
Rationale: fundamental needs or
 Because it also shortens the components of nursing care
life span like a disease UNAIDED

Example: Martha Rogers

 Alcoholism  Positive health symbolizes
o A disease rather than a wellness
social problem  Health is a value term defined
by a certain culture
Wellness
 Feeling of being well Sister Calista Roy
 A state and process of being
Definitions of Health and becoming an
INTEGRATED PERSON
World Health Organization
 Health is the complete Dorothea Orem
physical, mental, social  Characterized by soundness
(totality) well-being and not and wholeness of
merely the absence of DEVELOPED HUMAN
disease or infirmity STRUCTURES and
 A high-level wellness! FUNCTIONS

Claude Barnard Imogene King

 Ability to maintain internal  A dynamic state in the life
milieu cycle (contrasted with illness)

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  Illness is interference in the o Perceived seriousness
life cycle o Perceived threat
 Likelihood of Action influenced
Betty Neuman by:
 Wellness is that all parts and o Perceived benefit out of
subparts are in harmony with the action
each other and the whole o Perceived barriers
system

Dorothy Johnson
 Elusive dynamic state Smith’s Four Levels of Health
influenced by biologic, 1. Clinical Model
psychologic and social factors  Man is viewed as a
Physiologic Being
Models of Health and Illness  If there are no signs and
symptoms of a disease, then
Health-Illness Continuum you are healthy
Dunn’s High Level Wellness and  Against WHO definition of
Grid Model health
 X-axis is HEALTH  This is the NARROWEST
 Y-axis is environment concept of health
Quadrant 1 2. Role Performance Model
 High-level wellness in  As long as you are able to
favorable environment perform SOCIETAL functions
Quadrant 2 and ROLES you are healthy
 Protected poor health in 3. Adaptive Model
favorable environment  Health is viewed in terms of
Quadrant 3 capacity to ADAPT.
 Poor health in unfavorable  Therefore, goal of treatment is
environment to restore capacity to adapt.
Quadrant 4  Failure to adapt is disease
 Emergent high-level wellness 4. Eudaemonistic Model
in unfavorable environment  This is the BROADEST
concept of health
Health Belief Model
 Because health is viewed in
 By Rosentock terms of Actualization
 Based on a motivational
theory Leavell and Clark’s Agent, Host,
 It assumed that good health is Environment Model
an objective common to all  Also known as the Ecologic
people Model
 Consider perceptions  Expands to the MULTI-
(influences individuals CAUSATION of a DISEASE
motivation toward results)  Definitions of a disease as to
o Perceived susceptibility its cause is expanded to a

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 multi-causation of a disease
(i.e. cancer is a multi-factorial Effects of Adrenalins
disease)  Increases Cardiac Rate
 Triad is composed of the  Response to increased
agent, host and susceptible metabolic rate and oxygen
host demand
 Based on the interplay of  Increases Respiratory Rate
three components of the  Response to increased
model metabolic rate and oxygen
demand
Concept of Health and Illness  Bronchodilation
 Vasoconstriction
Stress  Increased Peripheral
 By Hans Selye Resistance
 Is a non-specific response of  Increased Cardiac Workload
the body to any demand  Increased Blood Pressure
placed upon it.
 Decreased Renal Perfusion
 General Adaptation Syndrome
 Decreased Renal Output
(GAS)
 Pale, Cool, Clammy Skin
 Local Adaptation Syndrome
(LAS)
Adrenal Gland is composed of:
1. Adrenal Medulla
General Adaptation Syndrome
 Releases adrenalins
Involves two (2) body systems:
2. Adrenal Cortex
 Nervous System
 Releases the following:
 Endocrine System
 Mineralocorticoids
o Aldosterone
Nervous System involves:
 Sympathetic Nervous System  Glucocorticoids
 Parasympathetic Nervous  Cortisol
system o A potent
vasoconstrictor
Endocrine System involves:
 Adrenal Glands Mineralocorticoids
 Increased Aldosterone levels
The Adrenal Gland is composed  Increases sodium retention
of: and water retention
 Adrenal Medulla  Increases circulating blood
 Adrenal Cortex volume
 Increases cardiac workload
Adrenal Medulla releases (due to vasoconstriction)
Adrenalins or Fight or Flight
Hormones: Glucocorticoids
 Epinephrine  Increased hyperglycemia
 Norepinephrine (transient)

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  Increased glycogenolysis  Stress resulted from
 Increased neogenesis interaction of man with his
 Increases blood sugar environment and fellowman
 Increases osmotic pressure  Therefore, Lazarus describes
 Increases fluid retention the SOCIAL ASPECT OF
(glucose is a colloid which STRESS
attracts water and adheres to  Also an adopted
it) PHYSIOLOGIC RESPONSE
 Increases cardiac workload
Key Concept!
Concept:  The most comprehensive
Complications of Stress: concept of stress is the stress
 Cerebrovascular Attack concept of LAZARUS as it
 Increased Diabetic combines Physiologic and
Ketoacidosis (if patient is Social aspects of stress.
diabetic)
 Hypertension leading to Statements about Stress
cardiac arrest  Stress is NOT a nervous
energy
Local Adaptation Syndrome  Man, whenever he encounters
 Also known as non-specific stress, tends to adopt
inflammatory response  Are you going around all
 Bradykinin stress? ANSWER IS NO!!!
o Activates inflammatory because stress is not always
response to be avoided and stress is
o Activates histamine not always undesirable
 Stress may lead to another
 Histamine
stress
o Activates the following:
 A single stress does not lead
 Prostaglandin
to a disease
 Serotonin
Concepts:
Concept:
 Adaptation to stress
 Bradykinin, Histamine, comprises of adjustments
Prostaglandin, and Serotonin made in order to cope with a
all increase swelling stressor
Key Concept!
 Man is holistic in his
 Hans Selye adaptation to stress
o Author of Physiologic
 It involves the totality of man:
Response to Stress o Physiologic
o Psychologic
Lazarus
o Social
 Stress is a transaction

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Illness Behavior and Stages of Factors Affecting Compliance
Illness  Client motivation
 Degree of required change in
Illness Behavior lifestyle
 Pertains to any activity  Perceived severity of health
undertaken by a person who problem
feels ill in order to  Difficulty of understanding
 Define his state of health instructions
 Discover a suitable remedy  Belief about the effectiveness
of the therapy
IGUN – Eleven stages of Illness  Nature of the therapy itself
and Health-seeking Behaviors o Adverse effects
1. Symptom Experience o Cost
 Client realizes there is a  Cultural influences
problem
 Degree of satisfaction with the
 Client responds emotionally relationship with health care
2. Self-medication / Self-treatment (if providers
not effective)
3. Communication to others Suggested Nursing Actions in
4. Assessment of symptoms case of Non-compliance
 Purpose is to verify the  Assess the reasons
veracity of the complaint
 Correct the misconception
5. Sick-Role Assumption
 Demonstrate a caring attitude
6. Concern Stage
7. Efficacy of treatment  Encourage and provide
positive reinforcement
 Assess sources of treatment
o Focusing on the
 Assess potential effectiveness
positive rather than on
of treatment
the negative
8. Selection of Treatment Stage
o Focus on things patient
 Availability
can still do and not on
 Cost of Treatment
what the patient can no
9. Treatment Proper
longer do
10. Assessment of Effectiveness of
 Establish a therapeutic
Treatment
relationship of freedom and
 May go back to stage 7
mutual responsibility
(Efficacy of Treatment) if
o Make patient realize he
treatment is not effective
is also responsible for
 May go to next stage if
his recovery
treatment is effective
o He is a partner with the
11. Recovery and Rehabilitation
health care team
o He is an active
Compliance
participant
 Adherence to professional’s
advice
Guidelines to Enhance
Compliance

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  Be sure patient understand
procedure by giving Martha Rogers
information  Nursing is a HUMANISTIC
 Make sure patient is capable SCIENCE dedicated to
of performing activity compassionate concern for
o Set realistic goals the promotion of health,
 Ensure that he is a WILLING prevention of illness and
participant rehabilitation of the sick
o Look for buying signals
 Looking at Sister Calista Roy
wound  Nursing is a THEORETICAL
 Looking at SYSTEM OF KNOWLEDGE
materials that prescribes analysis and
needed action related to the care of
the sick or ill
Definitions of Nursing:  It is a set of knowledge
American Nurses Association
 Nursing is the diagnosis and Dorothea Orem
treatment of human  Nursing is a helping service to
responses to illness (to actual any individual who is sick
and potential health problems)  It comprises of wholly
dependent or partly
Canadian Nurses Association dependent care when the
 The same definition plus… person is unable to do so.
 … includes the supervision of  Defines nursing in terms of a
functions and services in NEED!
collaboration with others to
promote health Imogene King
 Nursing is a helping
Florence Nightingale profession that assists a
 Nursing is the act of utilizing person (same with
the ENVIRONMENT for the Henderson) towards a
following purposes: DIGNIFIED DEATH
o Recovery
o Reparative process Betty Neuman
 Nursing is a profession that is
Virginia Henderson concerned with
INTRAPERSONAL,
 The unique function of the
INTERPERSONAL, and
nurse is to assist individuals,
EXTRAPERSONAL
sick or well, with the activities
VARIABLES affecting a
towards health that he would
person’s response to
do unaided, if with strength
stressors
and knowledge. If that is not
possible, towards a
PEACEFUL DEATH

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Dorothy Johnson 2. Dorothy Johnson
 Nursing is an EXTERNAL  Behavioral Systems Model
REGULATORY FORCE that  Seven Subsystems
regulates the ACTION or o Attachment and
BEHAVIOR of a person when Affiliative
such behavior constitutes a o Dependency
threat, in order to preserve his o Ingestive
organization o Eliminative
o Sexual Achievement
 Example: o Aggressive
o In a COPD patient who
remains a smoker, the 3. Virginia Henderson
nurse who encourages
 Fourteen (14) Fundamental
the patient not to
Needs focusing on
smoke, serves as an
PHYSIOLOGIC SOCIAL
external regulatory
RECREATION
force
4. Faye Abdella
Faye Abdella
 Problem Solving Approach to
 Nursing is a service to
Twenty-One (21) Nursing
individuals, families… and
Problems
therefore, to society
 Focus is on PROPER
 Conceptualized nursing as an
IDENTIFICATION of the
ART and SCIENCE of
problem
MOLDING THE INTELLECT,
 Particularly about the proper
ATTITUDE and SKILLS of the
nursing diagnosis
nurse
 Nursing in terms of providing
5. Marjorie Gordon
education
 Proposed the Human
Functional Health Patterns
Hildegard Peplau
used as a systematic
 Nursing is the
framework for data collection
INTERPERSONAL process of
 Focus is on Eleven (11)
THERAPEUTIC
Health Patterns
INTERACTION between the
nurse and the patient.  Advantage to the nurse:
o It enables the nurse to
NURSING THEORIES determine the client’s
response as functional
Concept: or dysfunctional
 First Nursing School –  Eleven Functional Health
Florence Nightingale Patterns
o Health perception
1. Florence Nightingale o Nutritional / Metabolic
 Environmental Nursing Theory o Elimination

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 o Activity and Exercise  3. Conservation of Personal
Pattern Integrity
o Cognitive Perceptual o Example: maintain
Pattern patient’s privacy
o Role Relationship  4. Conservation of Social
Pattern Integrity
o Sexuality / o Example: maintenance
Reproductive of patient’s
o Coping-Stress- relationships
Tolerance
o Value Belief Patterns 9. Betty Neuman
 Health Care Systems Model
6. Imogene King  The concern of nursing is to
 Goal Attainment Theory PREVENT STRESS
 Patient has three (3) INVASION
interacting systems:
o Individuals / Personal 10. Dorothea Orem
systems  Self-care and Self-care Deficit
o Group systems / Theory
Interpersonal systems  Three (3) Nursing Systems
fraternity based on Art of Care of
o Social systems Patient Needs
 1. Partial Compensatory
7. Madeleine Lehninger o Patient performs some
 Transcultural Nursing Theory / of nursing care needs
Model  2. Wholly Compensatory or
 Nursing is a HUMANISTIC Total Compensatory
and SCIENTIFIC mode of o For paralyzed patients,
helping through CULTURE- for ICU patients
SPECIFIC PROCESS  3. Supportive-Educative
o For up and about
8. Myra Levine patient
 Four (4) Conservation
Principles of Nursing 11. Hildegard Peplau
 1. Conservation of Energy  Interpersonal Model
o Example: complete bed  Four (4) Phases of Nurse-
rest without bathroom Patient Interaction
privileges  1. Orientation
 2. Conservation of Structural o Nurse and patient test
Integrity the role each one
o Example: turn patient assumes
from side to side every o Prepares patient for
two hours to avoid bed termination
sores o Patient identifies areas
of difficulty

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  2. Identification Phase  Man is a
o Patient identifies with BIOPSYCHOSOCIAL BEING
the personnel who can  Four (4) modes of Adaptation
satisfy his needs o Physiologic Mode
 3. Exploitation Phase  Compatible with
o Nurse maximizes all Hans Selye
the resources to benefit o Self Consent
the patient o Role Function
 4. Resolution Phase or o Interdependence
Termination Phase
o Occurs when patient’s 14. Lydia Hall
needs have been met  CARE, CORE, CURE
 Care
Concepts: o Comfort measures
 Various settings for given by the nurse to a
application of: patient
o Pre-Interaction Phase o Nurturance aspect of
 In psychiatric Nursing
setting, this  Core
consists of o Therapeutic use of self
gathering data  Cure
o Pre-Entry Phase o Activities in relation to
 In community doctors’ orders
health nursing, o Dependent orders
this consists of a
courtesy call 15. Jean Watson
12. Martha Rogers
 Human Caring Model
 Science of Unitary Human
 Nursing involves the
Beings
application of ART and
 Man is composed of energy HUMAN SCIENCE through
fields, which are in constant TRANSPERSONAL
interaction with the TRANSACTIONS in order to
environment help the person achieve mind,
body and soul harmony
Concept:
 The most reliable method of 16. Rosemarie Rizzo Parse
identification is the Energy  Theory of Human Becoming
Field. This is better than the
 Emphasis is a FREE CHOICE
fingerprints as a person’s
(with personal meaning)
energy field is absolutely
 Actions of patients may either
unique!
be:
o Revealing or
13. Sister Calista Roy
concealing
 Adaptation Model
o Enabling or limiting

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  Therefore, there is a 20. Margaret Newman
consequence  Health as Expanding
o This pertains to Consciousness
behavior and action  Humans are Unitary Human
Beings
17. Josephine Patterson and  The nurse is a NOT A GOAL-
Loretta Zderad SETTER or an OUTCOME
 Humanistic Nursing Practice PREDICTOR, rather is a
Theory PARTNER OF THE PATIENT
 Nursing is an EXISTENTIAL
EXPERIENCE between the 21. Joyce Travelbee
nurse and the patient  Interpersonal Process Theory
(nagkataon-nagkatagpo!)  Nurse needs to go beyond
 Nursing is a LIVE DIALOGUE nursing roles to establish
between the patient who therapeutic relationship
wants to be nursed and the  TRANSPERSONAL
nurse who has the skill to COMMUNICATION as the
nurse means to establish
therapeutic relationship
18. Helen Tomlin, Evelyn Tomlyn  This implies that the nurse
and Mary Ann Swain should not be rigid in the
 Modeling and Remodeling nursing role
Theory
 Focus is on the PERSON 22. Ida Jean Orlando
 Emphasis is on the  Dynamic Nurse-Patient
UNCONDITIONAL Relationship Model
ACCEPTANCE of the  There is movement, the
PATIENT relationship is not static
 If the patient’s condition
19. Ann Boykin and Savina improved, then the
Schoenhofer intervention is effective and
 Grand Theory of Nursing as the patient moves on to new
Caring Theory problems
 Nursing is NOT BASED on a
DEFICIT but rather it is an 23. Nola Pender
EGALITARIAN MODE of  Health Promotion Model
helping  Motivation to participate in
 This theory is against the health care activities is
theory of OREM influenced by COGNITIVE
 Nursing is an obligation and PERCEPTUAL
towards humanity, whether FACTORS, which are:
there is a need or NOT! o Importance of health to
the person
o Perceived control of
health

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 o Self-efficiency o Patient’s illness is
o Perceived health status controlled
o Definition of health o Patient may still be in
o Perceived barriers to the hospital
action  6. Unstable Phase
o Patient is on a critical
24. Poppy Buchanan, Barker and period
Phil Barker o Signs and symptoms
 Tidal Model (Psychiatric are present
Nursing) o Patient is NOT in the
 Helping patients recall their hospital
own personal stories of o Patient is NOT under
DISTRESS is the FIRST control
STEP in helping them regain o Patient is OUT of the
control of their lives again! hospital
 7. Downward Phase
25. Corbin and Strauss o Patient is in a
 Trajectory Model deteriorating phase
 The patient moves in a  8. Death
TRAJECTION of Eight (8)
Phases 26. Bonnie Weaver and Duldt
 Nurse needs to follow the Battey
patient along the eight phases  Humanistic Nursing
of trajection: Communication Theory
 1. Pre-Trajectory Phase  Emphasis is on the
o Patient shows no signs interpersonal relationship
and symptoms of between the nurse, the
illness patient, the peers and
o No sickness colleagues

27. McGill Model of Nursing

 Emphasis is to encourage and
 2. Trajectory Onset Phase engage the patient and the
o Patient now has signs family to actively participate in
and symptoms of learning about health
illness
 3. Crisis Phase 28. Kathryn Barnard
o Patient is unstable  Parent-Child Interaction Model
o Patient is in a life- (Pediatric Nursing)
threatening situation  In order to produce a healthy
o Patient is critical person, the baby’s need
 4. Acute Phase should be ADDRESSED AT
o Patient is in a state of ONCE!
active illness  Application: Bonding
 5. Stable Phase

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29. Alfred Adler o Environmental
 The personality of an Sanitation
individual is affected by the o Recreation and
BIRTH ORDER Housing

30. Gladys Husted and James 2. Secondary Prevention

Husted  Emphasis placed on:
 Symphonological Bioethical o Early detection /
Theory diagnosis
 Symphono- means harmony o Prompt treatment
and agreement o Health maintenance of
 Governed by ethical persons already having
standards, which influence health problems
nursing actions. o Prevention of
complications
LEVELS OF PREVENTION:  When given:
o During illness
1. Primary Prevention
 Examples:
 Emphasis on: o Screening survey
o Generalized health
o Encouraging regular
promotion and specific
check-ups
protection
o Complying with regular
o Recipients are
check-ups
GENERALLY
o Teaching Breast-self-
HEALTHY PEOPLE
examination
 When given:
o Teaching Testicular-
o Before onset of illness
self-examination
or before onset of
disease
 Concept:
 Examples:
o Most effective method
o Generalized health
of teaching is
education
DEMONSTRATION
 Prevention of
accidents
 Additional Examples of
 Standards of Secondary Prevention
nutrition o Assessment of growth
o Immunizations
and development
 Specific o General nursing
preventions assessment and care
o Risk Assessment for at the hospital,
specific disease community and the
o Family Planning home
Services and Marriage
Counseling 3. Tertiary Prevention
 Emphasis placed on:

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 o Support of the client to o Helping the patient
achieve the following: develop new coping
 Successful re- skills
adaptation
 Optimal Concept:
reconstitution  Do not give advice!
 Regain high- o This is meant to
level wellness facilitate decision-
 Therefore, the purpose is making on the part of
more of REHABILITATION the client
 When given: o This is observed so
o Begins after the illness that the client would not
or when a defect or develop
disability is fixed or DEPENDENCY
irreversible
 Examples: 3. Client Advocate
o Referring a client to  Protects rights of patients
support groups  Activity:
o Teaching a diabetic o Speaking on behalf of
client how to inject the patient
insulin
4. Change Agent
ROLES OF A NURSE  Brings change or adjustments
 Nurse only influences a
1. Caregiver / Care Provider patient
 To convey understanding and  Nurse does not change the
support patient
 Activities:
o Support and comfort 5. Teacher
measures (mothering  Teaching
aspect of nursing /  Imparting of knowledge
nurturance aspect of
nursing) 6. Leader
 Application of interpersonal
influence to bring out desired
behavior (leadership)
2. Counselor
 Involves helping patient 7. Manager
identify and avoid stressful  Decision-making
and psychological problems  Planning
 Focuses on:  Giving directions
o Helping client establish  Monitoring operations
capacity for successful  Facilitating staff development
interpersonal relations

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  Therefore, this is done on the  Addresses affective and
supervisory level of cognitive learning
organization
3. Answering Questions
8. Researcher  Cognitive
 After graduation, nurse cannot
yet be a researcher 4. Demonstration
 He can only be a researcher  Motor
after he receives his Master of
Arts in Nursing (M.A.N) 5. Discovery
degree  Cognitive and Affective

TEACHING AND LEARNING Concept:

STRATEGIES  Learning is more effective if
the learner discovers the
Basic Guidelines content for himself. (That is,
 Develop a well-defined through experience!)
objective
 Assess client’s readiness to 6. Group Discussion
learn  Affective and Cognitive
 Start with what the client is  Sharing feelings during group
concerned about dynamics
 Assess and start with what the
client already knows; proceed 7. Practice
from the known to the  Motor
unknown
 Start with the simple 8.Printed and Audiovisual Material
proceeding to the complex
 Schedule a review of the 9. Role-playing
content  For pediatric and psychiatric
nursing settings
Concept:
 Areas of Learning Domain 10. Modeling
o Knowledge – cognitive  What you say is what you do
o Skills – motor
o Attitude – emotional 11. Computer Assisted Learning
Programs
TEACHING STRATEGIES  Online review

1. Explanation and Description THE NURSING PROCESS

 Address cognitive aspect of
learning Concept:
 The Nursing Process was
2. One-to-one Discussion introduced by LYDIA HALL!

Definition:

16
  The Nursing Process is a BENEFITS DERIVED FROM THE
systematic, organized, rational NURSING PROCESS
method of planning and
providing individualized, Concepts:
humanistic nursing care  Both the nurse and the patient
benefit from the nursing
Purposes of the Nursing Process: process
 To identify health status  Patient obtains greater benefit
o Actual health problems  Remember:
o Potential health  Nursing process is CLIENT-
problems CENTERED or PATIENT-
 To establish plans CENTERED and NOT
 To deliver specific nursing NURSE-CENTERED
care
Benefits from Nursing Process:
Characteristics of Nursing  Improves quality of care
Process (MEMORIZE THIS!!!)  Ensures continuity and
1. Goal-oriented and client- appropriate level of care
centered  Facilitates client participation
2. Cyclical (no absolute through planning with patient
beginning and end), dynamic  Enables nurse to maximize
(moving) rather than static resources
3. Plan of care organized  Feedback allows nurse to
according to client problems evaluate care
rather than nursing goals  Serves as a framework for
4. Basis of prioritizing nursing accountability through
activities would be the documentation
problems and not the goals  Promotes a positive working
5. Follows a logical sequence atmosphere through
6. Universally applicable (to any collaboration
type of patient)
 Helps the nurse define roles
7. Interpersonal and
to those outside the
collaborative
profession
 Work with patients and
 For job satisfaction
relatives
 Facilitates professional growth
 Work with colleagues and
 Avoidance of legal action
other members of the
health team  Meeting standards of
8. Adaptation of problem-solving accredited hospitals
techniques and principles
9. Problem-oriented, flexible,
open to new information
10. Allows creativity of nurse and
patient
PARTS OR COMPONENTS OF
THE NURSING PROCESS

17
  When performed:
ASSESSMENT PHASE OF THE o Integrated throughout
NURSING PROCESS the nursing process
 Purpose of On-going
Nursing Activities in the Assessment:
Assessment Phase o To identify problems
 Data collection overlooked earlier
 Data Organization o To determine the status
 Data Validation of a health problem (i.e.
 Data Recording hydration status every
fifteen minutes)
IMPORTANT CONCEPT!
 No conclusion is developed in 3. Emergency Assessment
the assessment phase  When done:
o During acute
Purposes of the Assessment physiologic and
Phase psychologic crisis
 To create a data base of the  Where done:
client’s response to health and o Emergency Room
illness o Comfort Room
 To determine the nursing care o Anywhere!!!
needs of the patient o On site!!!
 Purpose of Emergency
Four (4) types of Assessment:
Assessment
o To identify life-
1. Initial Assessment
threatening condition
 When performed:
 Framework or Principle in
o At specified time after
Emergency Assessment
admission
o A – Airway
 Where done:
o B – Breathing
o Done at the ward
o C – Circulation
 Where Admitted:
o Utilize either Maslow’s
o At the ward
Hierarchy of Needs or
 Purpose of Initial Assessment: ABC principle
o To create a data base
for problem 4. Time-Lapsed Assessment
identification  When done:
o For reference and o Several months after
future comparison initial assessment
 Purpose of Time-Lapsed
Assessment
o To compare current
status of patient with
2. Focus Assessment or On-going
base line data (initial
Assessment
assessment)

18
  The person who brought the
ASSESSMENT PROCESS patient to the hospital

Concepts: 3. Environment of the Patient

 Data is equivalent to  Example:
information o Patient with diabetes
mellitus exhibits
What is the initial output of the acetone breath
Assessment Phase?  Assess for
 Data or Recorded Data diabetic
 Never validated data!!! ketoacidosis

Types of Data: Methods of Data Collection

 Observing
1. Subjective or Covert Data  Interviewing
 Felt by the patient  Examining
 During the recording of data,
this should be stated using the 1. Observing
patient’s own words  It should be deliberate
 These are the symptoms felt  Exert effort
by the patient
Two (2) aspects of observation
2. Objective or Overt Data process:
 Capable of being observed by  Noticing the stimuli
use of senses – sight, touch,  Do an interpretation of the
smell, taste, hearing stimuli
 These are the signs which are
observable 2. Interviewing
Two (2) types of Interview:
Sources of Data:
Directive Type of Interview
1. Primary Source  Structured
 Patient himself except when:  Uses closed-ended questions
o He is unconscious calling for specific data
o Patient is a baby  When used:
o Patient is insane o When you need to elicit
specific data
2. Secondary Source o When there is little time
 Patient’s record available
 Health care members
 Related literature or journals Concept:
 Significant others (they Characteristics of Closed-ended
become primary source when questions:
patient is unconscious  Yes or No questions
 Family or relatives

19
  Asks when or asks for the
time when event happened
 Asks how many
 Point with finger when asking
to provide clarity
 Therefore, they call for highly
specific answers
you already know or what
information is available
 An interview is a planned
conversation with a purpose
 An interview is a two-way
process

Non-Directive Type or Rapport-  When is it done?

Building Interview o When patient is
 Uses more open-ended available
questions o When patient is
 Advantage is that it allows the comfortable
patient to volunteer
information  Recommended distance from
the patient is three (3) to four
Types of Interview Questions: (4) feet.
1. Open-Ended Questions
 Questions not answerable by Stages of the Interview
“yes” or “no” 1. Opening Stage
 Questions that elicit Key Concept!!!
information or explanation  This is the most important part
of the interview
2. Closed-Ended Questions Rationale
 Questions answerable by  What was said and done
“yes” or “no” during the opening stage sets
 Leading Questions the tone all throughout the
 Phrasing of question suggests interview
what answer the interviewer is
expecting 2. Body of the Interview
 Occurs when patient responds
3. Neutral Questions to questioning
 Phrasing allows patient to
answer with least pressure 3. Closing Stage
 Usually NOT addressed to  How to close the interview:
patient personally (i.e. what is o Summarizing
your opinion about…) Technique
 Raised as a general topic
Validation of Data
Planning the Interview Setting  Act of double-checking the
data
Concepts:  Purposes of Data Validation
 Before the interview, o To ensure the:
determine what information  Correctness
 Completeness

20
  Accuracy  Problem present at the time
of the data the statement was made

Guidelines in Validating Data 2. High-Risk Nursing Diagnosis

 Compare subjective and  A diagnosis that a patient is
objective data more vulnerable or
 Be familiar with word usage susceptible compared with
(particularly if the patient is a others in the same situation
child)
 Reassess / double-check data 3. Possible Nursing Diagnosis
which are extremely abnormal  There is an evidence of a
 Be sure that your data health problem but the causes
contains CUES and not are NOT fully understood
INFERENCES
 Be sure that your data is 4. Wellness Nursing Diagnosis
FREE OF BIASES  A positive statement
 Avoid jumping to conclusions  Indicates a healthy response
 Examples:
Data Recording o Potential for increased
Concepts: compliance related to
 Data Recording COMPLETES increased level of
the Assessment Phase knowledge
 Initial Output of the o Potential for enhanced
Assessment Phase is DATA body image related to
 Final Output of the regular exercise
Assessment Phase is o Potential for effective
RECORDED DATA coping related to
adequate support
DIAGNOSING PHASE OF THE systems
NURSING PROCESS
Domains of Nursing Diagnosis
Activities during the Diagnosing Key Concept!
Phase:  It only includes health
 This involves sorting, problems that a nurse is
clustering, analyzing and capable and licensed to treat
interpreting data
Parts of a Nursing Diagnosis
Concept: 1. Problem Statement
 The final output in the  Example:
Diagnosing Phase is a o Fluid Volume Deficit
NURSING DIAGNOSIS!!! 2. Presumed Etiology
 Example:
Different Types of Nursing o …related to frequent
Diagnoses: loss of bowel
1. Actual Nursing Diagnosis movement

21
3. Defining Characteristics o At specified time upon
 Example: or after admission of
o …as manifested by the patient
decreased skin turgor
2. On-going Planning
Advantages of Using Standardized  Who are involved:
Diagnostic Terminology o Done by all nurses who
 Provides professional worked with the patient
accountability and autonomy o The patient himself
by defining and describing the o The family
independent areas of practice o But primarily, the
 Provides effective vehicle of NURSE
communication  Purposes of On-going
 Provides an organizing Planning
principle for meaningful o To determine if the
research client’s health status
 Facilitates continuity and has changed
individualized care o To decide which
problems to focus on
PLANNING PHASE OF THE during the shift
NURSING PROCESS o To set priorities for
client care during the
Concept: shift
Planning means: o To coordinate the
 Determining ahead of time patient care and
 Forecasting a course of action activities so that more
than one problem can
Key Concept!!! be addressed at the
 For your plans to be effective, same time
involve the patient and the
family 3. Discharge Planning
 Purpose of Discharge
IMPORTANT CONCEPT!!! Planning
 Final output of the Planning o To ensure continuity of
Phase is a NURSING CARE care
PLAN or a WRITTEN CARE
PLAN Characteristics or the Planning
Process
Types of Planning  S – Specific
 M – Measurable
1. Initial Planning
 A – Attainable
 Done by the nurse
 R – Realistic
 When done:
 T – Time bound

Activities during Planning Process

22
  Set priorities
 Set goals Requirements for Implementation
 Identify alternatives of nursing  Adequate knowledge
care  Technical Skills
 Select nursing measures  Communication skills
 Write nursing orders  Therapeutic use of self
(supervisors do this)  Right attitude as a
 Write the nursing care plan requirement

Purposes of Goal-setting Nursing Activities during the

 To set direction Implementation Phase
 To provide a time span  Reassess the patient
 To have a criteria for o Rationale
evaluation  To determine if
 To enable the nurse and the the procedure is
patient to determine whether still needed
the problem has been  Determine the need for
resolved or not nursing assistance
 To help motivate the client  Implement the nursing
and the patient by providing a strategies
sense of accomplishment  Communicate the procedure
performed by documenting
Key Concept!!! the procedure
 For your goal to be useful  Understand orders
during evaluation, it should be o Clarify / verify doctors’
stated in BEHAVIORAL orders
TERMS  Encourage patient to
participate actively
IMPLEMENTING PHASE OF THE
NURSING PROCESS Guidelines for Implementation of
the Nursing Strategies
Implementation
 Putting the care plan into Key Concept!!!
action  It should be based on
scientific knowledge,
Purpose of Implementation research, professional
 To carry out planned activities standards of practice (care)
 To help the client o Rationale:
 This is done to
Concept!!! ensure safe
 The implementation phase nursing care
ends upon recording of the  It should be adapted to the
care given and the response individual patient
of the patient to that  It should always be safe. Do
procedure not compromise

23
  It should be holistic o Allows the nurse to
 It should be accompanied by decide and make on-
support, comfort and teaching the-spot modification/s
in an intervention

EVALUATION PHASE OF THE

NURSING PROCESS
2. Intermittent Evaluation
Purpose of the Evaluation Phase  When done:
 To determine client’s progress o At a specified time
 To determine the  Purpose:
effectiveness of the care plan o It shows the extent of
 To determine as to what progress of the patient
extent the nursing goals have  Importance:
been met o Enables the nurse to
Importance of doing an Evaluation correct deficiencies and
 It determines if the care plan modify the nursing care
will be: plan
o Continued
o Modified 3.Terminal Evaluation
o Discontinued  When done:
o At or immediately
Activities during the Evaluation before discharge
Phase  Importance:
 Identify the OUTCOME  States the status of a health
CRITERIA to be used as problem at the time of
measurement discharge
 Gather information (data)  It determines whether the
relevant to the outcome goals are:
criteria o Met
 Compare outcome (data) with o Partially met
the criteria o Unmet
 Assess the reasons for the
outcome DOCUMENTATION
 Revise the nursing care plan  It is a written, formal
as needed document
 A record of client’s progress
Types of Evaluation
1. On-going Evaluation Purposes of Documentation
 When done:  Planning Care
o During or immediately  Communication
after the intervention  For legal documentation
 Importance: purposes
 For research

24
  For education assembled into an orderly or
 Reimbursements scientific manner
 For statistics, reporting,  Classification of information is
epidemiology based on SOURCE
 Accreditation, licensing  Each person or department
maintains a different section
Guidelines on Documentation on chart
 Timing
o Document patient care Components of a Source Oriented
as soon as possible Clinical Record
 Observe confidentiality  Admission Sheet
 Observe permanence  Face Sheet
o Use non-erasable ink  Medical History and Physical
o Do not use sign pen Examination Sheet
 Signature  Diagnostic Findings Sheet
o Sign full name and  TPR Graphic Sheet
append R.N.  Doctor’s Treatment and Order
 Accuracy Sheet
o Ensure that data is  Therapeutic Sheet
correct
o Avoid biases Problem Oriented Clinical Record
o Avoid ambiguous terms  Same as Problem Oriented
Medical Record
 Appropriateness
 Entry of data is based on
o Write only appropriate
CLIENT’S PROBLEM
information
 Example:
 Completeness
o Problem No. 1:
 Use standard terminology
constipation
 Brevity
 Increase fluid
o Make it concise yet
intake: doctor
meaningful
 Diatabs:
 Legal Awareness pharmacist
o Cross out erroneous
 NPO:
entry
 Includes observations about
o Write “Error”
the patient
o Countersign
 Example:
o Radiologist’s notes are
TYPES OF RECORDS
with doctor’s notes
under one problem
Source Oriented Clinical Record
 Accumulation of Problem List
chronological, variative
 Contains only ACTIVE
notations that are difficult to
problems (and relevant
follow because they are not
information about the
problem)

25
  No potential problems (these  Is the Kardex a part of the
are contained only in the patient’s record?
progress notes)  No, it is not!!!
 It is just a bulletin board
Four (4) Basic Components of
Problem Oriented Clinical Record Purpose of the Kardex
 To make valuable information
1. Baseline Data readily available
 All information gathered from  Allergies are written in red ink
a patient when he first entered  It is a reminder
the agency  It is not a record
2. Problem List Concept:
 A Nursing Care Plan is not a
3. Initial list of orders or Care
record
Plans
COMMUNICATION TECHNIQUES
4. Progress Notes
IN NURSING
 Includes:
o Nurses’ narrative notes Communication
(SOAPIE)  Exchange of ideas,
o Flow sheets information, feelings, data
o Discharge Notes and between two communicators
Referral Summaries
Concept:
Formats:  Communication is the basic
 SOAPIE – for revisions component of Human
Relationships
COMMON METHODS OF
COMMUNICATION AMONG Elements of Communication
NURSES 1. Message
 Data
1. Referring 2. Sender
 To endorse patient’s special  Encoder
concern to a higher authority 3. Receiver
or a specialized department or  Decoder
personnel 4. Feedback
5. Context
2. Confer
 Setting
 Verifying information
 Overall environment where
the communication takes
3. Reporting
place
 Giving information to a
concerned person Modes of Communication
1. Verbal
KARDEX

26
  Oral o One person believes
 Spoken that the space and all
 Written communication the things in that space
 Texted communication belongs to him
 Cable communication o Do not enter abruptly;
 Telex communication this may result in
 Facsimile communication breach of privacy
 Roles and relationships
2. Non-verbal communication
 Facial expression Therapeutic Communication in
Nursing
 Grimacing
 Using Silence
 Posture
o Supplement with non-
 Gait
verbal communication
 Adornment
 Provide General Leads
 Make-up o Examples:
 Gestures
 “…go on”
Factors Affecting Communication  “…tell me more”
 Ability of the communicator  Open-ended questions
 Perceptions  Use Touch
o But assess the culture
 Proxemics
o Distances between of the patient
o If the patient is a child,
communicators
touch the patient on the
 Intimate
top of the head
Distance
o If the patient is an
• Actual
elderly, touch the
physical
patient on the hand
contact to
o If the patient is of the
1.5 feet
same age level, touch
 Personal
the patient on the
Distance
shoulder
• 1.5 feet to
 Offering yourself
4 feet
o For autistic child
• 3 feet to 4
feet for  Stay nearby or
interview stay beside the
patient
 Social Distance
 Presenting Reality
• 4 feet to
o Example:
12 feet
 Public Distance  “You are in the
hospital”
• 12 feet
and  Reflecting
beyond o Example:
 Territoriality

27
  “What do you  REM sleep is NOT AS
think will make RESTFUL as NON-REM
you happy” sleep
o Never agree nor  However, REM sleep is
disagree NEEDED
o Reflect it back or throw  Dreaming is a psychological
it back outlet of pent up emotions

Non-therapeutic Communication Nursing Alert!

 Stumbling blocks to effective  Deprivation of REM sleep
communication results to:
 Stereotyping o Irritability
 Generalizing o Restlessness
 Agreeing and Disagreeing o Poor concentration
 No confrontation
 No argument 2. Non-Rapid Eye Movement Sleep
 Being defensive (Non-REM Sleep)
 Moralizing or Passing  Deep restful sleep
Judgment  Benefit is that it restores the
 Giving Common Advise body physically and
 Examples: psychologically (especially for
 “If I were you…” post-operative patients)
 “You should have done it…”
Concept!
PROMOTING REST AND SLEEP  Deprivation of Non-REM sleep
causes:
Circadian Rhythm o Physical exhaustion
 A biological rhythm o Decreased resistance
 A biological clock against infection
 Regulated from outside the
Wellness Teachings to Enhance or
person’s body
Promote Sleep
Types of Sleep  Establish a regular routine
1. Rapid Eye Movement Sleep  Have adequate exercise at
(REM sleep) daytime
 Increased brain metabolism o Avoid stimulating
and activity activity by bedtime
 Also called PARADOXICAL  Avoid all types of stimulants
SLEEP o Caffeine-containing
 Characterized by: foods
o Vivid dreams  Coffee
o Easily recalled upon  Cocoa
awakening  Chocolate
 Tea
Concepts!  Cola

28
 o Nicotine  Fats
o Alcohol
 Prolongs the Concepts:
REM stage of  Glucose is a ready source of
sleep energy for metabolic
 It excites the processes
patient like an
anesthetic Carbohydrates
 Not a stimulant  When eaten are metabolized
 Avoid shabu to glucose for energy
 Use the bed mainly for sleep  Excess carbohydrates are
 If unable to sleep, get up and converted to glycogen and
pursue satisfying activity stored in the liver
 Drink something warm or hot  Other excess carbohydrates
(except stimulants) go to the fat cells
o Milk contains L-
tryptophan Key Concept!
o L-tryptophan is an  During starvation, stored
amino acid with a glycogen is converted to
natural sedative effect glucose via a process called
that induces one to glycogenolysis
sleep
 Do something HOT!  If glycogen is used up, fat
o Twice-a-week resources are converted to
glucose via a process called
masturbation is ideal
gluconeogenesis
o Facilitates release of
tension of the day
Nursing Alert!
 Side-to-side turning every two
 Fat conversion to glucose
hours with back tapping
produces waste products
 Support bedtime rituals called KETONE BODIES
 Remove all music in order to  These give rise to metabolic
sleep acidosis as in Diabetic
Ketoacidosis
PROMOTING NUTRITION
Additional concepts!
Proteins
 During starvation protein
 Macromolecules composed of reserves are converted to
o Carbon glucose via process called
o Hydrogen gluconeogenesis
o Oxygen
o Nitrogen Gluconeogenesis
 Production of glucose out of
Basic Body Needs: non-carbohydrate products
 Carbohydrates
 Proteins Lipoproteins

29
  Substances composed of fats 2. Non-essential Proteins
and proteins  Proteins that can be produced
by the body
Types of Lipoproteins
1. High Density Lipoproteins Functions of Protein
(HDL)  Main element of our cells.
 High-grade lipoprotein o Building blocks of the
 Good grade lipoprotein cells are proteins
 Good cholesterol  Resistance against infection
 Function of HDLs o Formation of
o Transports the bad Immunoglobulins
cholesterol from (globular proteins)
systemic circulation to  Maintenance of normal
the liver for metabolism intravascular fluid volume
and eventual o Works with glucose
elimination and sodium
o Albumin
2. Low Density Lipoproteins (LDL)  Main protein of
 Low-grade lipoprotein blood
 Bad cholesterol  Acts as a colloid
 Function of LDLs  Attracts water
 They clog the blood vessels around it

3. Very Low Density Lipoproteins Concepts!!!

(VLDL)  If protein levels are
 Very bad cholesterol decreased, sodium and
glucose will not be enough to
Functions of Fats hold plasma inside blood
 Insulation vessel resulting into edema
 Heat Conservation
 Source of Energy  In liver cirrhosis,
hypoalbuminemia results to
Proteins edema
Two (2) types in terms of needs of
the body: VITAMINS
1. Essential Proteins
 Proteins that cannot be Two (2) types of Vitamins
produced by the body itself  Fat Soluble Vitamins
 To be sourced out from food  Water Soluble Vitamins
eaten
 Animal protein is complete Fat Soluble Vitamins
protein 1. Vitamin A
 Plant protein is considered as  Essential for normal vision
incomplete protein  For transmission of light
stimulus via the optic nerve

30
  Forms:
2. Vitamin D o Tablet
 Source is food o Liquid
 Precursor is in the skin o Injectable
 Sunlight is needed for Vitamin  Oral (tablet and liquid forms)
D to be converted to its active o Take on an empty
form stomach
 Function: o If there is GI distress
o Influences calcium (i.e. diarrhea), take with
metabolism food
o To metabolize calcium o If GI distress subsides,
take on an empty
Concept! stomach
 Without Vitamin D, there  Toxic effects:
would be decreased calcium o Constipation (first
levels option)
 Oral Liquid Iron
 Increased levels of Vitamin D o Use dropper and apply
leads to increased calcium at the back of the
levels tongue or use a straw
Vitamin E
 Anti-oxidant o Rationale:
 Promotes cell membrane  To avoid
integrity (like Vitamin C) staining the
 Vitamin for the heart and skin teeth
 Sources are meats and in  Health Teaching!!!
vegetables o To enhance iron
 Deficiency results to Vitamin E absorption, advice
deficiency hemolytic anemia taking orange juice
o Vitamin C in orange
Vitamin K juice enhances iron
 Synthesis of clotting factors absorption
 Synthesis of prothrombin o Do not take milk
o Milk inhibits absorption
Concept! of iron
 Decreased levels of Vitamin K o Too much fiber
leads to prothrombin prevents absorption of
deficiency iron
o Thus, do not take oats
 Deficiency in prothrombin when taking iron.
leads to bleeding  Injectable Iron
o Route is deep I.M.
MICRONUTRIENTS o Use Z-track technique
Ferrous sulfate (FeSO4)

31
 o Gauge of Needle is at  Whole grains
least 18 and cereals
o Length of Needle is
1.5” to 2.0” 3. Pureed Diet
o Site of administration is  Osteorized diet
the GLUTEAL
MUSCLE ONLY!!! 4. Full Liquid Diet
o Rationale:  Foods that melt or liquefy at
 To avoid body temperature
staining the skin
 Concept: 5. Clear Liquid Diet
o Use an airlock  Given to surgical patients
o Place 0.5 ml of air in  Limited to:
syringe so that o Water
medication would not o Coffee
leak into the o Tea
subcutaneous tissues o Cola
 Nursing Alert! o Clear stained broth
o Apply firm pressure for o Gelatin
at least five (5) minutes o Hard candies
after injection  Nursing Alert!
 Do NOT massage o Dairy products are
avoided

SPECIAL DIETS 6. High Fiber Diet

1. Light Diet  For patients at risk for
 Given for post-operative constipation
patients
 Plainly cooked 7. Candidiasis Diet
 No spices  Free of the following:
 Large amounts of FAT omitted o Fruits
 Avoid bran and high fiber o Sugar
o Yeast
2. Soft Diet o Fermented foods
 For people with difficulty with
swallowing and chewing 8. Low Residue Diet
 Generally low residue diet  Reduced fiber
 Nursing Alert!  To decrease GI irritation
o Avoid the following:  For patients with bowel
 Nuts inflammatory diseases:
 Seeds (tomato, o Chron’s disease
guava, berry) o Ulcerative colitis
 Raw fruits and
vegetables Acid-Ash Diet
 Fried Foods

32
  To alkalinize urine 1. NASOGASTRIC TUBE FEEDING
 To soothe an irritated bladder (NGT)
and urethra  Purpose of NGT insertion
 Give citrus fruits o For gastric gavage and
 Give vegetables lavage
 Exceptions are: o For administration of
o Prune Juice food and medication
o Cranberry Juice o To keep the stomach
o Both produce ACIDIC empty
URINE o To prevent aspiration
from regurgitation of
Ash-Acid Diet gastric contents
 Given to acidify urine o For gastric
 To minimize or help control decompression
Urinary Tract Infections  How to Insert NGT
 Give the following: o Depth of Insertion
o Protein  Measure length
o Meat from the tip of
o Poultry the nose to the
ears to the tip of
ASSESSMENT OF NUTRITIONAL the xiphoid
STATUS process
 Insertion:
Anthropometric Measurements o Position the patient in
semi-Fowler’s or
Fowler’s position
Skin Fold Test o While inserting to
 Derived from reserved fat of NASOPHARYNX
the body  Position the
head in a
Mid-upper arm Circumference hyperextended
Measurement manner
 Obtains the muscle mass of o When glottis, epiglottis
the body are approached
 This reflects the protein  Flex the head
reserves of the body o Rationale:
 Laboratory diagnostic  To prevent entry
procedure for albumin of the tube into
the trachea
SUPPORTING NUTRITION OF  Nursing Alert!
PATIENT: ENTERAL AND o Watch for signs and
PARENTERAL FEEDING symptoms of
RESPIRATORY
ENTERAL FEEDING DIFFICULTY

33
 o If there are signs, therefore, from
WITHDRAW TUBE lung contents
o While inserting tube,  IMPORTANT CONCEPTS!!!
observe for coughing or o To insure safety of the
difficulty of breathing patient prior to feeding,
 After inserting, ascertain CHECK THE
proper placement on the FOLLOWING:
stomach  Placement of the
 Concept! tube
o Most accurate method • For
to test for proper patient
placement of the NGT safety
is via X-RAY • To
 Other ways to test proper prevent
placement: LUNG
o 1. Let patient hum aspiration
 If positive for of food
humming, tube  Patency of the
is in the tube
esophagus and • To insure
stomach successful
 If negative for introduction or
humming, tube administration
is in the trachea of food
 Nursing Alert! o 3. By auscultating the
o Small-bore tube allows epigastric region while
patient to hum insufflating 50 ml of air
o Therefore, this method  Hear gurgling
is NOT RELIABLE sound
o 2. Determine the pH of TUBE FEEDING
the aspirate  Never try to submerge the
 Use litmus paper free end of the NGT to water
 Change of color o This is potentially
from BLUE to dangerous
RED indicates o If in trachea and
that the aspirate submerging of free end
is acidic and, to water coincides with
therefore, from inspiration, it will suck
stomach the water and lead to
contents pulmonary aspiration
 Change of color  Position during feeding:
from RED to o Fowler’s Position
BLUE indicates  Measure gastric residual
that the aspirate volume
is basic and,

34
 o Subtract this from total
feeding to introduce
o If aspirate is greater
than 50 ml for adult or
10 ml for infant, then
WITHHOLD FEEDING
for 2 – 3 hours.
o Rationale:
 Patient is not yet
ready for next
feeding.
o If same occurs after 2 –
3 hours, NOTIFY
DOCTOR.
 There is
problem with
gastric emptying
 Watch out for COUGHING
o Leakage to trachea
 If with DIFFICULTY OF
BREATHING
o Stop the procedure
 Flush with water after feeding
to avoid clogging of the tube
 After the procedure
o Do not place the
patient on bed before
30 minutes have
lapsed
o Rationale:
 To prevent
aspiration and
regurgitation
 Average volume of feeding:
o 300 ml to 400 ml
TOTAL PARENTERAL NUTRITION
 Introduced directly to the
bloodstream
 Tube is inserted via the:
o Subclavian vein
o Internal jugular vein of
the neck
o External jugular vein of
the neck
 Important Concept!!!
o Tube must reach two
(2) centimeters before
or above the RIGHT
ATRIUM
 Nursing Responsibilities:
o Watch out for signs and
symptoms of embolism
 Care of Insertion Site
o Application of sterile
dressing with anti-
bacterial ointment as
ordered by doctor (prn)
a GASTROSTOMY TUBE FEEDING
(Enteral)
 No auscultation needed
 Assess for the patency of the
tube
 Use water to do this
PROMOTING OXYGENATION
DEEP BREATHING
Two (2) types of Deep Breathing:
1. APICAL DEEP BREATHING
 Done to expand the upper
portion of the lungs
 Let the patient place palms on
the upper chest
 Concentrate on that area
 Take a slow deep breath at a
count of 1,2,3
 Release it slowly through the
nose or a pursed lip at a count
of 4,5,6,7
 Therefore, expiration is longer
than inspiration
 Rationale:
o To prevent respiratory
alkalosis
 Taught to patients who will
undergo:
o Upper abdominal
surgery
35
 o Cholecystectomy o Coughing is
 Incision site on contraindicated in the
diaphragm following patients:
 Patient does not  With increased
want to breathe intracranial
 Predisposed to pressure (ICP)
hypostatic  With increased
pneumonia intraoptical
pressure (IOP)
2. BASAL DEEP BREATHING  With cardiac
 Same procedure arrhythmias (but
 Area of concentration is the are allowed to
lower ribcage do deep
 When to teach patient: breathing)
o Before surgery
o Before pain is present Concepts!!!
 Rationale:  Deep Breathing and Coughing
o If pain is already o Purpose is to stimulate
present, it would be surfactant production
difficult for patient to  Yawning and sneezing also
follow stimulate surfactant
 When done: production
o Done q2 hours together
OXYGEN INHALATION AND
with turning
ADMINISTRATION

Practical Application Concept!

COUGHING EXERCISES
 When administering oxygen,
 Purpose
be sure to open the valve of
o To expand the lungs
the oxygen tank first.
o To facilitate
 Be certain that the valve on
expectoration of
the regulator is closed so that
secretions
the flow meter would not
 How often done: break!
o At least every two (2)
hours Concept!
 Procedure  Humidifier moistens the
o Teach the patient to oxygen administered
inhale and exhale  Purpose
o Tell the patient to o To avoid drying and
inhale and exhale a irritation of the mucosal
second time lining
o Tell the patient to o Also traps particulates
inhale and cough out from the tank
 NURSING ALERT!!!

36
  Iron oxide may 2. High Flow Administration
be present in the  Uses a venturi mask
tank (iron plus
oxygen NEBULIZATION
produces iron  With sodium chloride and
oxide or rust) salbutamol
 A physiologic solution
Concept!  Water liquefies secretions
 Fire Precaution  Sodium chloride stimulates
o Place ‘NO SMOKING’ coughing
sign at the door or at  Salbutamol is a bronchodilator
the head part of the  Purpose:
patient o For expectoration of
 Tank and oxygen do not secretions
explode
 They merely support Nursing Pre-therapy Assessment
combustion Prior to Nebulization
 Have baseline data of
Other Concepts! patient’s breath sounds
 Do not use volatile  Assess again after
substances nebulization to assess
 Acetone and alcohol can react effectiveness of the procedure
with oxygen and lead to
toxicity of patient SPIROMETRY
 Do not use oil based or  Purpose is to expand the
grease on any part of the lungs
oxygen set  Done when inhaling
 Do not allow the patient to use  Instruction to the patient:
an electric razor as sparks o Inhale from the
may trigger combustion spirometer and NOT
blow to the spirometer
 Procedure:
Nursing Alert!
o Inhale – exhale
 Retrolental Fibroplasia occurs
o Inhale – exhale fully
if there is excess oxygen
o Place mouthpiece
administration in infants.
Excess oxygen leads to between teeth
destruction of the retina and o Hold breath for four (4)
blindness seconds
o Then inhale, fully rising
Modes of Administration the ball
1. Low Flow Administration  Upon inhalation, the ball rises
 Utilizes nasal cannula or nasal
prongs or nasal catheters CHEST PHYSIOTHERAPY
 Given to COPD patients  This is a dependent procedure

37
  There are no absolute  Assess breath sounds to
contraindications to this know which lung fields have
procedure secretions
 Contraindicated for the  Then assess again after
following patients with: procedure to check
o Pacemakers effectiveness of the
o Lung abscess procedure.
o Hemoptysis
o Dangerous Arrhythmias Concepts!!!
o Active PTB (which  Vibration and percussion are
goes to the other lobe) done to mechanically dislodge
o Lung CA (malignancy secretions
goes to other lung)  Nebulization is done to liquefy
secretions
Three components of Chest  Suctioning is done to clear
Physiotherapy secretions
 Vibration  Postural Drainage is done to
 Percussion drain secretions using gravity
 Postural Drainage
Postural Drainage
Vibration  When done:
 Palms of your hand are o Before meals
placed on chest or back of o Two (2) hours after
patient giving quivering meals
motions  Before doing the procedure,
 Palms remain in contact with the following baseline data are
the chest or back needed:
Percussion o Breath sounds
 Use cupped hands o Vital signs
 Hands alternate in rising and o Continuous ECG
coming into contact with chest monitoring
or back of patient  During the procedure:
o Ensure the comfort of
Postural Drainage the patient
 Drain secretions by gravity o Provide a kidney basin
 Change positions and tissue paper
 IMPORTANT CONCEPT!!!  Nursing Alert!
o Rule out o Watch out for signs of
contraindications symptoms which may
before performing require stopping of the
chest physiotherapy procedure:
 Sudden dyspnea
Pre-therapy Assessment for  Cyanosis
Vibration and Percussion  Extreme
diaphoresis

38
  Sudden
alteration of SUCTIONING
blood pressure,  Purpose is to seek out
respiratory rate, secretions
pulse rate
 Appearance of Concepts!!!
arrhythmias  Question:
 Hemoptysis o If you have only one (1)
 General suction catheter, which
intolerance of will you suction first,
the procedure the nose or the mouth?
 Answer:
Important Concept! o If the patient is an
 If any of the above occurs, infant or a newborn:
STOP THE PROCEDURE  Start on the
and inform the physician mouth then
proceed to the
Concepts! nose
 After the procedure assess  Rationale:
the following: o If you start on the nose,
o Breath sounds you will trigger the
o Vital signs sneezing reflex and this
o Quantity and quality of would result into
sputum aspiration
o Overall response of the  Answer:
patient to the o If the patient is an
procedure adult, suction the
 Give oral hygiene mouth first, then
o Rationale: proceed to the nose
 To eliminate  Rationale:
phlegm from the o This is done for
mouth aesthetic reasons

Important Concept!!!
 Patients with cystic fibrosis
benefit much from postural
drainage

TYPES OF SUCTIONING
Type of Position of Depth Duration Interval Total
Suctioning the Patient with Time
while each
Suctioning Pass of
Suction
Oropharyngeal

39
Suctioning

If patient is Fowler’s (high 10 – 15 Not more 20 – 30 Not

conscious or moderate); centimeters than 10 – seconds more
Head turned to 15 than 5
one side seconds minutes
(towards the
nurse)

If the patient is Place on one 10 – 15 Not more 20 – 30 Not

unconscious side (facing the centimeters than 10 – seconds more
nurse); 15 than 5
Tilt neck to seconds minutes
move head
slightly forward
towards the
basin to avoid
aspiration
during
suctioning
Nasopharyngeal
Suctioning

If the patient is Neck should be From tip of Not more 20 – 30 Not

conscious hyperextended; the nose to than 10 – seconds more
Fowler’s tip of the 15 than 5
position earlobe seconds minutes

If the patient is Flat on bed From tip of Not more 20 – 30 Not

unconscious with head the nose to than 10 – seconds more
turned to the the tip of 15 than 5
nurse the earlobe seconds minutes
Lateral position
may be
assumed

TYPES OF SUCTIONING
Type of Position of Depth Duration Interval Total
Suctioning the Patient with each Time
while Pass of
Suctioning Suction
Orotracheal
Suctioning

40
If patient is Low to Measure Not more 20 – 30 Not more
conscious semi- from mouth than 10 seconds than 5
fowler’s to mid- seconds minutes
position sternum

If the patient Flat on Measure Not more 20 – 30 Not more

is bed; from mouth than 10 seconds than 5
unconscious Suction to mid- seconds minutes
trachea sternum
through the
mouth
Nasotracheal
Suctioning

If the patient Low to From tip of Not more 20 – 30 Not more

is conscious semi- the nose to than 10 seconds than 5
fowler’s earlobe to seconds minutes
position dominating
side of
neck to the
thyroid
cartilage

If the patient Flat on From tip of Not more 20 – 30 Not more

is bed; the nose to than 10 – seconds than 5
unconscious Suction earlobe to 15 minutes
trachea dominating seconds
through the side of
nose neck to the
thyroid
cartilage

41
TYPES OF SUCTIONING
Type of Position of Depth Duration Interval Total
Suctioning the Patient with Time
while each
Suctioning Pass of
Suction
Endotracheal Semi-Fowler’s 12.5 5 – 10 2 – 3 Not
Tube if not centimeters seconds minutes more
Suctioning contraindicated or 6 inches; than 5
Insert as minutes
far as it
goes until
you meet
resistance
or until
patient
coughs

42
Tracheostomy Semi-Fowler’s Insert as 5 – 10 2 – 3 Not
Tube if not far as it seconds minutes more
Suctioning contraindicated gets until than 5
you meet minutes
resistance
or until the
patient
coughs

Important Concepts!!!  For Endotracheal and

 For Endotracheal Suctioning Tracheostomy (Naso and Oral
o NO TUBE IS USED and Tube)
HERE o Before suctioning,
o This is suctioning of the HYPEROXYGENATE
trachea through the the patient
mouth or through the o During intervals,
nose HYPEROXYGENATE
 Two (2) types of Endotracheal the patient
Suctioning  For ET, Tracheostomy, ET
o Orotracheal Suctioning Tube
 Oral approach o Nursing Alert!
o Nasotracheal  During insertion,
Suctioning if you encounter
 Nasal approach resistance,
withdraw the
General Conditions for Suctioning catheter about
one centimeter

43
 (1 cm) before o Instill 2.5 ml to 5.0 ml
applying suction Normal Saline Solution
o Rationale: for adults to liquefy the
 To avoid trauma mucous plug
on the mucous o Instill 2.0 ml Normal
membrane Saline Solution for
o Do suctioning children to liquefy the
intermittently mucous plug
o Suctioning should not  Instill 0.5 ml to 1.0 ml Normal
be continuous Saline Solution for infants to
o Rotate the catheter liquefy the mucous plug
(between the thumb
and the index finger) as VITAL SIGNS
you withdraw
o Apply suction only TEMPERATURE
when you are ready to  Oral
withdraw (i.e. keep  Axillary
finger away from  Rectal
suction port if you are
still not ready) Oral Method
 Most convenient
How to Hyperoxygenate the  Most accessible
Patient  Nursing Alert!
 Give two (2) to three (3) blows o Applicability is for
by ambubag children aged six (6)
 Increase flow rate and years and above
concentration of oxygen o Not applicable for
 Nursing Alert! children below six (6)
o If the patient has thick, years old
tenacious secretions,  Contraindicated in patients
DO NOT USE AN with:
AMBUBAG o Oral surgery
o Use an OXYGEN o Mouth breathers
INSUFFLATION o History of convulsive
SUCTION CATHETER seizures
instead!!! o Unconscious
o This is a two-lumen o Incoherent
catheter (one lumen o Irrational
brings oxygen to the
o Mentally disrupted
patient, the other lumen
o Insane
brings out secretions
from the patient)  Procedure
 In the event of encrustations, o Nothing Per Orem for
PERFORM TRACHEAL about thirty (30)
LAVAGE minutes before taking
temperature

44
 o No food intake
o No drinks Rectal Method
o No smoking  Most reliable (except for
o No chewing gum tympanic thermometer)
o No whistling  Most accurate (except for
o No gargling tympanic thermometer)
 Rationale:  Concept!
o Any of the above would o If tympanic method is
alter the result used using a tympanic
 Placement: thermometer, the rectal
o Under the tongue, method is only second
most reliable and
beside the frenulum
second most accurate
(right or left)
 Disadvantage:
 Total Time:
o Placement on a
o Two (2) to three (3)
different site yields a
minutes
different reading
o Therefore, ensure that
Axillary Method
the bulb of the rectal
 Least realiable
thermometer rests on
 Safest method
the mucous membrane
 Nursing Alert!
 Contraindications:
o During application, be
o Hemorrhoids
sure that axilla is dry
o Rectal Surgery
o Dry using a patting
o Certain Cardiac
motion
ailments due to
 Nursing Alert!
stimulation of the vagus
o Do NOT RUB!!!
nerve; valsalva
 Rationale: maneuver leads to
o This increases heat arrhythmias
due to friction  Position of Patient when
o Rubbing increases taking the reading:
blood supply to the o Sim’s left position
area o Sim’s right position
o Therefore, there will be o For Newborn, lift up
increase in temperature ankles to keep buttocks
reading up
o Rubbing provides a o In Toddlers, set on
false-positive elevation prone position on
of temperature reading adult’s lap
 Duration:  Duration:
o In adults – nine (9) o Two (2) minutes
minutes
o In children – five (5) Conversion of Centigrade to
minutes Fahrenheit

45
  Centigrade = (5/9)F – 32 pilorum or pilo
 Centigrade = (F/1.8) – 32 arecti muscles
o Vasoconstriction
Conversion of Fahrenheit to  Decreases blood
Centigrade supply to the
 Fahrenheit = (9/5)C + 32 skin
 Fahrenheit = (1.8)C + 32  Pallid Skin
o Cyanotic nail beds
Concepts!!!  Key Concept!!!
 Peak body temperature o Patient complains of
occurs at 12NN to 3PM or feeling cold
4PM o Sweating will stop
 Lowest body temperature because body will
occurs in the early morning minimizes heat loss
hours of the day  Also called:
o Onset Stage
FEVER o Chill Stage
 Normally, the hypothalamus is o Cold Stage
able to adjust body  This stage is characterized by
temperatures between 37°C low febrile temperatures
to 40°C  Nursing Management
 But due to the presence of o Key Concept
pyrogenic materials like the
 Aim is to
following:
minimize heat
o Pathogenic
loss
microorganisms o Key Concept
o Toxins
 Do NOT apply
o Foreign substances
TEPID SPONGE
o Any substance capable BATH because
of increasing body this would make
temperature patient progress
 Creates a deficiency of -3°C, to SHOCK
making a person enter the  Provide additional clothing as
FIRST STAGE OF FEVER necessary
 Provide additional blankets as
First Stage of Fever necessary
 Typical signs and symptoms  Provide something warm to
indicate the body’s drink
compliance mechanism to
 These measures would result
increase and conserve heat:
to a gradual increase in body
o Chills
temperature
o Shivering
 Question:
o Gooseflesh
o When will you start
 Contraction of application of TSB?
arectores
 Answer:

46
 o If there is a 1°C to 2°C o Loss of appetite
increase in body o Myalgia or muscle
temperature pains due to increased
catabolism
Second Stage of Fever  Nursing Management
 Also called: o Tepid Sponge Bath
o Coarse Stage of Fever o Cooling Bed Bath
o Peak Stage of Fever
 Key Concept! Tepid Sponge Bath
o Patient does not feel  Temperature of water is
hot or cold 32°C
o Skin is warm to touch o This temperature is
o Skin is flushed maintained
o Fever blisters are throughout the
present procedure
 Herpetic lesions  How to apply:
o Absence of shivering o Done by patting
o Possible dehydration  Rationale:
 Important Concept!!! o To avoid friction,
o For every increase of which increases
temperature, there is a temperature
corresponding increase  Important Concept!
in pulse rate o Do NOT use
 Rationale: ALCOHOL when
o Increase in applying TSB
temperature results in  Rationale:
an increase in pulse o Alcohol dries the
rate due to increased skin and leads to
metabolic rate irritation
o Increased metabolic  Key Concept!
rate increases oxygen o TSB should not be
demand done hurriedly
o Due to increased  Rationale:
oxygen demand of o When done
susceptible brain cells, hurriedly, TSB will
CONVULSIVE stimulate shivering
SEIZURES may occur. o Shivering would
These may also be due lead to increased
to irritation of nerve muscle activity
cells – FEBRILE o Increased muscle
CONVULSIONS activity would lead
 Increased oxygen demand to increased
also leads to an increase in temperature
respiratory rate
 Patient complains of: Cooling Bed Bath

47
  Water temperature will  If pulse is regular, count or
start at 32°C monitor pulse for thirty (30)
 Procedure will go on with seconds and multiply by
gradual decrease in water two (2). This is legal!
temperature until it is
maintained at 18°C  If pulse is irregular, count
 Therefore, to achieve this or monitor the pulse for
drop in temperature, utilize one (1) FULL minute
ice
 Same procedure of Assessment of the Pulse Deficit
application as in Tepid  This is the most accurate
Sponge Bath method
Types of Fever  Involves two nurses using one
1. Intermittent Fever watch
 A fever that is alternated at  Starts at the same time
regular intervals by periods  Ends at the same time
of normal and subnormal  Comparison of results ensues
temperature  Count is done for one (1) full
minute
2. Remittent Fever
 Fever alternated by wide Scale in Pulse Assessment
range of fluctuations in  0 - Absent or cannot be felt
temperature, all of them  1+ - Weak or thready
are ABOVE NORMAL.  2+ - Normal
 Duration is within a 24-  3+ - Grounding
hour period
BLOOD PRESURE
3. Relapsing Fever
 Short periods of febrile Systolic
episodes alternated by one  Produced by ventricular
(1) to two (2) days of contraction
normal temperature
 Pressure on blood vessels
during depolarization or
4. Constant Fever
ventricular contraction
 Minimal fluctuations of
temperature, all of which Diastolic
are ABOVE NORMAL
 Pressure that remains in the
walls of the blood vessels
5. Staircase or Spiking Fever
during relaxation or
 Common in patients with repolarization or resting
TYPHOID FEVER
Broadly two (2) types:
PULSE ASSESSMENT
 Direct
o By insertion of a
Concepts!
catheter

48
  Indirect Method o 160 / no muffling / 110
o Auscultatory method
o Palpatory method Concepts!!!
o Flush Method  Take systolic on loudest
sound if patient is an adult
Auscultatory Method  If patient is pediatric or up to
 Uses Korotkoff sound ten (10) years old, take the
o A popping sound first sound, whether it is faint
o NOT the heart beat or loud
o It is a phenomenon –  If, for example, first sound is
an unknown at 190 mmHg and there is
phenomenon! silence up to 140 mmHg and
then there is a sound at 130
Determining Amount of Inflation mmHg down to 80 mmHg
 Using auscultatory method then…
o Ask patient what is his  Use the PALPATORY
last BP reading and METHOD in combination with
then add 30 – 40 the AUSCULTATORY
mmHg from last METHOD because there is an
systolic reading. auscultatory gap
o Deflate gradually – rate
Repeat using:
is approximately 2 – 3
mmHg per second  Auscultatory method
 Alternative auscultatory  Palpatory method
method
o Auscultate for the last How to do the Palpatory Method
sound as you go up.  Inflate
Then add 30 – 40 o Determine up to what
mmHg point to inflate
o Then deflate o Palpate pulse
o If pulse is absent, add
Tripartite Blood Pressure 30 – 40 mmHg
 Done if patient is an adult.  Deflate
 Example: o First palpable pulse is
 140 mmHg systolic – first true systolic pressure
loudest sound  For diastolic pressure,
 100 mmHg 1st diastolic – proceed using the
muffling auscultatory method
 70 mmHg 2nd diastolic – last
sound Flush Method
o Therefore, the tripartite  Represents the mean blood
blood pressure is 140 / pressure
100 / 70  Represents the average of the
 If there is no muffling, an systolic and diastolic
example would be: pressures

49
  When done:
o When you have a BP Stage 1
apparatus without a  Involves the epidermis
stethoscope  Manifestation
o Used for pediatric o Non-blanchable
patients erythema of INTACT
 How done: SKIN
o Inflate up to the point o This is the first
where extremity heralding sign of
becomes pale decubitus ulceration
o Deflate slowly and look
for a REBOUND Stage 2
FLUSH – when  Partial Thickness Skin Loss
extremity becomes red  Involves epidermis and dermis
again  Manifestation
 This is the true reading!! o Blister formation
 Note that there is only ONE o Shallow craters
reading!!! o Shallow abrasion and
ulceration
SKIN INTEGRITY
 Decubitus ulcers are caused Stage 3
by: Full Thickness Skin Loss
o Unrelieved, sustained Ulceration
pressure  There is skin loss already
o Localized ischemia  Involves necrosis of the skin
o Shearing force and subcutaneous tissues
o Pressure plus friction EXTENDING TO but NOT
 Predisposing Factors: THROUGH the underlying
o Unconsciousness fascia
o Incontinence
o Loss of Sensation Stage 4
o Hypoproteinemia  Formations and
manifestations of Stage 3
 Decreased lean
plus…
muscle mass
o Involvement of bones,
 Increase in fluid
supporting structures
shifting leads to
(tendons), joint
edema
capsules
 Dependent
o Massive damage
position is the
skin attached to
Tools to Assess Risk of Ulceration
or facing the bed
o Emaciation  Norton’s Pressure Area Risk
Assessment Form
Stages of Decubitus Ulcer  Shannon’s Scoring System
Formation

50
  Branden Scale of Predicting  3+ - 3 cm induration
Ulceration  4+ - 4 cm induration
 Waterlow Risk Assessment  5+ - 5 cm induration
Cards
o Most important tool PAIN MANAGEMENT
o Most common tool
o Most often used tool Pain
 A noxious stimulation of actual
EDEMA or threatened / potential tissue
 Caused by shifting of fluid into damage
the interstitial tissues
Categories of Pain according to
Management of Edema Origin
1. Elevation of the edematous part  Cutaneous
Nursing Alert! o Skin
 If edema is due to Congestive  Deep Somatic
Heart Failure (Right Sided), o Tendons, ligaments
NEVER ELEVATE THE o Bones
LOWER EXTREMITIES o Blood Vessels
Rationale:  Visceral Pain
 This increases the workload of o Organs of the body
the right side of the heart
Categories of Pain based on
Concept! Cause
 If edema is due to prolonged  Acute
standing, DO THE o Due to trauma or
ELEVATION surgery
o Persists for less than
2. Wear elastic stockings
six (6) months
 Chronic Malignant Pain
3. Use warm compress alternated
o Related to cancer
with cold compress
Rationale: o On and off
 Vasoconstriction and o Persists for more than
vasodilation causes re- six (6) months
circulation of fluid  Chronic Non-malignant Pain
o Persists for more than
Concept! six (6) months
 This is contraindicated if there
is inflammation Categories of Pain according to
Where It Is Experienced
Assessment of Edema  Radiating Pain
Induration o Felt on the source and
 1+ - 1 cm induration is extending to nearby
 2+ - 2 cm induration tissues
 Referred Pain

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 o Felt on other parts o Pain signals are carried
detached from the to the spinal cord by
source the small diameter
o Example: nerve fibers
o Pain on a lacerated  Large diameter nerve fibers
liver may be felt on the also pass through the
right shoulder and not substancia gelatinosa
on the right upper o Large diameter nerve
quadrant fibers close the gate –
 Intractable Pain prevents the
o Highly resistant to pain- transmission of
relief methods impulses through the
 Phantom Pain spinal cord
o Pain that is felt on a o Therefore, when
MISSING BODY PART LARGE DIAMETER
or a PART THAT IS NERVE FIBERS ARE
PARALYZED by STIMULATED, THE
SPINAL CORD GATE IS CLOSED
INJURY.  Pain management operates
on the principle of how to
Pain Threshold stimulate the Large Diameter
 Amount of pain stimulation Nerve Fibers to close the
that is required in order to feel gate.
pain
Pain Management Strategies
Pain Tolerance
 Maximum amount of pain and Pharmacologic Methods
duration that a person is  Narcotics
willing to endure  NSAIDs
 Adjuvants or Co-analgesics
Gate Control Theory
Concept! Non-Pharmacologic Methods
 This is the most widely used  Physical Interventions
theory in pain management  Cognitive / Behavioral
Interventions
Concepts!
 At the dorsal horn of the Non-Pharmacologic Physical
spinal cord is a gate. Interventions
 This gate is called the 1. Cutaneous Stimulation
SUBSTANCIA GELATINOSA  Massage
 A series of nerves pass o Effleurage
through this gate o Soft massage
 Small diameter nerve fibers o Gentle stroking
pass through the substancia  Petrissage
gelatinosa o Hard massage

52
 o Large and quick natural analgesic
pinches effects
o Also done by striking o This started in Ancient
 Application of Counter-Irritant China
o Bengay  Accupuncture
o Menthol o Insertion of long
o Omega Pain Killer slender needles on
o Flax Seeds certain chemical
o Poultices pathways
o Origin is also Ancient
 Heat and Cold Application
o Nursing Alert! china
o Rebound Phenomenon  Contralateral Stimulation
o Example: Injury on left
 When you apply
side and massage is
heat (usually
done on the right side
done for 20
o Useful when patient
minutes),
vasodilation is cannot be accessed:
produced  For patients in a
 If heat is applied cast
for more than 20  For patients with
minutes, there is burns
vasoconstriction  For patients with
 This is an phantom pain
inherent defense
mechanism from 2. Immobilization
burning of  Application of splints
tissues
 Cold Application 3.Transcutaneous Electrical Nerve
o Maximum Stimulation
vasoconstriction is  Composed of electrodes
reached when skin  Operated by battery
reaches 15°C  Electrodes are applied on
o If there is further drom painful site or over the spinal
in temperature, there is cord
vasodilation (skin
becomes reddish) 4.Administration of a Placebo
o This is the inherent  Relieves pain because of its
defense mechanism intent and not because of
from being frozen physical or chemical
 Accupressure properties
o Pressure on certain
points of the body Cognitive or Behavioral Non-
o Stimulates release of Pharmacologic Interventions
endorphins, which have  Purpose:
o To alter pain perception

53
 o To alter pain behavior
o To provide client with a URINARY ELIMINATION
greater sense of control
over the pain Oliguria
 Renal output of less than 500
Specific Interventions ml per day
1.Distraction
 Purpose is to divert attention Anuria
from pain  Renal output of less than 100
 Slow Rhythmic Breathing ml per day
o Stare at a certain
object Retention
o Take deep breath  Positive for distended bladder
slowly  May also occur in the absence
o Release or exhale of bladder distention
slowly
o Concentrate on
breathing Altered Urinary Elimination
o Picture a peaceful
scene Enuresis
o Establish a rhythmic  Common among pediatric
pattern patients
 Age 4 – 5 years old child has
2.Massage and Slow Rhythmic adequate bladder control
Breathing  Primary Enuresis
o Never had a dry period
3.Rhythmic Singing and Tapping  Secondary Enuresis
 Key Concept! o Acquired enuresis
o Faster beat music is o At age 7, bladder
more preferable control is present for at
least one year
4.Guided Imagery o Then, enuresis comes
 Imagine that you are walking back
along a peaceful shore o Urinating could NOT be
 Eyes are closed and controlled again
suggestions are given
Incontinence
5.Hypnosis  Involuntary passage of urine
 The success of hypnosis
depends on the ability of the Types of Incontinence
patient to concentrate and the
capacity of the hypnotist to 1.Functional Incontinence
suggest  Involuntary passage
 Based on suggestion  Unpredictable time
 Progressive relaxation

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2.Reflex Incontinence o Advise patient to stand
 Occurs at somewhat with legs slightly apart
predictable times when o Concentrate on
specific bladder volume is perineum
reached o Draw perineum upward
 No awareness of bladder slowly
filling  Alternative way:
 No urge to void o When urinating, try to
 It may be related to neurologic stop in the middle of
impairment flow or try to stop
diarrhea from flowing
3.Stress Incontinence o Advantage of Kegel’s
 Loss of urine is less than 50 Exercises
ml occurring with increased o Increases muscle tone
intra-abdominal pressure of the pelvis
o Occurs when laughing o Increases muscle
o Occurs when sneezing control
o Occurs when smiling
Total Incontinence 2.Clean Intermittent Self
 Continuous flow of urine Catheterization
 No bladder distention  Applicable for Reflex
 No bladder spasm Incontinence
 No awareness of bladder  How done:
filling o Use a mirror for:
 Obese male
Urge Incontinence patients
 Urine flows as soon as a  Female patients
strong sense of feeling to void  Concept!
occurs o Possible Board
 Strong bladder spasm Question:
 Is your Clean
Management of Incontinence Intermittent Self
Catheterization
1.Kegel’s Exercises procedure a
 Also called: sterile
o Pubococcygeal Muscle procedure?
Exercises o Answer:
o Pelvic Floor Muscle  No, it is just a
Exercises clean procedure.
 Applicable for: Therefore, you
o Functional can just wash
Incontinence the catheter for
o Stress Incontinence the next use.
 How done:
3.Crede’s Maneuver

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  Application of a steady but o Let patient wash
gentle pressure on the supra- genitals
pubic region to force urine out o Dry the genitals
of the bladder o Get to bed
 Nursing Alert!  Place patient in semi-Fowler’s
o Do not use if there is position when she is ready to
OBSTRUCTION (i.e. void
renal obstruction in the  Clean and spread labia with
form of renal stones) two fingers
o This is done only for  Remain holding labia
patients who are no  Then let patient urinate
longer expected to  Let go of first flow
regain control (Reflex  Collect next flow
incontinence and
retention) CATHETERIZATION
4.Prompted Voiding or Scheduled
 Coude Catheter
Toileting
o Elbowed catheter for
 For Reflex Incontinence
Benign Prostatic
Hypertrophy patients
5.Application of Adult Catheter and
 Robinson Catheter
External Condom Catheter
o Straight catheter
 For elderly with Total
Incontinence  Multi-Lumen Retention
Catheter
6.Catheterization o Foley catheter
 One lumen is for inflation
MIDSTREAM CLEAN CATCH  One lumen is for drainage of
URINE SPECIMEN urine
How is this done?  One lumen is for irrigation
 If patient is a Male…  A three-way catheter
o Clean the penis  Aspirate using syringe and
o Do this from the needle
meatus down to the  This is made with a self-
shaft sealing rubber
o Let the patient urinate
o Discard the first or the Concepts!!!
initial urine  See to it that penis is
o Collect midstream urine perpendicular to body to
o Purpose is to attain straighten up the urethra to
sterile specimen for bladder
urine culture and  While inserting the catheter,
sensitivity testing ask the patient to breathe
 If patient is a Female… through the mouth
 Cleanse the penis before
insertion

56
  Grasp penis firmly to avoid  Avoid ignoring the urge to
stimulating erections defecate
 Where to tape catheter  Do not abuse laxatives
o Tape it upward on the
abdomen Concepts!
 Rationale:  For Flatulence
o To avoid scrotal o Avoid carbonated
excoriation drinks
o Tape on the inner thigh o Do not use straw
(with penis sideways o Avoid chewing gum
either on left or right o Avoid gas-forming
and follow the normal foods:
contour of the penis  Camote
 Length of Catheter  Cabbage
o 40 centimeters  Cauliflower
 Depth of Insertion  Onions
o While inserting, the
point at which urine For Constipation:
starts to flow, insert  Increase fluid intake
further by five (5)  Prune juice
centimeters and then  Papaya
inflate the balloon –  Increase fiber in the diet
KOZIER
 Use METAMUCIL (natural
o Insert up to a the Y-
fiber) instead of laxatives
point, retract after
inflating (this method is Special Laboratory Procedures
more prone to infection
 For females 1.Guiac Test
o Insert at female Urethra  To determine the presence of
 Length of Catheter occult blood
o 22 centimeters  Concepts!!!
 Depth of Insertion o Have a meat-less diet
o Point at which urine three (3) days before
starts to flow, insert examination
further by five (5) o Withhold oral iron
centimeter before supplements
inflating balloon o Injectible iron is
allowed
GIT – FECAL ELIMINATION o Avoid any food that
discolors the stool.
Wellness Teachings
 Fluid intake of at least 2,000 2.GI SERIES
ml per day Upper GI Series – Barium Swallow
 Regular exercise  Nursing Considerations:
 High fiber diet

57
 o Elimination of contrast  Rationale:
medium o Can lead to rupture of
 How: the appendix
o Increase fluid intake
o Increase fiber in the 2. Carminative Enema
diet  Used to expel out flatus
 Rationale:  Burned sugar
o To offset the risk of  Now commercially available
constipation
o Inform patient that the 3. Oil Retention Enema
color of the stool will be  Purpose:
WHITE o To lubricate the colon
and to soften the feces
Lower GI Series – Barium Enema o Retention time is one
 Done at the radiology (1) to three (3) hours
department
 Nursing Concern: 4. Retention Flow Enema
o Elimination of Barium  Also called Harish Flush
 How: Enema
o Cleansing enema may  Solution is continually
be needed after barium administered until what comes
enema out of the body is clear.

Different Types of Enema Positions in Enema

 Cleansing Enema
1. Cleansing Enema  High Cleansing Enema
 Soap suds enema o Clean as much of the
 Alkaline solution colon as possible
 Nursing Alert! o On introduction, Sim’s
o Contraindicated in Left position facilitates
patients with liver flow of enema to
cirrhosis and with sigmoid colon
increased ammonia in o Then, assume Dorsal
the blood Recumbent position to
 Rationale: facilitate flow of enema
o Alkaline solution to transverse colon
facilitates transfer of o Then, Right Side-Lying
ammonia from the GI position to facilitate
tract to the bloodstream flow of enema to the
 Therefore, use lemon juice or descending colon
dilute vinegar instead!!!  Low Cleansing Enema
 Nursing Alert! o For cleaning of rectum
o Also contraindicated in and colon only
possible appendicitis or
appendicitis patients SEXUALITY

58
 o Erection of the penis
Human Sexual Response  Females
o Redness near the ear
Excitement / Physical Stimulation o Nipples, breasts move
 Erotic stimuli causes sexual up
stimulation o Fourchette retracts
 Lasts for a few minutes to o Clitoris becomes visible
several hours o Increased vaginal
secretion
Types of Stimulation o If female is unaroused,
Physical Stimulation
there is backpain as
 Oral stimulation penis hits the cervix
o Fellatio
 If the female is well-
 Oral stimulation stimulated, the cervix rises
of the penis
using the mouth Plateau Stage
o Cunningulus  Lasts thirty (30) seconds to
 Oral stimulation three (3) minutes
of the vagina  In males:
o Anningulus o Scrotum rises upward
 Oral stimulation o Shaft of penis
of the anus increases in length and
 In homosexual width
male, typhoid  In females:
fever may be o Cervix rises
obtained from
 In both sexes:
anningulus
o There is increased
 Male and
muscle tone
Female oral sex
o Myotonia
is called
SOIXANTE
Orgasmic Phase or Orgasmic
NEUF
Stage
Physiological Sexual Stimulation  Climax of sexual tension
 Stimulation by:  Peak of sexual experience
o Smell  Lasts three (3) to ten (10)
o Sight seconds
o Hearing
Resolution Stage
o Fantasy
 Key Concepts!
o Spoken words
o Females have longer
o Mental imagery
resolution phase
o Males have shorter
During stimulation or Period of
resolution phase
Excitement
 Males PERIOPERATIVE NURSING

59
  If hair needs to be removed,
Stages of Perioperative Nursing the best method would be
 Pre-operative Phase through the use of:
 Intra-operative Phase o Clippers
 Post-operative Phase o Depilatory cream
 Shaving is NOT ADVISED.
Pre-operative Phase This is the last choice
 Begins upon decision of  Where is shaving done?
patient to undergo the o Not at the Operating
operation Room!
 Ends when patient is placed
on the operating table TYPES OF WOUNDS

Intra-operative Phase 1. Clean Wound

 Begins when patient is placed  Uninfected
on the operating table  No inflammation
 Ends when client is admitted  Respiratory, Alimentary and
to the Post-Anesthesia Care Urinary tracts are not entered
Unit or PACU
2. Clean Contaminated Wound
Post-operative Phase  A surgical wound
 Begins upon admission to the  No evidence of infection
PACU  Respiratory, GI, Urinary tracts
 Ends upon the discharge of are entered
the patient

Skin Preparation
 Purpose: 3. Contaminated Wound
o To reduce post-  Involves large spillage of
operative infection by: content from the GI, Urinary
 Removing soil and Respiratory tracts
and transient  Positive for inflammation
microbes  Positive for infection
 Reducing  Dirty Infected Wound
microbial count  Old wounds
to  Necrotic, gangrenous wound
subpathological
level in a short Modes of Applying Gauze
period of time Dressing
with minimal
skin irritation. 1. Dry to Dry
 Concepts!  A wide mesh of cotton applied
 Hair on the skin should not be to the surface of the wound
shaved if it does not interfere  A second layer is applied over
with the procedure it

60
2. Wet to Dry
 Inner layer is saturated with
NSS or anti-microbial agent
 On top is a moist absorbent
material

3. Wet to Damp
 A variation of wet to dry
 It is removed before it is
completely dried

4. Wet to Wet
 Inner layer is saturated with
NSS or anti-microbial solution
 Second layer is a wide mesh
 It is kept moist with a wetting
agent

61