Fundamentals of Nursing

FUNDAMENTALS OF NURSING
CONCEPT OF MAN
MAN
Forms the foundation of Nursing
FOUR COMPONENTS OR ATTRIBUTES OF MAN

Capacity to think on an Abstract Level Establish a family Establish a territory Ability to use verbal symbols as language
CONCEPT
Animals form a family by instinct Via hormonal scents
NURSING CONCEPTS OF MAN

Biopsychosocial Being Open System Unified Whole Vital Reparative Process Man is a whole. Man is complete
BIOPSYCHOSOCIAL BEING
By Sister Calista Roy Man interacts with the environment
OPEN SYSTEM
By Martha Rogers Man interacts with the environment Exchanges matter with energy Exchanges energy with environment
UNIFIED WHOLE
By Martha Rogers Man is composed certain parts of
Total of those parts is more than the sum of all parts This is because man has attributes
VITAL REPARATIVE PROCESS

By Florence Nightingale Man is passive in influencing the nurse or the environment
MAN IS A WHOLE. MAN IS COMPLETE

By Virginia Henderson Man has fourteen (14) fundamental needs
HUMAN NEEDS
Needs are physiologic and psychologic. Both these needs must be met in order to maintain wellbeing.
KEY CONCEPT
Basic Human Needs are equivalent to COMMON NEEDS
CHARACTERISTICS OF HUMAN NEEDS

Universal Interrelated One need is related to another need May be stimulated by internal or external factors May be deferred (but not indefinitely)
ABRAHAM MASLOWS HIERARCHY OF NEEDS

Why do we study this?
In order to prioritize nursing actions

Physiologic needs
Food Air Drink Shelter Warmth Sex Sleep Maintenance of homeostasis

Safety and security
Protection Security Order Law Limits Stability

Love and Belongingness
Family Affection Relationships Work group

Self-esteem Feeling good about ones self Two factors affecting Self-esteem Yourself Sense of adequacy Accomplishment Others Appreciation Recognition Admiration

Self-actualization
Personal growth and fulfillment Able to fulfill needs and ambitions Maximizing ones full potential
ABRAHAM MASLOWS MODIFIED HIERARCHY OF EIGHT NEEDS (1990)

Additional needs:
Need to know understand Aesthetic needs Transcendence and

Need to know and understand or Cognitive needs is supported by Richard Kalish who says that: Man needs stimulation Needs to explore Sex Activity Novelty Stimulator Desire to come up with something of your own

Aesthetic needs:
Beauty Balance Form

Transcendence:
Helping others to selfactualize
CHARACTERISTICS OF SELF-ACTUALIZED PERSONS

Judges people correctly Superior perception Decisive Capable of making decisions Clear notion as to what is right and wrong
CHARACTERISTICS OF SELF-ACTUALIZED PERSONS

Open to new ideas Not adopts new ideas Not one track mind Highly creative and flexible Does not need fame Problem-centered rather than self-centered
CONCEPT
Self-Actualization is very difficult to attain It is impossible to attain New needs come after getting one need
ILLNESS, WELLNESS AND HEALTH
ILLNESS
Highly subjective feeling of being sick or ill
TWO TYPES OF ILLNESS

Acute Illness Chronic Illness
ACUTE ILLNESS
Sudden in onset (most of the time, but not always) Less than six (6) months
CHRONIC ILLNESS
Gradual in onset (most of the time, but not always) Types of Chronic Illness Exacerbation Period characterized by active signs and symptoms of the illness Remission Periods where no signs and symptoms are present
DISEASE
Objective pathologic process
CONCEPTS ON DISEASE
Illness without disease is possible Disease without illness is possible Illness may or may not be related to a disease One can have a disease without necessarily feeling ill
DEVIANCE
Any behavior that goes against social norms Shortens life span Results to disrupted family and community
CONCEPT
Deviant behavior can be considered a disease
RATIONALE
Because it also shortens the life span like a disease
EXAMPLE OF DEVIANCE
Alcoholism A disease rather than a social problem
WELLNESS
Feeling of being well
DEFINITIONS OF HEALTH
World Organization Health
Health is the complete physical, mental, social (totality) well-being and not merely the absence of disease or infirmity A high-level wellness!
Claude Barnard
Ability to maintain internal milieu
Walter Cannon
Ability to homeostasis maintain
A dynamic equilibrium A state of balance of the internal environment while external environment is changing
Florence Nightingale
Health is using ones power to the fullest Being well Can be maintained by manipulating the environment
Virginia Henderson
Viewed in terms of ability to perform the fourteen (14) fundamental needs or components of nursing care UNAIDED
Martha Rogers
Positive health symbolizes wellness Health is a value term defined by a certain culture
Sister Calista Roy
A state and process of being and becoming an INTEGRATED PERSON
Dorothea Orem
Characterized by soundness and wholeness of DEVELOPED HUMAN STRUCTURES and FUNCTIONS
Imogene King
A dynamic state in the life cycle (contrasted with illness) Illness is interference in the life cycle
Betty Neuman
Wellness is that all parts and subparts are in harmony with each other and the whole system
Dorothy Johnson
Elusive dynamic state influenced by biologic, psychologic and social factors
MODELS OF HEALTH AND ILLNESS

Health-Illness Continuum: Dunns High-level Wellness and Grid Model Health Belief Model by Rosentock Four Levels of Health by Smith Agent, Host and Environment Model by Leavell and Clark
DUNNS HIGH-LEVEL WELLNESS AND GRID MODEL

X-axis is HEALTH Y-axis is environment Quadrant 1 High-level wellness in favorable environment Quadrant 2 Protected poor health in favorable environment Quadrant 3 Poor health in unfavorable environment Quadrant 4 Emergent high-level wellness in unfavorable environment
HEALTH BELIEF MODEL BY ROSENTOCK

Based on a motivational theory It assumed that good health is an objective common to all people Consider perceptions (influences individuals motivation toward results) Perceived susceptibility Perceived seriousness Perceived threat Likelihood of Action influenced by: Perceived benefit out of the action Perceived barriers
FOUR LEVELS OF HEALTH BY SMITH

1. Clinical Model
Man is viewed as a Physiologic Being If there are no signs and symptoms of a disease, then you are healthy Against WHO definition of health This is the NARROWEST concept of health

2. Role Performance Model
As long as you are able to perform SOCIETAL functions and ROLES you are healthy

3. Adaptive Model
Health is viewed in terms of capacity to ADAPT. Therefore, goal of treatment is to restore capacity to adapt. Failure to adapt is disease

4. Eudaemonistic Model
This is the BROADEST concept of health Because health is viewed in terms of Actualization
AGENT, HOST, ENVIRONMENT MODEL BY LEAVELL AND CLARK

Also known as the Ecologic Model Expands to the MULTI-CAUSATION of a DISEASE Definitions of a disease as to its cause is expanded to a multi-causation of a disease (i.e. cancer is a multifactorial disease) Triad is composed of the agent, host and environment Based on the interplay of three components of the model
DEFINITIONS OF NURSING
American Association Nurses
Nursing is the diagnosis and treatment of human responses to illness (to actual and potential health problems)
Canadian Nurses Association

The same definition as that of the American Nurses Association plus includes the supervision of functions and services in collaboration with others to promote health
Florence Nightingale
Nursing is the act of utilizing the ENVIRONMENT for the following purposes:
Recovery Reparative process
Virginia Henderson
The unique function of the nurse is to assist individuals, sick or well, with the activities towards health that he would do unaided, if with strength and knowledge. If that is not possible, towards a PEACEFUL DEATH
Martha Rogers
Nursing is a HUMANISTIC SCIENCE dedicated to compassionate concern for the promotion of health, prevention of illness and rehabilitation of the sick
Sister Calista Roy
Nursing is a THEORETICAL SYSTEM OF KNOWLEDGE that prescribes analysis and action related to the care of the sick or ill It is a set of knowledge
Dorothea Orem
Nursing is a helping service to any individual who is sick It comprises of wholly dependent or partly dependent care when the person is unable to do so. Defines nursing in terms of a NEED!
Imogene King
Nursing is a helping profession that assists a person (same with Henderson) towards a DIGNIFIED DEATH
Betty Neuman
Nursing is a profession that is concerned with INTRAPERSONAL, INTERPERSONAL, and EXTRAPERSONAL VARIABLES affecting a persons response to stressors
Dorothy Johnson
Nursing is an EXTERNAL REGULATORY FORCE that regulates the ACTION or BEHAVIOR of a person when such behavior constitutes a threat, in order to preserve his organization
Dorothy Johnson
Example:
In a COPD patient who remains a smoker, the nurse who encourages the patient not to smoke, serves as an external regulatory force
Faye Abdella Nursing is a service to individuals, families and therefore, to society Conceptualized nursing as an ART and SCIENCE of MOLDING THE INTELLECT, ATTITUDE and SKILLS of the nurse Nursing in terms of providing education
Hildegard Peplau
Nursing is the INTERPERSONAL process of THERAPEUTIC INTERACTION between the nurse and the patient.
NURSING THEORIES
1) FLORENCE NIGHTINGALE: ENVIRONMENTAL NURSING THEORY

Often considered the first nurse theorist Defined nursing as the act of utilizing the environment of the patient to assist him in his recovery. Nightingales theory remains an integral part of nursing and healthcare today.

5 Environmental Factors:
Pure or fresh air Pure water Efficient drainage Cleanliness Light, especially direct sunlight

Nightingales concepts are:
Ventilation Cleanliness Quiet Warmth Diet
general
CONCEPT
First Nursing School Florence Nightingale
2) DOROTHY JOHNSON: BEHAVIORAL SYSTEMS MODEL

Seven Subsystems
Attachment and Affiliative Dependency Ingestive Eliminative Sexual Achievement Aggressive
3) VIRGINIA HENDERSON: FOURTEEN FUNDAMENTAL NEEDS

Fourteen (14) Fundamental Needs focusing on PHYSIOLOGIC SOCIAL RECREATION

1) Breathing normally 2) Eating and drinking adequately 3) Eliminating body waste 4) Moving and maintaining a desirable position 5) Sleeping and resting 6) Selecting suitable clothes 7) Maintaining body temperature within normal range by adjusting clothing and modifying the environment

8) Keeping the body clean and well groomed to protect the integument. 9) Avoiding dangers in the environment and avoiding injuring others. 10) Communicating with others in expressing emotions, needs, fears, or opinions 11) Worshipping according to ones faith

12) Working in a such way that one feels a sense of accomplishment 13) Playing or participating in various forms of recreation 14) Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities
4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS

Focus is on PROPER IDENTIFICATION of the problem Particularly about the proper nursing diagnosis

1.To maintain good hygiene. 2.To promote optimal activity: exercise, rest, and sleep. 3.To promote safety. 4.To maintain good body mechanics. 5.To facilitate the maintenance of supply of oxygen.

6.To facilitate maintenance of nutrition. 7.To facilitate maintenance of elimination. 8.To facilitate the maintenance of fluid and electrolytes balance. 9.To recognize the physiologic response of the body to disease conditions.

10.To facilitate the maintenance of regulatory mechanisms and functions. 11.To facilitate the maintenance of sensory function. 12.To identify and accept positive and negative expressions, feelings and reactions. 13.To identify and accept the interrelatedness of emotions and illness.

14.To facilitate the maintenance of effective verbal and non-verbal communication. 15.To promote the development of productive interpersonal relationship. 16.To facilitate progress toward achievement of personal spiritual goals. 17.To create and maintain a therapeutic environment.

14.To facilitate the maintenance of effective verbal and non-verbal communication. 15.To promote the development of productive interpersonal relationship. 16.To facilitate progress toward achievement of personal spiritual goals. 17.To create and maintain a therapeutic environment.

18.To facilitate awareness of self as an individual with varying needs. 19.To accept the optimum possible goals. 20.To use community resources as an aid in resolving problems arising from illness. 21.To understand the role of social problems as influencing factors.
5) MARJORIE GORDON: HUMAN FUNCTIONAL HEALTH PATTERNS

Focus is on Eleven (11) Health Patterns Advantage to the nurse:
It enables the nurse to determine the clients response as functional or dysfunctional

Eleven Functional Health Patterns
Health perception Nutritional / Metabolic Elimination Activity and Exercise Pattern Cognitive Perceptual Pattern

Eleven Functional Health Patterns Sleep and Rest Self perception / Self concept Role Relationship Pattern Sexuality / Reproductive Coping-StressTolerance Value Belief Patterns
6) IMOGENE KING: GOAL ATTAINMENT THEORY

Patient has three interacting systems: (3)
Individuals / Personal systems Group systems / Interpersonal systems fraternity Social systems
7) MADELEINE LEHNINGER: TRANSCULTURAL NURSING THEORY

Nursing is a HUMANISTIC and SCIENTIFIC mode of helping through CULTURE-SPECIFIC PROCESS
8) MYRA LEVINE: FOUR CONSERVATION PRINCIPLES OF NURSING

1. Conservation of Energy Example: complete bed rest without bathroom privileges 2. Conservation of Structural Integrity Example: turn patient from side to side every two hours to avoid bed sores
8) MYRA LEVINE: FOUR CONSERVATION PRINCIPLES OF NURSING

3. Conservation of Personal Integrity Example: maintain patients privacy 4. Conservation of Social Integrity Example: maintenance of patients relationships
9) BETTY NEUMAN: HEALTH CARE SYSTEMS MODEL

The concern of nursing is to PREVENT STRESS INVASION
10) DOROTHEA OREM: SELF CARE AND SELF CARE DEFICIT THEORY
Three (3) Nursing Systems based on Art of Care of Patient Needs
10) DOROTHEA OREM: SELF CARE AND SELF CARE DEFICIT THEORY
1. Partial Compensatory Patient performs some of nursing care needs 2. Wholly Compensatory or Total Compensatory For paralyzed patients, for ICU patients 3. Supportive-Educative For up and about patient
11) HILDEGAARD PEPLAU: INTERPERSONAL MODEL

Four (4) Phases of Nurse-Patient Interaction
1. Orientation
Nurse and patient test the role each one assumes Prepares patient for termination Patient identifies areas of difficulty

2. Identification Phase
Patient identifies with the personnel who can satisfy his needs
3. Exploitation Phase
Nurse maximizes all the resources to benefit the patient

4. Resolution Phase or Termination Phase
Occurs when patients needs have been met
CONCEPTS!
Various settings for application of:
Pre-Interaction Phase In psychiatric setting, this consists of gathering data Pre-Entry Phase In community health nursing, this consists of a courtesy call
12) MARTHA ROGERS: SCIENCE OF UNITARY HUMAN BEINGS

Man is composed of energy fields, which are in constant interaction with the environment
CONCEPT!
The most reliable method of identification is the Energy Field. This is better than the fingerprints as a persons energy field is absolutely unique!
13) SISTER CALISTA ROY: ADAPTATION MODEL

Man is a BIOPSYCHOSOCIAL BEING Four (4) modes of Adaptation Physiologic Mode Compatible with Hans Selye Self Consent Role Function Interdependence
14) LYDIA HALL: CARE, CORE, CURE Care Comfort measures given by the nurse to a patient Nurturance aspect of Nursing Core Therapeutic use of self Cure Activities in relation to doctors orders Dependent orders
15) JEAN WATSON: HUMAN CARING MODEL

Nursing involves the application of ART and HUMAN SCIENCE through TRANSPERSONAL TRANSACTIONS in order to help the person achieve mind, body and soul harmony
16) ROSEMARIE RIZZO PARSE: THEORY OF HUMAN BECOMING

Emphasis is a FREE CHOICE (with personal meaning) Actions of patients may either be: Revealing or concealing Enabling or limiting Therefore, there is a consequence This pertains to behavior and action
17) JOSEPHINE PATTERSON & LORETA ZDERAD: HUMANISTIC NURSING PRACTICE THEORY
Nursing is an EXISTENTIAL EXPERIENCE between the nurse and the patient (nagkataon-nagkatagpo!) Nursing is a LIVE DIALOGUE between the patient who wants to be nursed and the nurse who has the skill to nurse
18) HELEN TOMLIN, EVELYN TOMLYN & MARY ANN SWAIN: MODELING AND REMODELING THEORY Focus is on the PERSON
Emphasis is on the UNCONDITIONAL ACCEPTANCE of the PATIENT
19) ANN BOYKIN & SAVINA SCHOENHOFER: GRAND THEORY OF NURSING AS A CARING THEORY
Nursing is NOT BASED on a DEFICIT but rather it is an EGALITARIAN MODE of helping This theory is against the theory of OREM
19) ANN BOYKIN & SAVINA SCHOENHOFER: GRAND THEORY OF NURSING AS A CARING THEORY
Nursing is an obligation towards humanity, whether there is a need or NOT!
20) MARGARET NEWMAN: HEALTH AS EXPANDING CONSCIOUSNESS

Humans are Unitary Human Beings The nurse is a NOT A GOAL-SETTER or an OUTCOME PREDICTOR, rather is a PARTNER OF THE PATIENT
21) JOYCE TRAVELBEE: INTERPERSONAL PROCESS THEORY

Nurse needs to go beyond nursing roles to establish therapeutic relationship TRANSPERSONAL COMMUNICATION as the means to establish therapeutic relationship This implies that the nurse should not be rigid in the nursing role
22) IDA JEAN ORLANDO: DYNAMIC NURSE-PATIENT RELATIONSHIP MODEL
There is movement, the relationship is not static If the patients condition improved, then the intervention is effective and the patient moves on to new problems
23) NOLA PENDER: HEALTH PROMOTION MODEL

Motivation to participate in health care activities influenced by COGNITIVE and PERCEPTUAL FACTORS: Importance of health to the person Perceived control of health Self-efficiency Perceived health status Definition of health Perceived barriers to
24) PHIL BARKER & POPPY BUCHANANBARKER: TIDAL MODEL

Helping patients recall their own personal stories of DISTRESS is the FIRST STEP in helping them regain control of their lives again!
25) CORBIN AND STRAUSS: TRAJECTORY MODEL
The patient moves in a TRAJECTION of Eight (8) Phases Nurse needs to follow the patient along the eight phases of trajection
EIGHT PHASES OF TRAJECTION BY CORBIN AND STRAUSS

1. Pre-Trajectory Phase Patient shows no signs and symptoms of illness No sickness 2. Trajectory Onset Phase Patient now has signs and symptoms of illness 3. Crisis Phase Patient is unstable Patient is in a life-threatening situation Patient is critical 4. Acute Phase Patient is in a state of active illness
EIGHT PHASES OF TRAJECTION BY CORBIN AND STRAUSS

5. Stable Phase Patients illness is controlled Patient may still be in the hospital 6. Unstable Phase Patient is on a critical period Signs and symptoms are present Patient is NOT in the hospital Patient is NOT under control Patient is OUT of the hospital 7. Downward Phase Patient is in a deteriorating phase 8. Death
26) BONNIE WEAVER DULDT BATTEY: HUMANISTIC NURSING COMMUNICATION THEORY

Emphasis is on the interpersonal relationship between the nurse, the patient, the peers and colleagues
27) MCGILL: MODEL OF NURSING

Emphasis is to encourage and engage the patient and the family to actively participate in learning about health
28) KATHRYN BARNARD: PARENT-CHILD INTERACTION MODEL

In order to produce a healthy person, the babys need should be ADDRESSED AT ONCE! Application: Bonding
29) ALFRED ADLER: THEORY OF PERSONALITY
The personality of an individual is affected by the BIRTH ORDER
30) GLADYS HUSTED & JAMES HUSTED: SYMPHONOLOGICAL-BIOETHICAL THEORY

Symphono- means harmony and agreement Governed by ethical standards, which influence nursing actions.
LEVELS OF PREVENTION
LEVELS OF PREVENTION
Primary Prevention Secondary Prevention Tertiary Prevention
PRIMARY PREVENTION
Emphasis on: Generalized health promotion and specific protection Recipients are GENERALLY HEALTHY PEOPLE When given: Before onset of illness or before onset of disease
PRIMARY PREVENTION
Examples: Generalized health education Prevention of accidents Standards of nutrition Immunizations Specific preventions Risk Assessment for specific disease Family Planning Services and Marriage Counseling Environmental Sanitation Recreation and Housing
SECONDARY PREVENTION
Emphasis placed on: Early detection / diagnosis Prompt treatment Health maintenance of persons already having health problems Prevention of complications When given: During illness
Examples: Screening survey Encouraging regular check-ups Complying with regular check-ups Teaching Breast-self-examination Teaching Testicular-self-examination
CONCEPT!
Most effective method of teaching is DEMONSTRATION
Additional Examples of Secondary Prevention Assessment of growth and development General nursing assessment and care at the hospital, community and the home
TERTIARY PREVENTION
Emphasis placed on: Support of the client to achieve the following: Successful re-adaptation Optimal reconstitution Regain high-level wellness Therefore, the purpose is more of REHABILITATION When given: Begins after the illness or when a defect or disability is fixed or irreversible
TERTIARY PREVENTION
Examples: Referring a client to support groups Teaching a diabetic client how to inject insulin
ROLES OF A NURSE
ROLES OF A NURSE
1. Caregiver / Care Provider
To convey understanding and support Activities: Support and comfort measures (mothering aspect of nursing / nurturance aspect of nursing)
ROLES OF A NURSE
2. Counselor
Involves helping patient identify and avoid stressful and psychological problems Focuses on: Helping client establish capacity for successful interpersonal relations Helping the patient develop new coping skills
CONCEPT!
Do not give advice!
This is meant to facilitate decision-making on the part of the client This is observed so that the client would not develop DEPENDENCY
ROLES OF A NURSE
3. Client Advocate
Protects rights of patients Activity: Speaking on behalf of the patient
ROLES OF A NURSE
4. Change Agent
Brings change or adjustments Nurse only influences a patient Nurse does not change the patient
ROLES OF A NURSE
5. Teacher
Teaching Imparting of knowledge
ROLES OF A NURSE
6. Leader
Application of interpersonal influence to bring out desired behavior (leadership)
ROLES OF A NURSE
7. Manager
Decision-making Planning Giving directions Monitoring operations Facilitating staff development Therefore, this is done on the supervisory level of organization
ROLES OF A NURSE
8. Researcher
After graduation, nurse cannot yet be a researcher He can only be a researcher after he receives his Master of Arts in Nursing (M.A.N) degree
TEACHING AND LEARNING STRATEGIES

Basic Guidelines
Develop a well-defined objective Assess clients readiness to learn Start with what the client is concerned about

Basic Guidelines
Assess and start with what the client already knows; proceed from the known to the unknown Start with the simple proceeding to the complex Schedule a review of the content
CONCEPT!
Areas of Learning Domain
Knowledge cognitive Skills motor Attitude emotional
TEACHING STRATEGIES
1. Explanation and Description
Address cognitive aspect of learning
TEACHING STRATEGIES
2. One-to-one Discussion
Addresses affective and cognitive learning
TEACHING STRATEGIES
3. Answering Questions
Cognitive
TEACHING STRATEGIES
4. Demonstration
Motor
TEACHING STRATEGIES
5. Discovery
Cognitive and Affective
CONCEPT!
Learning is more effective if the learner discovers the content for himself. (That is, through experience!)
TEACHING STRATEGIES
6. Group Discussion
Affective and Cognitive Sharing feelings during group dynamics
TEACHING STRATEGIES
7. Practice
Motor
TEACHING STRATEGIES
8.Printed and Audiovisual Material
TEACHING STRATEGIES
9. Role-playing
For pediatric and psychiatric nursing settings
TEACHING STRATEGIES
10. Modeling
What you say is what you do
TEACHING STRATEGIES
11. Computer Assisted Learning Programs
Online review
NURSING PROCESS
THE NURSING PROCESS
Definition:
The Nursing Process is a systematic, organized, rational method of planning and providing individualized, humanistic nursing care
PURPOSES OF THE NURSING PROCESS

To identify health status Actual health problems Potential health problems To establish plans To deliver specific nursing care
CHARACTERISTICS OF THE NURSING PROCESS

Goal-oriented and client-centered Cyclical (no absolute beginning and end), dynamic (moving) rather than static Plan of care organized according to client problems rather than nursing goals

Basis of prioritizing nursing activities would be the problems and not the goals Follows a logical sequence Universally applicable (to any type of patient) Interpersonal and collaborative Work with patients and relatives Work with colleagues and other members of the health team

Adaptation principles of problem-solving techniques and
Problem-oriented, flexible, open to new information Allows creativity of nurse and patient
BENEFITS DERIVED FROM THE NURSING PROCESS

Concepts:
Both the nurse and the patient benefit from the nursing process Patient obtains greater benefit Remember: Nursing process is PATIENT-CENTERED CENTERED
CLIENT-CENTERED or and NOT NURSE-

Improves quality of care Ensures continuity and appropriate level of care Facilitates client participation through planning with patient Enables nurse to maximize resources

Feedback allows nurse to evaluate care Serves as a framework for accountability through documentation Promotes a positive working atmosphere through collaboration Helps the nurse define roles to those outside the profession

For job satisfaction Facilitates professional growth Avoidance of legal action Meeting standards of accredited hospitals
PARTS OR COMPONENTS OF THE NURSING PROCESS

Assessment Phase Diagnosing Phase Planning Phase Intervention Phase Evaluation Phase
ASSESSMENT PHASE OF THE NURSING PROCESS

Nursing Activities in the Assessment Phase
Data Collection Data Organization Data Validation Data Recording
IMPORTANT CONCEPT!
No conclusion is developed in the assessment phase

Purposes of the Assessment Phase
To create a data base of the clients response to health and illness To determine the nursing care needs of the patient
FOUR TYPES OF ASSESSMENT

Initial Assessment Focus Assessment or On-going Assessment Emergency Assessment Time-Lapsed Assessment

1. Initial Assessment When performed: At specified time after admission Where done: Done at the ward Where Admitted: At the ward Purpose of Initial Assessment: To create a data base for problem identification For reference and future comparison

2. Focus Assessment or On-going Assessment
When performed: Integrated throughout the nursing process Purpose of On-going Assessment: To identify problems overlooked earlier To determine the status of a health problem (i.e. hydration status every fifteen minutes)

3. Emergency Assessment When done: During acute physiologic and psychologic crisis Where done: Emergency Room Comfort Room Anywhere!!! On site!!! Purpose of Emergency Assessment To identify life-threatening condition

3. Emergency Assessment
Framework or Principle in Emergency Assessment A Airway B Breathing C Circulation Utilize either Maslows Hierarchy of Needs or ABC principle

4. Time-Lapsed Assessment
When done: Several months after initial assessment Purpose of Time-Lapsed Assessment To compare current status of patient with base line data (initial assessment)
ASSESSMENT PROCESS
Concept:
Data is equivalent to information
ASSESSMENT PROCESS
What is the initial output of the Assessment Phase?
Data or Recorded Data Never validated data!!!
TYPES OF DATA
1. Subjective or Covert Data
Felt by the patient During the recording of data, this should be stated using the patients own words These are the symptoms felt by the patient
TYPES OF DATA
2. Objective or Overt Data
Capable of being observed by use of senses sight, touch, smell, taste, hearing These are the signs which are observable
SOURCES OF DATA
1. Primary Source
Patient himself except when: He is unconscious Patient is a baby Patient is insane
SOURCES OF DATA
2. Secondary Source
Patients record Health care members Related literature or journals Significant others (they become primary source when patient is unconscious) Family or relatives The person who brought the patient to the hospital
SOURCES OF DATA
3. Environment of the Patient
Example: Patient with diabetes mellitus exhibits acetone breath Assess for diabetic ketoacidosis
METHODS OF DATA COLLECTION

Observing Interviewing Examining
METHODS OF DATA COLLECTION: OBSERVING

It should be deliberate Exert effort!!!
METHODS OF DATA COLLECTION: OBSERVING

Two (2) aspects of observation process:
Noticing the stimuli Do an interpretation of the stimuli
METHODS OF DATA COLLECTION: INTERVIEWING
Two types of Interview

Directive Type of Interview Non-directive Type of Interview or Rapportbuilding Interview
DIRECTIVE TYPE OF INTERVIEW

Structured Uses closed-ended questions calling for specific data When used: When you need to elicit specific data When there is little time available
CONCEPT!
Characteristics of Closed-ended questions:
Yes or No questions Asks when or asks for the time when event happened Asks how many Point with finger when asking to provide clarity Therefore, they call for highly specific answers
NON-DIRECTIVE TYPE OR RAPPORT-BUILDING INTERVIEW

Uses more open-ended questions Advantage is that it allows the patient to volunteer information
TYPES OF INTERVIEW QUESTIONS

Open-Ended Questions Closed-Ended Questions Neutral Questions

1. Open-Ended Questions
Questions not answerable by yes or no Questions that elicit information or explanation

2. Closed-Ended Questions
Questions answerable by yes or no Leading Questions Phrasing of question suggests what answer the interviewer is expecting

3. Neutral Questions
Phrasing allows patient to answer with least pressure Usually NOT addressed to patient personally (i.e. what is your opinion about) Raised as a general topic
PLANNING THE INTERVIEW SETTING

Concepts: Before the interview, determine what information you already know or what information is available An interview is a planned conversation with a purpose An interview is a two-way process
PLANNING THE INTERVIEW SETTING

Concepts:
When is it done? When patient is available When patient is comfortable Recommended distance from the patient is three (3) to four (4) feet.
STAGES OF THE INTERVIEW

1. Opening Stage
Key Concept!!! This is the most important part of the interview Rationale What was said and done during the opening stage sets the tone all throughout the interview
THE INTERVIEW
2. Body of the Interview
Occurs when patient responds to questioning
THE INTERVIEW
3. Closing Stage
How to close the interview: Summarizing Technique
VALIDATION OF DATA
Act of double-checking the data Purposes of Data Validation
To ensure the: Correctness Completeness Accuracy of the data
GUIDELINES IN VALIDATION OF DATA

Compare subjective and objective data Be familiar with word usage (particularly if the patient is a child) Reassess / double-check data which are extremely abnormal Be sure that your data contains CUES and not INFERENCES Be sure that your data is FREE OF BIASES Avoid jumping to conclusions
DATA RECORDING
Concepts:
Data Recording COMPLETES the Assessment Phase Initial Output of the Assessment Phase is DATA Final Output of the Assessment Phase is RECORDED DATA
DIAGNOSING PHASE OF THE NURSING PROCESS

Activities during the Diagnosing Phase:
This involves sorting, interpreting data clustering, analyzing and

Concept:
The final output in the Diagnosing Phase is a NURSING DIAGNOSIS!!!
DIFFERENT TYPES OF NURSING DIAGNOSES

1. Actual Nursing Diagnosis
Problem present at the time the statement was made

Describes a clinical judgment that the nurse has validated because of the presence of major defining characteristics. Example: Ineffective Airway Clearance related to excessive and tenacious secretions

2. High-Risk Nursing Diagnosis
A diagnosis that a patient is more vulnerable or susceptible compared with others in the same situation
Example: Risk for Impaired Skin Integrity related to immobility secondary to fractured hip.

3. Possible Nursing Diagnosis
There is an evidence of a health problem but the causes are NOT fully understood
An option to indicate that some data are present to confirm a diagnosis but are insufficient as of this time Example: Possible Self Care Deficit related to impaired ability to use left hand secondary to presence of intravenous therapy.

4. Wellness Nursing Diagnosis A positive statement Indicates a healthy response Examples: Potential for increased compliance related to increased level of knowledge Potential for enhanced body image related to regular exercise Potential for effective coping related to adequate support systems
DOMAINS OF NURSING DIAGNOSES

Key Concept!
It only includes health problems that a nurse is capable and licensed to treat
PARTS OF A NURSING DIAGNOSIS

1. Problem Statement Example: Fluid Volume Deficit 2. Presumed Etiology Example: related to frequent loss of bowel movement 3. Defining Characteristics Example: as manifested by decreased skin turgor
ADVANTAGES OF USING A STANDARDIZED DIAGNOSTIC TERMINOLOGY

Provides professional accountability and autonomy by defining and describing the independent areas of practice Provides effective vehicle of communication Provides an organizing principle for meaningful research Facilitates continuity and individualized care
PLANNING PHASE OF THE NURSING PROCESS

Concept:
Planning means: Determining ahead of time Forecasting a course of action

Key Concept!!!
For your plans to be effective, involve the patient and the family

IMPORTANT CONCEPT!!!
Final output of the Planning Phase is a NURSING CARE PLAN or a WRITTEN CARE PLAN
TYPES OF PLANNING
1. Initial Planning
Done by the nurse When done: At specified time upon or after admission of the patient
TYPES OF PLANNING
2. On-going Planning
Who are involved: Done by all nurses who worked with the patient The patient himself The family But primarily, the NURSE
TYPES OF PLANNING
2. On-going Planning Purposes of On-going Planning To determine if the clients health status has changed To decide which problems to focus on during the shift To set priorities for client care during the shift To coordinate the patient care and activities so that more than one problem can be addressed at the same time
TYPES OF PLANNING
3. Discharge Planning
Purpose of Discharge Planning To ensure continuity of care
CHARACTERISTICS OF THE PLANNING PROCESS

S Specific M Measurable A Attainable R Realistic T Time bound
ACTIVITIES DURING THE PLANNING PROCESS

Set priorities Set goals Identify alternatives of nursing care Select nursing measures Write nursing orders (supervisors do this) Write the nursing care plan
PURPOSES OF GOAL-SETTING
To set direction To provide a time span To have a criteria for evaluation To enable the nurse and the patient to determine whether the problem has been resolved or not To help motivate the client and the patient by providing a sense of accomplishment
KEY CONCEPT IN GOAL SETTING!

For your goal to be useful during evaluation, it should be stated in BEHAVIORAL TERMS
IMPLEMENTATION PHASE OF THE NURSING PROCESS
IMPLEMENTING PHASE OF THE NURSING PROCESS

Implementation
Putting the care plan into action

Purpose of Implementation
To carry out planned activities To help the client

Concept!!!
The implementation phase ends upon recording of the care given and the response of the patient to that procedure

Requirements for Implementation
Adequate knowledge Technical Skills Communication skills Therapeutic use of self Right attitude as a requirement
NURSING ACTIVITIES DURING THE IMPLEMENTATION PHASE

Reassess the patient Rationale To determine if the procedure is still needed Determine the need for nursing assistance Implement the nursing strategies
NURSING ACTIVITIES DURING THE IMPLEMENTATION PHASE

Communicate the procedure performed by documenting the procedure Understand orders Clarify / verify doctors orders Encourage patient to participate actively
GUIDELINES FOR IMPLEMENTATION OF NURSING STRATEGIES

It should be based on scientific knowledge, research, professional standards of practice (care) Rationale: This is done to ensure safe nursing care It should be adapted to the individual patient
GUIDELINES FOR IMPLEMENTATION OF NURSING STRATEGIES

It should always be safe. Do not compromise It should be holistic It should be accompanied by support, comfort and teaching
EVALUATION PHASE OF THE NURSING PROCESS

Purpose of the Evaluation Phase
To determine clients progress To determine the effectiveness of the care plan To determine as to what extent the nursing goals have been met

Importance of doing an Evaluation
It determines if the care plan will be: Continued Modified Discontinued

Activities during the Evaluation Phase
Identify the OUTCOME CRITERIA to be used as measurement Gather information (data) relevant to the outcome criteria Compare outcome (data) with the criteria Assess the reasons for the outcome Revise the nursing care plan as needed
TYPES OF EVALUATION
1. On-going Evaluation
When done: During or immediately after the intervention Importance: Allows the nurse to decide and make on-the-spot modification/s in an intervention
TYPES OF EVALUATION
2. Intermittent Evaluation
When done: At a specified time Purpose: It shows the extent of progress of the patient Importance: Enables the nurse to correct deficiencies and modify the nursing care plan
TYPES OF EVALUATION
3. Terminal Evaluation When done: At or immediately before discharge Importance: States the status of a health problem at the time of discharge It determines whether the goals are: Met Partially met Unmet
DOCUMENTATION
DOCUMENTATION
It is a written, formal document A record of clients progress
PURPOSES OF DOCUMENTATION
Planning Care Communication For legal documentation purposes For research For education Reimbursements For statistics, reporting, epidemiology Accreditation, licensing
GUIDELINES ON DOCUMENTATION
Timing Document patient care as soon as possible Observe confidentiality Observe permanence Use non-erasable ink Do not use sign pen
Signature Sign full name and append R.N. Accuracy Ensure that data is correct Avoid biases Avoid ambiguous terms Appropriateness Write only appropriate information
Completeness Use standard terminology Brevity Make it concise yet meaningful Legal Awareness Cross out erroneous entry Write Error Countersign
TYPES OF RECORDS
Source-Oriented Clinical Record Problem-Oriented Clinical Record
SOURCE-ORIENTED CLINICAL RECORD

Accumulation of chronological, variative notations that are difficult to follow because they are not assembled into an orderly or scientific manner Classification of information is based on SOURCE Each person or department maintains a different section on chart
COMPONENTS OF A SOURCE-ORIENTED CLINICAL RECORD

Admission Sheet Face Sheet Medical History and Physical Examination Sheet Diagnostic Findings Sheet TPR Graphic Sheet Doctors Treatment and Order Sheet Therapeutic Sheet
PROBLEM-ORIENTED CLINICAL RECORD

Same as Problem Oriented Medical Record Entry of data is based on CLIENTS PROBLEM Example: Problem No. 1: constipation Increase fluid intake: doctor Diatabs: pharmacist NPO: Includes observations about the patient Example: Radiologists notes are with doctors notes under one problem
FOUR BASIC COMPONENTS OF PROBLEM-ORIENTED CLINICAL RECORD
1. Baseline Data
All information gathered from a patient when he first entered the agency
2. Problem List
Contains only ACTIVE problems information about the problem) (and relevant
No potential problems (these are contained only in the progress notes)
3. Initial list of orders or Care Plans
4. Progress Notes
Includes: Nurses narrative notes (SOAPIE) Flow sheets Discharge Notes and Referral Summaries Formats: SOAPIE for revisions
COMMON METHODS OF COMMUNICATION AMONG NURSES

1. Referring
To endorse patients special concern to a higher authority or a specialized department or personnel

2. Confer
Verifying information

3. Reporting
Giving information to a concerned person
KARDEX
Is the Kardex a part of the patients record? No, it is not!!! It is just a bulletin board
PURPOSES OF THE KARDEX

To make valuable information readily available Allergies are written in red ink It is a reminder It is not a record
IMPORTANT CONCEPT
A Nursing Care Plan is not a record!!!
COMMUNICATION
COMMUNICATION
Exchange of ideas, information, feelings, data between two communicators
CONCEPT!
Communication is the basic component of Human Relationships
ELEMENTS OF COMMUNICATION
1. Message Data 2. Sender Encoder 3. Receiver Decoder 4. Feedback 5. Context Setting Overall environment where the communication takes place
MODES OF COMMUNICATION
1. Verbal Oral Spoken Written communication Text communication Cable communication Telex communication Facsimile communication
MODES OF COMMUNICATION
2. Non-verbal communication Facial expression Grimacing Posture Gait Adornment Make-up Gestures
FACTORS AFFECTING COMMUNICATION

Ability of the communicator Perceptions Proxemics Distances between communicators Intimate Distance Actual physical contact to 1.5 feet Personal Distance 1.5 feet to 4 feet 3 feet to 4 feet for interview Social Distance 4 feet to 12 feet Public Distance 12 feet and beyond
FACTORS AFFECTING COMMUNICATION

Territoriality One person believes that the space and all the things in that space belongs to him Do not enter abruptly; this may result in breach of privacy Roles and relationships
THERAPEUTIC COMMUNICATION IN NURSING

Using Silence Supplement with non-verbal communication Provide General Leads Examples: go on tell me more Open-ended questions

Use Touch But assess the culture of the patient If the patient is a child, touch the patient on the top of the head If the patient is an elderly, touch the patient on the hand If the patient is of the same age level, touch the patient on the shoulder Offering yourself For autistic child Stay nearby or stay beside the patient

Presenting Reality Example: You are in the hospital Reflecting Example: What do you think will make you happy Never agree nor disagree Reflect it back or throw it back
NON-THERAPEUTIC COMMUNICATION
Stumbling blocks to effective communication Stereotyping Generalizing Agreeing and Disagreeing No confrontation No argument Being defensive Moralizing or Passing Judgment Giving Common Advise Examples: If I were you You should have done it
PROMOTING REST AND SLEEP
CIRCADIAN RHYTHM
A biological rhythm A biological clock Regulated from outside the persons body
TYPES OF SLEEP
1. Rapid Eye Movement Sleep (REM Sleep)
Increased brain metabolism and activity Also called PARADOXICAL SLEEP Characterized by: Vivid dreams Easily recalled upon awakening
TYPES OF SLEEP: REM SLEEP
Colorful, dramatic, emotional, implausible dream Characterized by rapid eye movements Almost complete loss of muscle control
Penile erection (males) and vaginal moistening (females) Easy to awaken Usually a time for more intensive, vivid dreams
REM sleep varies
Adolescents spend 30% of total sleep time in REM sleep Adults spend 15% of total sleep in REM sleep
CONCEPTS!
REM sleep is NOT AS RESTFUL as NON-REM sleep However, REM sleep is NEEDED Dreaming is a psychological outlet of pent up emotions
NURSING ALERT!
Deprivation of REM sleep results to:
Irritability Restlessness Poor concentration
TYPES OF SLEEP
2. Non-Rapid Eye Movement Sleep (Non-REM Sleep)
Deep restful sleep Benefit is that it restores the body physically and psychologically (especially for post-operative patients)
TYPES OF SLEEP: NON-REM SLEEP STAGE 1
Stage of very light sleep The eyes roll from side to side Heart and respiratory rates drop slightly The sleeper can be readily awakened Stage only lasts for a few minutes
Stage of light sleep in which the body processes continue to slow down The eyes are generally still The heart and respiratory rates decrease slightly The body temperature falls Lasts only about 10 to 15 minutes but constitutes 40 45% of total sleep
The heart and respiratory rates, as well as other body processes, slow further because of the domination of the parasympathetic nervous system The sleeper becomes more difficult to arouse The person is not disturbed by sensory stimuli The skeletal muscles are very relaxed The reflexes are diminished and snoring may occur
Delta sleep or deep sleep Heart and respiratory rates drop 20 30% below that exhibited during waking hours Sleeper is very relaxed, rarely moves and is difficult to arouse This stage is thought to restore the body physically The eyes usually roll and some dreaming occurs
CONCEPT!
Deprivation of Non-REM sleep causes:
Physical exhaustion Decreased resistance against infection
WELLNESS TEACHINGS TO ENHANCE OR PROMOTE SLEEP

Establish a regular routine Have adequate exercise at daytime Avoid stimulating activity by bedtime

Avoid all types of stimulants Caffeine-containing foods Coffee Cocoa Chocolate Tea Cola Nicotine Alcohol Prolongs the REM stage of sleep It excites the patient like an anesthetic Not a stimulant

Avoid shabu Use the bed mainly for sleep If unable to sleep, get up and pursue satisfying activity

Drink something warm or hot (except stimulants)
Milk contains L-tryptophan L-tryptophan is an amino acid with a natural sedative effect that induces one to sleep

Do something HOT!
Twice-a-week masturbation is ideal Facilitates release of tension of the day

Side-to-side turning every two hours with back tapping Support bedtime rituals Remove all music in order to sleep
PROMOTING OXYGENATION
DEEP BREATHING
Two (2) types of Deep Breathing:

Apical Deep Breathing Basal Deep Breathing
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: To prevent respiratory alkalosis
APICAL DEEP BREATHING

Taught to patients who will undergo:
Upper abdominal surgery Cholecystectomy Incision site on diaphragm Patient does not want to breathe Predisposed to hypostatic pneumonia
BASAL DEEP BREATHING

Same procedure Area of concentration is the lower ribcage When to teach patient: Before surgery Before pain is present Rationale: If pain is already present, it would be difficult for patient to follow
BASAL DEEP BREATHING

When done:
Done q2 hours together with turning
COUGHING EXERCISES
Purpose To expand the lungs To facilitate expectoration of secretions How often done: At least every two (2) hours
COUGHING EXERCISES
Procedure
Teach the patient to inhale and exhale Tell the patient to inhale and exhale a second time Tell the patient to inhale and cough out
NURSING ALERT!
Coughing patients: is contraindicated in the following
With increased intracranial pressure (ICP) With increased intraoptical pressure (IOP) With cardiac arrhythmias (but are allowed to do deep breathing)
CONCEPTS!
Deep Breathing and Coughing Purpose is to stimulate surfactant production Yawning and production sneezing also stimulate surfactant
OXYGEN INHALATION AND ADMINISTRATION

Practical Application Concept!
When administering oxygen, be sure to open the valve of the oxygen tank first. Be certain that the valve on the regulator is closed so that the flow meter would not break!
CONCEPTS!
Humidifier moistens oxygen administered Purpose the
To avoid drying and irritation of the mucosal lining Also traps particulates from the tank Iron oxide may be present in the tank (iron plus oxygen produces iron oxide or rust)
CONCEPTS!
Fire Precaution Place NO SMOKING sign at the door or at the head part of the patient Tank and oxygen do not explode They merely support combustion
OTHER CONCEPTS!
Do not use volatile substances Acetone and alcohol can react with oxygen and lead to toxicity of patient Do not use oil based or grease on any part of the oxygen set Do not allow the patient to use an electric razor as sparks may trigger combustion
NURSING ALERT!
Retrolental Fibroplasia occurs if there is excess oxygen administration in infants. Excess oxygen leads to destruction of the retina and blindness
MODES OF ADMINISTRATION
1. Low Flow Administration
Utilizes nasal cannula or nasal prongs or nasal catheters Given to COPD patients
2. High Flow Administration
Uses a venturi mask
NEBULIZATION
With sodium chloride and salbutamol A physiologic solution Water liquefies secretions Sodium chloride stimulates coughing Salbutamol is a bronchodilator Purpose: For expectoration of secretions
NURSING PRE-THERAPY ASSESSMENT PRIOR TO NEBULIZATION

Have baseline data of patients breath sounds Assess again after nebulization to assess effectiveness of the procedure
SPIROMETRY
Purpose is to expand the lungs Done when inhaling Instruction to the patient:
Inhale from the spirometer and NOT blow to the spirometer Procedure: Inhale exhale Inhale exhale fully Place mouthpiece between teeth Hold breath for four (4) seconds Then inhale, fully rising the ball Upon inhalation, the ball rises
CHEST PHYSIOTHERAPY
This is a dependent procedure There are no absolute contraindications procedure Contraindicated for the following patients with: Pacemakers Lung abscess Hemoptysis Dangerous Arrhythmias Active PTB (which goes to the other lobe) Lung CA (malignancy goes to other lung)
to
this
THREE COMPONENTS OF CHEST PHYSIOTHERAPY

Percussion Vibration Postural Drainage

1. Percussion
Use cupped hands Hands alternate in rising and coming into contact with chest or back of patient

2. Vibration
Palms of your hand are placed on chest or back of patient giving quivering motions Palms remain in contact with the chest or back

3) Postural Drainage Drain secretions by gravity Change positions
POSTURAL DRAINAGE POSITIONS
IMPORTANT CONCEPT!
Rule out contraindications before performing chest physiotherapy
PRE-THERAPY ASSESSMENT FOR VIBRATION AND PERCUSSION

Assess breath sounds to know which lung fields have secretions Then assess again after procedure to check
effectiveness of the procedure.
CONCEPTS!
Vibration and percussion are mechanically dislodge secretions
done
to
Nebulization is done to liquefy secretions Suctioning is done to clear secretions Postural Drainage is done to drain secretions using gravity
POSTURAL DRAINAGE
When done: Before meals Two (2) hours after meals Before doing the procedure, the following baseline data are needed: Breath sounds Vital signs Continuous ECG monitoring
POSTURAL DRAINAGE
During the procedure:
Ensure the comfort of the patient Provide a kidney basin and tissue paper
NURSING ALERT!
Watch out for signs of symptoms which may require stopping of the procedure: Sudden dyspnea Cyanosis Extreme diaphoresis Sudden alteration of blood pressure, respiratory rate, pulse rate Appearance of arrhythmias Hemoptysis General intolerance of the procedure
IMPORTANT CONCEPT!
If any of those written on the previous slide occurs, STOP THE PROCEDURE and inform the physician
CONCEPT!
After the procedure assess the following: Breath sounds Vital signs Quantity and quality of sputum Overall response of the patient to the procedure Give oral hygiene Rationale: To eliminate phlegm from the mouth
IMPORTANT CONCEPT!
Patients with cystic fibrosis benefit much from postural drainage
SUCTIONING
SUCTIONING
Purpose is to seek out secretions
CONCEPTS ON SUCTIONING
Question: If you have only one (1) suction catheter, which will you suction first, the nose or the mouth? Answer: If the patient is an infant or a newborn: Start on the mouth then proceed to the nose Rationale: If you start on the nose, you will trigger the sneezing reflex and this would result into aspiration
CONCEPTS ON SUCTIONING
Question: If you have only one (1) suction catheter, which will you suction first, the nose or the mouth? Answer: If the patient is an adult, suction the mouth first, then proceed to the nose Rationale: This is done for aesthetic reasons
TYPES OF SUCTIONING
TYPE OF SUCTIONING: OROPHARYN -GEAL SUCTIONING If the patient is conscious POSITION OF THE PATIENT WHILE SUCTIONING Fowlers (high or moderate); Head turned to one side (towards the nurse) DEPTH DURATION INTERVAL WITH EACH PASS OF SUCTION 20 30 seconds TOTAL TIME
10 15 cm
Not more than 10 15 seconds
Not more than 5 minutes
If the patient is unconscious
Place on one side (facing the nurse); Tilt neck to move head slightly forward towards the basin to avoid aspiration during suctioning
10 15 cm
20 30 seconds
TYPES OF SUCTIONING
TYPE OF SUCTIONING: NASOPHARYNGEAL SUCTIONING If the patient is conscious POSITION OF THE PATIENT WHILE SUCTIONING DEPTH DURATION INTERVAL WITH EACH PASS OF SUCTION TOTAL TIME
Neck should be hyperextended; Fowlers position
From tip of the nose to tip of the earlobe
20 30 seconds
Flat on bed with head turned to the nurse Lateral position may be assumed
From tip of the nose to tip of the earlobe
20 30 seconds
TYPES OF SUCTIONING
TYPE OF SUCTIONING: OROTRACHEAL SUCTIONING If the patient is conscious POSITION OF THE PATIENT WHILE SUCTIONING DEPTH DURATION INTERVAL WITH EACH PASS OF SUCTION TOTAL TIME
Low to semifowlers position
Measure from mouth to midsternum
Not more than 10 seconds
20 30 seconds
Flat on bed; Suction trachea through the mouth
Measure from mouth to midsternum
20 30 seconds
TYPES OF SUCTIONING
TYPE OF SUCTIONING: NASOTRACHEAL SUCTIONING If the patient is conscious POSITION OF THE PATIENT WHILE SUCTIONING DEPTH DURATION INTERVAL WITH EACH PASS OF SUCTION TOTAL TIME
Low to semifowlers position
From tip of the nose to earlobe to dominating side of neck to the thyroid cartilage From tip of the nose to earlobe to dominating side of neck to the thyroid cartilage
20 30 seconds
Flat on bed; Suction trachea through the nose
20 30 seconds
TYPES OF SUCTIONING
TYPE OF SUCTIONING: POSITION OF THE PATIENT WHILE SUCTIONING Semi-Fowlers not contraindicated if DEPTH DURATION INTERVAL WITH EACH PASS OF SUCTION 2 3 minutes TOTAL TIME
ENDOTRACHEAL TUBE SUCTIONING
12.5 cms. or 6 inches; Insert as far as it goes until you meet resistance or until patient coughs Insert as far as it gets until you meet resistance or until the patient coughs
5 10 seconds
TRACHEOSTOMY TUBE SUCTIONING
Semi-Fowlers not contraindicated
if
5 10 seconds
2 3 minutes
IMPORTANT CONCEPTS ON SUCTIONING!!!

For Endotracheal suctioning: NO TUBE IS USED HERE This is suctioning of the trachea through the mouth or through the nose Two (2) types of Endotracheal Suctioning: Orotracheal Suctioning Oral approach Nasotracheal Suctioning Nasal approach
GENERAL CONDITIONS FOR SUCTIONING

For Endotracheal and Tracheostomy (Naso and Oral and Tube)
Before suctioning, HYPEROXYGENATE the patient During intervals, HYPEROXYGENATE the patient

For ET, Tracheostomy, ET tube:
Nursing Alert! During insertion, if you encounter resistance, withdraw the catheter about one centimeter (1 cm) before applying suction Rationale: To avoid trauma on the mucous membrane

For ET, Tracheostomy, ET Tube:
Do suctioning intermittently Suctioning should not be continuous Rotate the catheter (between the thumb and the index finger) as you withdraw Apply suction only when you are ready to withdraw (i.e. keep finger away from suction port if you are still not ready)
HOW TO HYPEROXYGENATE THE PATIENT

Give two (2) to three (3) blows by ambubag Increase flow rate and concentration of oxygen Nursing Alert! If the patient has thick, tenacious secretions, DO NOT USE AN AMBUBAG Use an OXYGEN INSUFFLATION SUCTION CATHETER instead!!! This is a two-lumen catheter (one lumen brings oxygen to the patient, the other lumen brings out secretions from the patient)
HOW TO HYPEROXYGENATE THE PATIENT

In the event of encrustations, PERFORM TRACHEAL LAVAGE
Instill 2.5 ml to 5.0 ml Normal Saline Solution for adults to liquefy the mucous plug Instill 2.0 ml Normal Saline Solution for children to liquefy the mucous plug Instill 0.5 ml to 1.0 ml Normal Saline Solution for infants to liquefy the mucous plug
VITAL SIGNS
TEMPERATURE
TEMPERATURE
Oral Temperature Axillary Temperature Rectal Temperature
ORAL TEMPERATURE
Most convenient Most accessible Nursing Alert!
Applicability is for children aged six (6) years and above Not applicable for children below six (6) years old
ORAL TEMPERATURE
Contraindicated in the patients with: Oral surgery Mouth breathers History of convulsive seizures Unconscious Incoherent Irrational Mentally disrupted Insane
ORAL TEMPERATURE
Procedure Nothing Per Orem for about thirty (30) minutes before taking temperature No food intake No drinks No smoking No chewing gum No whistling No gargling Rationale Any of the above would alter the results
ORAL TEMPERATURE
Placement: Under the tongue, beside the frenulum (right or left) Total Time: Two (2) to three (3) minutes
AXILLARY TEMPERATURE
Least reliable Safest method Nursing Alert!
During application, be sure that axilla is dry Dry using a patting motion
Nursing Alert! Do not RUB! Rationale This increases heat due to friction Rubbing increases blood supply to the area Therefore, there will be increase in temperature reading Rubbing provides a false-positive elevation of temperature reading
Duration:
In adults nine (9) minutes In children five (5) minutes
RECTAL TEMPERATURE
Most reliable (except for Tympanic Thermometer) Most accurate (except for Tympanic Thermometer) Concept! If tympanic method is used using a tympanic thermometer, the rectal method is only second most reliable and second most accurate
RECTAL TEMPERATURE
Disadvantage: Placement on a different site yields a different reading Therefore, ensure that the bulb of the rectal thermometer rests on the mucous membrane. Contraindications: Hemorrhoids Rectal Surgery Certain Cardiac ailments due to stimulation of the vagus nerve; valsalva maneuver leads to arrhythmias
RECTAL TEMPERATURE
Position of the patient when taking the reading: Sims left position Sims right position For Newborn, lift up ankles to keep buttocks up In Toddlers, set on prone position on adults lap Duration: Two (2) minutes
TEMPERATURE SCALES
Conversion of Centigrade to Fahrenheit
Centigrade = (5/9)F 32 Centigrade = (F/1.8) 32
TEMPERATURE SCALES
Conversion of Fahrenheit to Centigrade
Fahrenheit = (9/5)C + 32 Fahrenheit = (1.8)C + 32
CONCEPTS ON HUMAN BODY TEMPERATURE

Highest body temperature is usually reached between 8:00 PM to 12:00 MN Lowest body temperature occurs in the early morning hours of the day at around 4:00 AM to 6:00 AM
FEVER
Normally, the hypothalamus is able to adjust body temperatures between 37C to 40C But due to the presence of pyrogenic materials like the following: Pathogenic microorganisms Toxins Foreign substances Any substance capable of increasing body temperature Creates a deficiency of -3C, making a person enter the FIRST STAGE OF FEVER
FIRST STAGE OF FEVER

Typical signs and symptoms indicate the bodys compliance mechanism to increase and conserve heat: Chills Shivering Gooseflesh Contraction of arectores pilorum or pilo arecti muscles Vasoconstriction Decreases blood supply to the skin Pallid Skin Cyanotic nail beds

Key Concept!!! Patient complains of feeling cold Sweating will stop because body will minimizes heat loss Also called: Onset Stage Chill Stage Cold Stage This stage is characterized by low febrile temperatures

Nursing Management:
Aim is to minimize heat loss Do NOT apply TEPID SPONGE BATH because this would make patient progress to SHOCK Provide additional clothing as necessary Provide additional blankets as necessary Provide something warm to drink These measures would result to a gradual increase in body temperature

Question: When will you start application of TSB? Answer: If there is a 1C to 2C increase in body temperature
SECOND STAGE OF FEVER

Also called: Coarse Stage of Fever Peak Stage of Fever Key Concepts! Patient does not feel hot or cold Skin is warm to touch Skin is flushed Fever blisters are present Herpetic lesions Absence of shivering Possible dehydration

Important Concept!!! For every increase of temperature, there is a corresponding increase in pulse rate Rationale: Increase in temperature results in an increase in pulse rate due to increased metabolic rate Increased metabolic rate increases oxygen demand Due to increased oxygen demand of susceptible brain cells, CONVULSIVE SEIZURES may occur. These may also be due to irritation of nerve cells FEBRILE CONVULSIONS

Increased oxygen demand also leads to an increase in respiratory rate Patient complains of: Loss of appetite Myalgia or muscle pains due to increased catabolism Nursing Management Tepid Sponge Bath Cooling Bed Bath
TEPID SPONGE BATH

Temperature of water is 32C This temperature is maintained procedure How to apply: Done by patting Rationale: To avoid friction, which increases temperature
throughout
the
TEPID SPONGE BATH

Important Concept! Do NOT use ALCOHOL when applying TSB Rationale: Alcohol dries the skin and leads to irritation Key Concept! TSB should not be done hurriedly Rationale: When done hurriedly, TSB will stimulate shivering Shivering would lead to increased muscle activity Increased muscle activity would lead to increased temperature
COOLING BED BATH

Water temperature will start at 32C Procedure will go on with gradual decrease in water temperature until it is maintained at 18C Therefore, to achieve this drop in temperature, utilize ice Same procedure of application as in Tepid Sponge Bath
TYPES OF FEVER
1. Intermittent Fever
A fever that is alternated at regular intervals by periods of normal and subnormal temperature
TYPES OF FEVER
2. Remittent Fever
Fever alternated by wide range of fluctuations in temperature, all of them are ABOVE NORMAL. Duration is within a 24-hour period
TYPES OF FEVER
3. Relapsing Fever
Short periods of febrile episodes alternated by one (1) to two (2) days of normal temperature
TYPES OF FEVER
4. Constant Fever
Minimal fluctuations of temperature, all of which are ABOVE NORMAL
TYPES OF FEVER
5. Staircase or Spiking Fever
Common in patients with TYPHOID FEVER
PULSE RATE
PULSE ASSESSMENT
Concepts!
If pulse is regular, count or monitor pulse for thirty (30) seconds and multiply by two (2). This is legal! If pulse is irregular, count or monitor the pulse for one (1) FULL minute
ASSESSMENT OF THE PULSE DEFICIT

Pulse Deficit is the difference between the apical pulse and the radial pulse. Obtained by having one person count the apical pulse as heard through a stethoscope over the heart and another person count the radial pulse at the same time.
ASSESSMENT OF THE PULSE DEFICIT

This is the most accurate method Involves two nurses using one watch Starts at the same time Ends at the same time Comparison of results ensues Count is done for one (1) full minute
SCALE IN PULSE ASSESSMENT

0 1+ 2+ 3+ Absent or cannot be felt Weak or thready Normal Bounding
BLOOD PRESSURE
BLOOD PRESSURE
Systolic Produced by ventricular contraction Pressure on blood vessels during depolarization or ventricular contraction Diastolic Pressure that remains in the walls of the blood vessels during relaxation or repolarization or resting
BLOOD PRESSURE
Broadly two (2) types:
Direct By insertion of a catheter Indirect Method Auscultatory method Palpatory method Flush Method
AUSCULTATORY METHOD
Uses Korotkoff sound
A popping sound NOT the heart beat It is a phenomenon an unknown phenomenon!
AUSCULTATORY METHOD
Determining Amount of Inflation
Using auscultatory method Ask patient what is his last BP reading and then add 30 40 mmHg from last systolic reading. Deflate gradually rate is approximately 2 3 mmHg per second Alternative auscultatory method Auscultate for the last sound as you go up. Then add 30 40 mmHg Then deflate
AUSCULTATORY METHOD
Tripartite Blood Pressure Done if patient is an adult. Example: 140 mmHg systolic first loudest sound 100 mmHg 1st diastolic muffling 70 mmHg 2nd diastolic last sound Therefore, the tripartite blood pressure is 140 / 100 / 70 If there is no muffling, an example would be: 160 / no muffling / 110
AUSCULTATORY METHOD
Concepts!!! Take systolic on loudest sound if patient is an adult If patient is pediatric or up to ten (10) years old, take the first sound, whether it is faint or loud If, for example, first sound is at 190 mmHg and there is silence up to 140 mmHg and then there is a sound at 130 mmHg down to 80 mmHg then Use the PALPATORY METHOD in combination with the AUSCULTATORY METHOD because there is an auscultatory gap Repeat using: Auscultatory method Palpatory method
HOW TO DO THE PALPATORY METHOD

Inflate Determine up to what point to inflate Palpate pulse If pulse is absent, add 30 40 mmHg Deflate First palpable pulse is true systolic pressure For diastolic pressure, proceed using the auscultatory method
FLUSH METHOD
Represents the mean blood pressure Represents the average of the systolic and diastolic pressures
FLUSH METHOD
When done:
When you have a BP apparatus without a stethoscope Used for pediatric patients
FLUSH METHOD
How done:
Inflate up to the point where extremity becomes pale Deflate slowly and look for a REBOUND FLUSH when extremity becomes red again
This is the true reading!! Note that there is only ONE reading!!!
PULSE PRESSURE
It is the difference between systolic and diastolic pressures Normal is 30 40 mmHg
HYPERTENSION
This is an abnormally high blood pressure over140 mmHg systolic and or above 90 mmHg diastolic for at least two consecutive readings
HYPOTENSION
This is an abnormally low blood pressure, systolic pressure below 100 mmHg and diastolic pressure below 60 mmHg
RESPIRATORY RATE
THREE PROCESSES IN RESPIRATION

Ventilation The movement of gases in and out of the lungs Involves inhalation or inspiration and exhalation or expiration Diffusion The exchange of gases from an area of higher pressure to an area of lower pressure It occurs at the alveolo-capillary membrane Perfusion The availability and movement of blood for transport of gases, nutrients, and metabolic waste products
ASSESSING RESPIRATIONS
Rate Normal is 12 20 cycles per minute in an adult Depth Observe the movement of the chest. May be normal, deep, or shallow
ASSESSING RESPIRATIONS
Rhythm Observe for regularity of exhalations and inhalations Quality or Characteristic Refers to respiratory effort and sound of breathing
MAJOR FACTORS AFFECTING THE RESPIRATORY RATE

Exercise
Increases respiratory rate
Stress
Increases respiratory rate
Environment
Increased temperature of the environment decreases RR; Decreased temperature, increases RR Increased altitude Increases RR Medications
(e.g., narcotics decrease RR)
SKIN INTEGRITY
DECUBITUS ULCERS
Decubitus ulcers are caused by:
Unrelieved, sustained pressure Localized ischemia Shearing force Pressure plus friction
DECUBITUS ULCERS
Predisposing Factors: Unconsciousness Incontinence Loss of Sensation Hypoproteinemia Decreased lean muscle mass Increase in fluid shifting leads to edema Dependent position is the skin attached to or facing the bed Emaciation
STAGES OF DECUBITUS ULCER FORMATION
Stage 1
Involves the epidermis Manifestation Non-blanchable erythema of INTACT SKIN This is the first heralding sign of decubitus ulceration
Stage 2
Partial Thickness Skin Loss Involves epidermis and dermis Manifestation Blister formation Shallow craters Shallow abrasion and ulceration
Stage 3
Full Thickness Skin Loss Ulceration There is skin loss already Involves necrosis of the skin and subcutaneous tissues EXTENDING TO but NOT THROUGH the underlying fascia
Stage 4
Formations and manifestations of Stage 3 plus Involvement of bones, supporting structures (tendons), joint capsules Massive damage
TOOLS TO ASSESS RISK OF ULCERATION

Nortons Pressure Area Risk Assessment Form Shannons Scoring System Branden Scale of Predicting Ulceration Waterlow Risk Assessment Cards Most important tool Most common tool Most often used tool
EDEMA
EDEMA
Caused by shifting of fluid into the interstitial tissues
MANAGEMENT OF EDEMA
1) Elevation of the edematous part
Nursing Alert! If edema is due to Congestive Heart Failure (Right Sided), NEVER ELEVATE THE LOWER EXTREMITIES Rationale: This increases the workload of the right side of the heart Concept! If edema is due to prolonged standing, DO THE ELEVATION
MANAGEMENT OF EDEMA
2) Wear elastic stockings
MANAGEMENT OF EDEMA
3) Use warm compress alternated with cold compress
Rationale: Vasoconstriction circulation of fluid
and
vasodilation
causes
re-
Concept! This is contraindicated if there is inflammation
ASSESSMENT OF EDEMA
Induration
1+ 2+ 3+ 4+ 5+ 1 cm induration 2 cm induration 3 cm induration 4 cm induration 5 cm induration
PAIN MANAGEMENT
PAIN
A noxious stimulation of actual or threatened / potential tissue damage
CATEGORIES OF PAIN ACCORDING TO ORIGIN

1) Cutaneous Skin 2) Deep Somatic Tendons, ligaments Bones Blood Vessels 3) Visceral Pain Organs of the body
CATEGORIES OF PAIN BASED ON CAUSE

1) Acute Due to trauma or surgery Persists for less than six (6) months 2) Chronic Malignant Pain Related to cancer On and off Persists for more than six (6) months 3) Chronic Non-malignant Pain Persists for more than six (6) months
CATEGORIES OF PAIN ACCORDING TO WHERE IT IS EXPERIENCED

1) Radiating Pain Felt on the source and is extending to nearby tissues 2) Referred Pain Felt on other parts detached from the source Example: Pain on a lacerated liver may be felt on the right shoulder and not on the right upper quadrant
CATEGORIES OF PAIN ACCORDING TO WHERE IT IS EXPERIENCED

3) Intractable Pain Highly resistant to pain-relief methods 4) Phantom Pain Pain that is felt on a MISSING BODY PART or a PART THAT IS PARALYZED by SPINAL CORD INJURY.
PAIN THRESHOLD
Amount of pain stimulation that is required in order to feel pain
PAIN TOLERANCE
Maximum amount of pain and duration that a person is willing to endure
PAIN MANAGEMENT STRATEGIES

1) Pharmacologic Methods Narcotics NSAIDs Adjuvants or Co-analgesics 2) Non-Pharmacologic Methods Physical Interventions Cognitive / Behavioral Interventions
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS TO PAIN

1) Cutaneous Stimulation 1A) Massage Effleurage Soft massage Gentle stroking

1) Cutaneous Stimulation
1B) Petrissage Hard massage Large and quick pinches Also done by striking

1C) Application of Counter-Irritant Bengay Menthol Omega Pain Killer Flax Seeds Poultices

1D) Heat and Cold Application Nursing Alert!
Rebound Phenomenon When you apply heat (usually done for 20 minutes), vasodilation is produced If heat is applied for more than 20 minutes, there is vasoconstriction This is an inherent defense mechanism from burning of tissues

1E) Cold Application Maximum vasoconstriction is reached when skin reaches 15C If there is further drop in temperature, there is vasodilation (skin becomes reddish) This is the inherent defense mechanism from being frozen

1) Cutaneous Stimulation 1F) Accupressure Pressure on certain points of the body Stimulates release of endorphins, which have natural analgesic effects This started in Ancient China

1) Cutaneous Stimulation 1F) Accupuncture Insertion of long slender needles on certain chemical pathways Origin is also Ancient china

1G) Contralateral Stimulation Example: Injury on left side and massage is done on the right side Useful when patient cannot be accessed: For patients in a cast For patients with burns
For patients with phantom pain

2) Immobilization Application of splints

3) Transcutaneous Electrical Nerve Stimulation Composed of electrodes Operated by battery Electrodes are applied on painful site or over the spinal cord

4) Administration of a Placebo Relieves pain because of its intent and not because of physical or chemical properties
COGNITIVE AND BEHAVIORAL NON-PHARMACOLOGIC INTERVENTIONS TO PAIN

Purpose:
To alter pain perception To alter pain behavior To provide client with a greater sense of control over the pain

1) Distraction Purpose is to divert attention from pain Slow Rhythmic Breathing Stare at a certain object Take deep breath slowly Release or exhale slowly Concentrate on breathing Picture a peaceful scene Establish a rhythmic pattern

2) Massage and Rhythmic Breathing

3) Rhythmic Singing and Tapping Key Concept! Faster beat music is more preferable
4) Guided Imagery Imagine that you are walking along a peaceful shore Eyes are closed and suggestions are given

5) Hypnosis The success of hypnosis depends on the ability of the patient to concentrate and the capacity of the hypnotist to suggest Based on suggestion Progressive relaxation
URINARY ELIMINATION
URINARY ELIMINATION
Oliguria Renal output of less than 500 ml per day Anuria Renal output of less than 100 ml per day Retention Positive for distended bladder May also occur in the absence of bladder distention
ALTERED URINARY ELIMINATION

Enuresis Common among pediatric patients Age 4 5 years old child has adequate bladder control Primary Enuresis Never had a dry period Secondary Enuresis Acquired enuresis At age 7, bladder control is present for at least one year Then, enuresis comes back Urinating could NOT be controlled again
ALTERED URINARY ELIMINATION

Incontinence Involuntary passage of urine
TYPES OF INCONTINENCE
1) Functional Incontinence
Involuntary passage Unpredictable time
2) Reflex Incontinence
Occurs at somewhat predictable times when specific bladder volume is reached No awareness of bladder filling No urge to void It may be related to neurologic impairment
3) Stress Incontinence Loss of urine is less than 50 ml occurring with increased intraabdominal pressure Occurs when laughing Occurs when sneezing Occurs when smiling
4) Total Incontinence
Continuous flow of urine No bladder distention No bladder spasm No awareness of bladder filling
5) Urge Incontinence Urine flows as soon as a strong sense of feeling to void occurs Strong bladder spasm
MANAGEMENT OF INCONTINENCE
1) Kegels Exercises Also called: Pubococcygeal Muscle Exercises Pelvic Floor Muscle Exercises Applicable for: Functional Incontinence Stress Incontinence How done: Advise patient to stand with legs slightly apart Concentrate on perineum Draw perineum upward slowly
1) Kegels Exercises
Alternative way: When urinating, try to stop in the middle of flow or try to stop diarrhea from flowing Advantage of Kegels Exercises Increases muscle tone of the pelvis Increases muscle control
2) Clean Intermittent Self Catheterization Applicable for Reflex Incontinence How done: Use a mirror for: Obese male patients Female patients
2) Clean Intermittent Self Catheterization
Question: Is your Clean Intermittent Self Catheterization procedure a sterile procedure? Answer: No, it is just a clean procedure. Therefore, you can just wash the catheter for the next use.
3) Credes Maneuver
Application of a steady but gentle pressure on the supra-pubic region to force urine out of the bladder Nursing Alert! Do not use if there is OBSTRUCTION (i.e. renal obstruction in the form of renal stones) This is done only for patients who are no longer expected to regain control (Reflex incontinence and retention)
4) Prompted Voiding or Scheduled Toileting
For Reflex Incontinence
5) Application of Adult Catheter and External Condom Catheter For elderly with Total Incontinence
6) Catheterization
MIDSTREAM CLEAN CATCH URINE SPECIMEN

How is this done? If patient is a Male Clean the penis Do this from the meatus down to the shaft Let the patient urinate Discard the first or the initial urine Collect midstream urine Purpose is to attain sterile specimen for urine culture and sensitivity testing
MIDSTREAM CLEAN CATCH URINE SPECIMEN

If patient is a Female Let patient wash genitals Dry the genitals Get to bed Place patient in semi-Fowlers position when she is ready to void Clean and spread labia with two fingers Remain holding labia Then let patient urinate Let go of first flow Collect next flow
CATHETERIZATION
TYPES OF URINARY CATHETERS

1) Coude Catheter Elbowed catheter for Benign Prostatic Hypertrophy patients
2) Robinson Catheter Straight catheter

Multi-Lumen Retention Catheter Foley catheter One lumen is for inflation One lumen is for drainage of urine One lumen is for irrigation A three-way catheter Aspirate using syringe and needle This is made with a self-sealing rubber
CONCEPTS IN MALE CATHETERIZATION

Procedure for Insertion:
See to it that penis is perpendicular to body to straighten up the urethra to bladder While inserting the catheter, ask the patient to breathe through the mouth Cleanse the penis before insertion Grasp penis firmly to avoid stimulating erections

Where to tape catheter Tape it upward on the abdomen Rationale: To avoid scrotal excoriation Tape on the inner thigh (with penis sideways either on left or right and follow the normal contour of the penis

Length of Catheter 40 centimeters Depth of Insertion While inserting, the point at which urine starts to flow, insert further by five (5) centimeters and then inflate the balloon KOZIER Insert up to a the Y-point, retract after inflating (this method is more prone to infection
CONCEPTS IN FEMALE CATHETERIZATION

Area of Insertion Insert at female Urethra Length of Catheter 22 centimeters Depth of Insertion Point at which urine starts to flow, insert further by five (5) centimeter before inflating balloon
GIT FECAL ELIMINATION
WELLNESS TEACHINGS
Fluid intake of at least 2,000 ml per day Regular exercise High fiber diet Avoid ignoring the urge to defecate Do not abuse laxatives
CONCEPTS FOR FLATULENCE

Avoid carbonated drinks Do not use straw Avoid chewing gum Avoid gas-forming foods: Camote Cabbage Cauliflower Onions
CONCEPTS FOR CONSTIPATION

Increase fluid intake Take prune juice Eat papaya Increase fiber in the diet Use METAMUCIL (natural fiber) instead of laxatives
SPECIAL GASTRO-INTESTINAL LABORATORY PROCEDURES

1) Guiac Test To determine the presence of occult blood
Concepts!!! Have a meat-less diet three (3) days before examination Withhold oral iron supplements Injectable iron is allowed Avoid any food that discolors the stool.

2) GI SERIES 2A) Upper GI Series Barium Swallow Nursing Considerations: Elimination of contrast medium How: Increase fluid intake Increase fiber in the diet Rationale: To offset the risk of constipation Inform patient that the color of the stool will be WHITE

2) GI SERIES
2B) Lower GI Series Barium Enema Done at the radiology department Nursing Concern:
Elimination of Barium How: Cleansing enema may be needed after barium enema
DIFFERENT TYPES OF ENEMA

1) Cleansing Enema Soap suds enema Alkaline solution Nursing Alert! Contraindicated in patients with liver cirrhosis and with increased ammonia in the blood Rationale: Alkaline solution facilitates transfer of ammonia from the GI tract to the bloodstream Therefore, use lemon juice or dilute vinegar instead!!!

1) Cleansing Enema Nursing Alert! Also contraindicated in possible appendicitis or appendicitis patients Rationale: Can lead to rupture of the appendix

2) Carminative Enema
Used to expel out flatus Burned sugar Now commercially available

3) Oil Retention Enema
To lubricate the colon and to soften the feces Retention time is one (1) to three (3) hours

4) Retention Flow Enema
Also called Harish Flush Enema Solution is continually administered until what comes out of the body is clear.
POSITIONS IN ENEMA
High Cleansing Enema
Clean as much of the colon as possible On introduction, Sims Left position facilitates flow of enema to sigmoid colon Then, assume Dorsal Recumbent position to facilitate flow of enema to transverse colon Then, Right Side-Lying position to facilitate flow of enema to the descending colon
POSITIONS IN ENEMA
Low Cleansing Enema
For cleaning of rectum and colon only

Fundamentals of Nursing

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Fundamentals of Nursing

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FUNDAMENTALS OF NURSING

FOUR COMPONENTS OR ATTRIBUTES OF MAN

NURSING CONCEPTS OF MAN

VITAL REPARATIVE PROCESS

MAN IS A WHOLE. MAN IS COMPLETE

CHARACTERISTICS OF HUMAN NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS MODIFIED HIERARCHY OF EIGHT NEEDS (1990)

ABRAHAM MASLOWS MODIFIED HIERARCHY OF EIGHT NEEDS (1990)

ABRAHAM MASLOWS MODIFIED HIERARCHY OF EIGHT NEEDS (1990)

ABRAHAM MASLOWS MODIFIED HIERARCHY OF EIGHT NEEDS (1990)

CHARACTERISTICS OF SELF-ACTUALIZED PERSONS

CHARACTERISTICS OF SELF-ACTUALIZED PERSONS

ILLNESS, WELLNESS AND HEALTH

TWO TYPES OF ILLNESS

MODELS OF HEALTH AND ILLNESS

DUNNS HIGH-LEVEL WELLNESS AND GRID MODEL

HEALTH BELIEF MODEL BY ROSENTOCK

FOUR LEVELS OF HEALTH BY SMITH

FOUR LEVELS OF HEALTH BY SMITH

FOUR LEVELS OF HEALTH BY SMITH

FOUR LEVELS OF HEALTH BY SMITH

AGENT, HOST, ENVIRONMENT MODEL BY LEAVELL AND CLARK

Canadian Nurses Association

Recovery Reparative process

1) FLORENCE NIGHTINGALE: ENVIRONMENTAL NURSING THEORY

1) FLORENCE NIGHTINGALE: ENVIRONMENTAL NURSING THEORY

1) FLORENCE NIGHTINGALE: ENVIRONMENTAL NURSING THEORY

2) DOROTHY JOHNSON: BEHAVIORAL SYSTEMS MODEL

3) VIRGINIA HENDERSON: FOURTEEN FUNDAMENTAL NEEDS

3) VIRGINIA HENDERSON: FOURTEEN FUNDAMENTAL NEEDS

3) VIRGINIA HENDERSON: FOURTEEN FUNDAMENTAL NEEDS

3) VIRGINIA HENDERSON: FOURTEEN FUNDAMENTAL NEEDS

4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS

4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS

4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS

4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS

4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS

4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS

4) FAYE ABDELLA: PROBLEM SOLVING APPROACH TO 21 NURSING PROBLEMS

5) MARJORIE GORDON: HUMAN FUNCTIONAL HEALTH PATTERNS

It enables the nurse to determine the clients response as functional or dysfunctional

5) MARJORIE GORDON: HUMAN FUNCTIONAL HEALTH PATTERNS

5) MARJORIE GORDON: HUMAN FUNCTIONAL HEALTH PATTERNS

6) IMOGENE KING: GOAL ATTAINMENT THEORY

7) MADELEINE LEHNINGER: TRANSCULTURAL NURSING THEORY

8) MYRA LEVINE: FOUR CONSERVATION PRINCIPLES OF NURSING

8) MYRA LEVINE: FOUR CONSERVATION PRINCIPLES OF NURSING

9) BETTY NEUMAN: HEALTH CARE SYSTEMS MODEL

11) HILDEGAARD PEPLAU: INTERPERSONAL MODEL

11) HILDEGAARD PEPLAU: INTERPERSONAL MODEL

Nurse maximizes all the resources to benefit the patient

11) HILDEGAARD PEPLAU: INTERPERSONAL MODEL

Occurs when patients needs have been met

12) MARTHA ROGERS: SCIENCE OF UNITARY HUMAN BEINGS

13) SISTER CALISTA ROY: ADAPTATION MODEL

15) JEAN WATSON: HUMAN CARING MODEL