FUNDAMENTALS

OF NURSING

MA.CRISTINA TAMPINCO-REYES, RN
NLE INSTRUCTOR, ICSEC-KAPLAN
History of Nursing
in the Philippines
EARLIEST HOSPITALS
1. Hospital Real de Manila – for Spanish
King’s soldiers
2. San Lazaro Hospital – for patients with
leprosy
3. Hospital de Indio – supported by alms 7
contributions from charitable persons
4. Hospital de Aguas Santas –near
medicinal spring
5. San Juan de Dios Hospital – supported
by alms & rents for gen.health of public
IMPORTANT PERSONS
JOSEPHINE BRACKEN
ROSA SEVILLA DE ALVERO
DOÑA HILARIA DE AGUINALDO – organized
Filipino Red Cross
DOÑA MARIA AGONCILLO DE AGUINALDO –
president of Filipino Red Cross in Batangas
MELCHORA AQUINO
FILIPINO RED CROSS – provided nursing care to
wounded Filipino soldiers by collecting war funds &
materials thru concerts, charity bazaar & contributions
HOSPITALS & SCHOOLS OF NURSING
1. Iloilo Mission Hospital School of Nursing
(1906)
2. St. Paul’s Hospital School of Nursing
(1907) – general hospital services with
free dispensary & dental clinic
3. Philippine General Hospital School of
Nursing (1907) – opened first dormitory
for enrollees of Philippine Normal Hall &
University of the Philippines
- Anastacia Giron-Tupas – 1st Filipino chief nurse
& superintendent
4. St. Luke’s Hospital School of Nursing
(1907) – started with 3 enrollees merged
with St.Paul & PGH for the 1st year (Central
School Idea)
-Helen Hicks – 1st principal
-Vitaliana Beltran – 1st Filipino
superintendent of nurses
-Dr. Jose Fores – 1st Filipino medical
director
5. Mary Johnston Hospital & School of
Nursing – called”Bethany Dispensary” for
suffering women & children
6. Philippine Christian Mission Institute
School of Nursing –
-Sallie Long Read Memorial School of Nursing
(Laoag)
-Mary Chiles Hospital School of Nursing
(Manila)
-Frank Dunn Memorial Hospital (Ilocos)
7. San Juan de Dios Hospital School of
Nursing
8. Emmanuel Hospital School of Nursing –
offered a 3-year training course with P100
annual fee
9. Southern Islands Hospital School of
Nursing – established under Bureau of
Health
FIRST COLLEGES OF NURSING
1. University of Santo Tomas College of
Nursing
2. Manila Central University College of
Nursing
3. University of the Philippines College of
Nursing
NURSING LEADERS IN THE PHILIPPINES
1. Anastacia Giron-Tupas – 1st Chief Nurse
Superintendent, founder of PNA
2. Cesaria Tan –1st to receive Masters degree
3. Socorro Sirilan- pioneered Hospital Social
Service in San Lazaro
4. Rosa Militar – pioneer in school health
education
5. Sor Ricarda Mendoza – pioneer in nursing
education
6. Socorro Diaz – 1st editor of PNA magazine
“The Message”
7. Conchita Ruiz – 1st editor of newly named
PNA magazine “The Filipino Nurse”
8. Loreto Tupaz –Dean of Philippine Nursing
- Florence Nightingale of Iloilo
PROFESSIONAL ORGANIZATIONS OF
NURSING
1. Philippine Nurses Association – national
organization of Filipino nurses
2. National League of Nurses – association
of nurses employed in DOH
3. Catholic Nurses Guild of the Philippines
4. ORNAP
5. MCNAP
6. ANSAP
EVOLUTION OF NURSING
1. PERIOD OF INTUITIVE NURSING- since
prehistoric times through eraly Christian era
-Nursing was untaught & instinctive,
performed out of compassion for others
2. PERIOD OF APPRENTICE NURSING –
extends from founding or religious nursing
orders and ended in 1836 when
KAISERWERTH INSTITUTE for the training of
DEACONESSES in Germany was established
- Called Period of “On-the-Job” training
3. DARK PERIOD OF NURSING – extends from
period of reformation until US Civil War
(17th to 19th century)
-Unity of Christian faith destroyed by Martin
Luther
-No provisions for the sick
-Nursing became work of least desirable
women
4. PERIOD OF EDUCATED NURSING – bagan
when Florence Nightingale School of
nursing opened
-Strongly influenced by the war, social
consciousness, emancipation of women &
increased educational opportunities
offered to women
5. PERIOD OF CONTEMPORARY NURSING –
covers after WWII to present.
- Scientific & technological developments
& social changes mark this period.
 Man and
His Basic Human
Needs
 THE 4 MAJOR ATTRIBUTES OF
HUMAN BEINGS
1. Capacity to think or conceptualize
2. Family formation
3. Tendency to seek and maintain territory
4. Ability to use verbal symbols as
language, means of developing &
maintaining culture
THE NURSING CONCEPTS OF MAN
ROY – “Man is a biopsychosocial & spiritual
being who is in constant contact with the
environment”
•As biologic being – man is LIKE ALL OTHER
MEN
•As psychologic being – man is LIKE NO
OTHER MAN.
•As social being – man is LIKE SOME OTHER
MEN
•As spiritual being – man is LIKE ALL OTHER
MEN
ROY – “Man is an Open system in constant
interaction with a changing environment”

-An open system allows input and output to

and from its boundaries
-Allows exchange of or is constantly
affected by matter, energy & information
-A closed system is one that will not allow
inputs & outputs
ROGERS – “Man is a unified whole
composed of parts which are
interdependent and interrelated with
each other”
-The different organs & systems functions
together to achieve a particular goal.
-“Man is composed of parts which are
greater than & different from the sum of
all his parts.”
-Greater than the sum of all his parts- he is
not simply a composite of physiologic body
parts
-Different from the sum of all his parts –
unpredictable, creature of contradictions
-”Man is composed of subsystems &
suprasystems.”
-Subsystems are cells, tissues, organs
-Suprasystems are family, community, society
-Both affect man as a whole.
-When certain subsystem is affected, the
whole body is affected while the suprasystem
affect man in all dimensions (physio, psycho,
social, cognitive & spiritual)
NIGHTINGALE – “ Man is an individual with
vital reparative processes to deal with
disease and desirous of health but passive
in terms of influencing the environment
or nurse.”
HENDERSON – “Man is a whole, complete
& independent being who has 14
fundamental needs.”
OREM – “Man is a unity who can be viewed
as functioning biologically, symbolically &
socially & who initiates & performs self-
care activities on own behalf in
maintaining life, health & well-being.”
ABRAHAM MASLOW’S HIERARCHY OF NEEDS

SELF
ACTUALIZATION

SELF ESTEEM

LOVE & BELONGING

SAFETY & SECURITY

PHYSIOLOGIC
MASLOW’S HIERARCHY OF NEEDS:
1. Physiologic Needs are as follows:
- Oxygen
- Fluids
- Nutrition
- Body temperature
- Elimination
- Rest & sleep
- Sex
** Sex is not necessary for individual survival but
rather for survival of mankind
2. Safety & security needs
-Physical safety
-Psychological safety
-The need for shelter & freedom from harm &
danger
3. Love & belongingness needs
-Need to love & be loved
-Need to care & be cared for
-Need for affection, to associate or to belong
-Need to establish fruitful & meaningful
relationships w/ people,institution or organization
4. Self-Esteem needs
-Self-worth
-Self-identity * Need to be well-thought of
by oneself as well as by
-Self-respect others
-Body image
5. Self-actualization needs
-Need to learn, create & understand or comprehend
- need for harmonious relationship
-Need for beauty or aesthetics
-Need to be self-fulfilled
-Need for spiritual fulfillment
CHARACTERISTICS OF HUMAN NEEDS

1. Needs are universal

2. Needs may be met in different ways
3. Needs may be stimulated by external
&internal factors
4. Priorities may be altered
5. Needs may be deferred
6. Needs are interrelated
 Concepts of
Health & Illness
CONCEPTS OF HEALTH & ILLNESS
WHO (World Health Organization)
Health is a state of complete physical,
mental & social well-being, and not merely
the absence of disease/infirmity
CLAUDE BERNARD
Health is the ability to maintain the
internal milieu. Illness is the result of
failure to maintain the internal
environment.
 WALTER CANNON
Health is the ability to maintain homeostasis
or dynamic equilibrium.
NIGHTINGALE
Health is being well & using one’s power to
the fullest extent. Health is maintained
through prevention of disease via
environmental health factors.
HENDERSON
Health is maintained through the individual’s
ability to perform 14 components of nursing
care unaided.
 ROGERS
Positive health symbolizes wellness.
ROY
Health is a state & process of being &
becoming an integrated & whole person.
OREM
Health is a state characterized by
soundness or wholeness of developed
human structures & of bodily & mental
functioning
 KING
Health is a dynamic state in the life cycle,
illness is an interference in the life cycle.
NEUMAN
Wellness is the condition in which all parts
& subparts of an individual are in harmony
with the whole system
JOHNSON
Health is reflected by the organization,
interaction, interdependence & integration
of the subsystems of the behavioral system.
MODELS OF HEALTH & ILLNESS

1. Health – Illness Continuum

2. Health Belief Model (HBM)
3. Smith’s Models of Health
4. Leavell & Clark’s Agent-Host-Environment
Model (Ecologic Model)
5. Health Promotion Model
THE HEALTH – ILLNESS CONTINUUM
(DUNN’S THEORY)
Protected poor health in HLW in favorable environment
favorable environment

ILLNESS HEALTH

Good Health High

Level
Precursor of Illness Wellness

Poor health in unfavorable Emergent HLW in unfavorable

environment environment

** HLW- High Level Wellness

 HEALTH BELIEF MODEL (HBM)
 Describes relationship between person’s
belief & behavior
 Individual perceptions & modifying
factors influence health belief
 Individual Perceptions include:
- perceived susceptibility to an illness
- perceived seriousness of an illness
- perceived threat of an illness
 Modifying Factors include:
- demographic , sociopsychologic, structural
variables & cues to action
 Interventions depend on:
- perceived benefit
- perceived barriers
 SMITH’S MODEL OF HEALTH
1. Clinical Model – man is a physiologic
system & health is absence of signs &
symptoms of disease
2. Role Performance Model – health is
individual’s ability to fulfill societal roles
3. Adaptive Model – focus on adaptation
4. Eudaemonistic Model – health is a
condition of actualization or realization
of a person’s potential
 LEAVELL & CLARK’S AGENT-HOST-
ENVIRONMENT MODEL
(ECOLOGIC MODEL)
• Three interactive factors affecting
health & illness:
1. AGENT – any factor/stressor that can lead
to illness / disease
2. HOST – persons who may or may not be
affected by a disease
3. ENVIRONMENT - any factor external to
the host that may or may not predispose
a person to a disease.
 HEALTH PROMOTION MODEL

-Describes the multi-dimensional nature of

persons as they interact with the
environment
-Advocates that health promotion involves
activities directed toward increasing level
of well-being and self-actualization. Focus
on: individual perception, modifying factors
& participation in health-promoting
behaviors
Illness
and
Disease
ILLNESS – personal state in which the
person feels unhealthy
-State where the person’s physical,
emotional, intellectual, social,
developmental or spiritual functioning is
diminished or impaired
-Not synonymous with DISEASE

DISEASE – alteration in body functions

resulting in reduction of capacities or
shortening of normal life span
STAGES OF ILLNESS
1. SYMPTOM EXPERIENCE
- Transition stage
- 3 aspects: physical, cognitive, emotional

2. ASSUMPTION OF SICK ROLE

- Acceptance of the illness
- Seeks advice, support, decision

3. MEDICAL CARE CONTACT

- Seeks advice of health professionals:
validation, explanation, reassurance
4. DEPENDENT PATIENT ROLE
-Person becomes client dependent on health
professional
-Accepts / rejects HP’s suggestions
-Becomes more passive and accepting
-May regress to an earlier behavioral stage

5. RECOVERY / REHABILITATION
-Gives up sick role & returns to former
roles/functions
RISK FACTORS

-Any situation, habit, condition or other

variable that increases the vulnerability of one
individual to an illness / accident
RISK FACTORS OF A DISEASE
1. Genetic and Physiological Factors
2. Age
3. Environment
4. Lifestyle
IMPORTANT TERMINOLOGIES:
Disease – disturbance of structure / function
of the body or its constituent parts
Morbidity – condition of being diseased
Morbidity Rate – proportion of disease to
health in a community
Mortality – condition or quality of being
subject to death
Ecology – deals with relationship between
disease & geographical environment
Epidemiology – study of patterns of health &
disease, its occurrence & distribution
Susceptibility – degree of resistance the
potential host has against the pathogen
Etiologic Agent – one that possesses the
potential for producing injury or disease
Virulence – relative power or degree of
pathogenicity of invading microorganism, the
ability to produce poisons that repel or destroy
phagocytes
Symptomatology – study of symptoms
Syndrome – set of symptoms, sum of which
constitutes a disease
- commonly occurs together
Sign – objective symptom or evidence or physical
manifestation made apparent by special methods
of examination or use of senses
Symptom – any disorder of appearance,
sensation or function experienced by the patient
indicative of a certain phase of a disease
Pathology – branch of medicine which deals with
the cause, nature, treatment & resultant
structural & functional changes of disease
Pathogenesis- method of origin & development
of a disease
Diagnosis – art or act of determining the
nature of a disease
Sequela – consequence that follows the
normal course of an illness
Complication – condition that occurs during
or after the course of an illness
Prognosis – prediction of the course & end of
a disease
Recovery – person has no observable or known
after effects from an illness, apparent
restoration to a pre-illness state
CLASSIFICATION OF DISEASES
I. ACCORDING TO ETIOLOGIC
FACTORS
1. Hereditary – defect in genes of 1 or both
parent transmitted to offspring
2. Congenital – present at birth; defect in
development, hereditary factors, prenatal
infection
3. Metabolic – disturbance in the process of
metabolism
4. Deficiency – from inadequate intake or
absorption of essential dietary factors
5. Traumatic – due to injury
6. Allergic – abnormal response of body to
chemical or protein subs or physical stimuli
7. Neoplastic – abnormal or uncontrolled
growth of cells
8. Idiopathic – unknown cause, self-originated,
spontaneous origin
9. Degenerative – from degenerative changes
that occur in tissues or organs
10. Iatrogenic – from treatment of a disease
II. ACCORDING TO DURATION OR
ONSET
1. Acute Illness – has short duration & severe
- S/S occurs abruptly , are intense & subsides
after a relatively short period of time
2. Chronic Illness – persists, longer than 6
months and can affect functioning & may
fluctuate between maximal functioning &
serious relapses that may be life threatening
& characterized by remission & exacerbation
REMISSION- period where the disease is
controlled & symptoms are not obvious
EXACERBATION- disease becomes active
again with pronounced symptoms

3. Sub- Acute – symptoms are pronounced but

more prolonged than in acute disease
III. OTHERS
1. Organic – from changes in the normal
structure, from anatomical changes in an
organ or tissue
2. Functional – no anatomical changes
observed, may be due to abnormal
responses to stimuli
3. Occupational – from factors associated
with the occupation of the patient
4. Familial – occurs in several individuals of
the same family
5. Venereal – usually acquired through sexual
relations
6. Epidemic – attacks a large number of
individuals in the community at the same time
7. Endemic – present more or less continuously
or recurs in a community
8. Pandemic – an epidemic disease which is
extremely widespread involving an entire
country or continent
9. Sporadic – occurs on occasional cases
 THREE LEVELS OF PREVENTION
1. PRIMARY PREVENTION – encourage
optimal health & increase person’s resistance
to illness
- seeks to prevent disease or condition at a
prepathologic state
- Health Promotion, Specific Protection
- ACTIVITIES: quit smoking, avoid alcohol,
regular exercise, well-balanced diet, reduce
fat, increase fiber, adequate fluids, maintain
ideal body weight, complete immunization
program
2. SECONDARY PREVENTION – known as
health maintenance
- seeks to identify specific
illness/condition at an early stage with prompt
intervention to prevent or limit disability
- Early Diagnosis, Detection, Screening,
Prompt Treatment
- ACTIVITIES: annual physical exam,
regular PAP smear, monthly BSE, sptum exam
for TB
3. TERTIARY PREVENTION – support
client’s achievement of successful adaptation
to known risks, optimal reconstitution or
establishment of high-level wellness
- occurs after a disease or disability has
occurred & recovery process has begun
- seeks to halt the disease or injury
process & obtain optimal health status
- ACTIVITIES: self monitoring of CBG
among diabetics, PT after CVA, cardiac
rehab, attending self-management education,
speech therapy after laryngectomy
 TYPES OF HEALTH PROMOTION
PROGRAMS

1. Information Dissemination
2. Health Appraisal and Wellness Assessment
Programs
3. Lifestyle & Behavior Change Programs
4. Worksite wellness Programs
5. Environment Control Programs
The Professional
Nurse
CHARACTERISTICS OF A PROFESSION
1. Education
2. Theory
3. Service
4. Autonomy
5. Code of Ethics
6. Caring
QUALIFICATIONS & ABILITIES OF A
PROFESSIONAL NURSE
1. Has faith in fundamental values
underlying democratic way of life
2. Has sense of responsibility for
understanding those with whom she
works
3. Has faith in the reality of spiritual &
aesthetic values
4. Has basic KSA to address present-day
problems, realistic & well-organized
5. Has skill both in spoken and written
language
6. Appreciates & understands importance of
good health
7. Has emotional balance
8. Likes hard work & possesses capacity for it
9. Appreciates high standards of workmanship
10. Accepts & tries to understands people of
all sorts
11. Knows nursing thoroughly
ROLES & FUNCTIONS OF A NURSE

1. Care provider
2. Communicator / Helper
3. Teacher
4. Counselor
5. Client Advocate
6. Change Agent
7. Leader
8. Manager
9. Researcher
10. Case Manager
11. Collaborator
TYPES OF NURSING INTERVENTIONS

1. Independent or Nurse-Initiated
2. Dependent or Physician-Initiated
3. Interdependent or Collaborative
NURSING CARE DELIVERY MODELS
Total Patient Care
Functional Nursing
Team Nursing
Primary Nursing
Case Management
Selected Nursing
Theories
FLORENCE NIGHTINGALE

-developed First Theory of Nursing

-Focused on changing & manipulating
environment to put patient in best possible
condition
- Environment includes noise, nutrition, light,
hygiene, comfort socialization and hope
VIRGINIA HENDERSON
-Nature of Nursing Model
-Identified 14 basic needs
-Nurses assists sick and well clients
FAYE ABDELLAH
-Patient-Centered Approach to Nursing
-Identified 21 nursing problems
-Nursing is service to individuals, families
and therefore to society
DOROTHY E. JOHNSON
-Behavioral System Model
-Each person has 7 subsystems:
ingestive, eliminative, affiliative,
aggressive, dependence, achievement,
sexual & role identity behavior
IMOGENE KING
-Goal Attainment Theory
-Nursing assists individuals & groups to
attain, maintain & restore health
MADELEINE LEININGER
-Transcultural Nursing Model
-Nursing is humanistic & scientific mode of
helping client thru specific cultural caring
processes to improve or maintain health
condition
MYRA LEVIN
-Four Conservation Principles
-Conservation of energy, structural
integrity, personal integrity and social
integrity
BETTY NEUMAN
-Health Care System Model
-Nursing is a unique because it is concerned
with all variables affecting response to
stresses which are intra, inter and
extrapersonal in nature
DOROTHEA OREM
-Self Care & Self-Care Deficit Theory
-Conceptualized 3 Nursing Systems:
-Wholly Compensatory, Partially
Compensatory & Supportive-Educative
HILDEGARD PEPLAU
-Interpersonal Model
-Nursing as interpersonal process of
therapeutic interactions between an
individual who is sick and a nurse who is
especially educated to recognize &
respond to the need
-4 Phases on Nurse-Client Relationship:
Orientation, Identification,
Exploitation, Resolution
MARTHA ROGERS
-Science of Unitary Human Beings
-Man is an energy field in constant
interaction with the environment
-Humans are more than & different from
the sum of their parts
SISTER CALLISTA ROY
-Adaptation Model
-Each person is a unified biopsychosocial
system in constant interaction wit a
changing environment
-Man has needs with 4 Modes:
physiological, self-concept, role function,
interdependence
-Believed that adaptive human behavior is
directed at an attempt to maintain
homeostasis
LYDIA HALL
-Introduced model on Nursing:What Is It?
-Focused on 3 Components:
CARE(nurturance,exclusive to nursing,
CORE(therapeutic use of self, uses reflection)
& CURE (nursing related to physician’s orders)
IDA JEAN ORLANDO
-Dynamic Nurse-Patient Relationship Model
-Nurse helps patients meet a perceived
need that patients cannot meet for
themselves
-Emphasized need of validating need &
evaluating care based on outcomes
-3 Elements of Nursing Situation: client
behavior, nurse reaction and nurse action
ERNESTINE WEIDENBACH
-Clinical Nursing – A Helping Art Model
-Components of Clinical Practice are:
Philosophy, purpose, practice and art
-Nurses meet individual needs thru
identification of need, administration of
help and validation of action
JEAN WATSON
-Human Caring Model
-Nursing is an art & science thru
transpersonal transactions to help persons
achieve mind-body-soul harmony which will
generate self-knowledge, self-control, self-
care, self-healing
ROSEMARIE RIZZO PARSE
-Theory of Human Becoming
-Emphasized free choice in value priorities
-Believes that each choice opens certain
opportunities while closing others
-Referred as: revealing-concealing,
enabling-limiting & connecting-separating
-Each has own choice, therefore nurse acts
as guide NOT decision-maker
JOYCE TRAVELBEE
-Interpersonal Aspects of Nursing Model
-Goal of nursing is to assist in
preventing/coping with illness, regaining
health, find meaning to illness or maintain
maximum degree of health
-Interpersonal process is a human-to-human
relationship formed during illness &
“experience of suffering”
HELEN ERICKSON, EVELYN TOMLIN,
MARY ANN SWAIN
-Modeling & Role Modeling Theory
-The nurse models (assesses), role models
(plans), and intervenes
-Nurses facilitate, nurture & accept person
unconditionally
ANNE BOYKIN & SAVINA SCHOENHOFER

-Grand Theory of Nursing as Caring

-All persons are caring & nursing is a
response to a unique social call
-Each nursing situation is original
The Nursing
Process
THE NURSING PROCESS
-cornerstone of nursing profession
-Problem-solving tool in utilizing clinical
application of knowledge & theory in
nursing practice
-6-Step Process – Assessment, Diagnosis,
Outcome, Identification, Planning,
Implementation & Evaluation
The Nursing Process History
Lydia Hall – originated term Nursing
Process. 3-Step Process: note observation,
ministration of care, validation
Dorothy Johnson- introduced 3-Step
Process:assessment, decision, nursing
action
Ida Jean Orlando – 3-Step Process:client’s
behavior, nurse’s reaction, nurse’s actions
Yura & Walsh – suggested 4 components of
the process:assessing, planning,
implementing and evaluating
Knowles- nursing process as: discover,
delve, decide, do, discriminate
American Nurses Association – innovations
introduced: (1) diagnosis as separate step,
(2) diagnosis of actual & potential health
problems as integral part of nursing
practice, (3) outcome identification as
distinct step, (4) 6 steps- assessment,
diagnosis, outcome identification, planning,
implementation, evaluation
-Characteristics of Nursing Process:
-Organized
-Systematic
-Humanistic
-Goal – Oriented
-Efficient
-Effective
Assessment
- collecting, validating, organizing &
recording data to establish data base
ACTIVITIES DURING ASSESSMENT
1. Collection of Data
2. Verifying / Validating Data
3. Organizing Data
TYPES OF DATA
1. Subjective Data (symptoms)
2. Objective Data (signs)
METHODS OF DATA COLLECTION
1. Interview
2. Observation
SOURCES OF DATA
1. Primary
2. Secondary
Diagnosis
-process resulting to diagnostic statement
-Clinical act of identifying problems
-PURPOSE: to identify client’s health care
needs & prepare diagnostic statements
-NURSING DIAGNOSIS – statement of
client’s potential or actual alteration of
health status
-Uses the PRS / PES format
P – problem ACTIVITIES DURING
DIAGNOSIS:
R – related to factors 1. Organize cluster/group
data
S – signs & symptoms
2. Compare data against
standards
3. Analyze data
P – problem
4. Identify gaps &
E – etiology inconsistencies
5. Determine client’s
S – signs & symptoms health problem, risks &
strengths
6. Formulate Nursing
Diagnoses statements
NURSING DIAGNOSIS SAMPLING
1. Patient underwent cardiac catheterization 3
days ago. VS stable, dressings dry.Refused to
move affected extremities and have his
indwelling catheter removed because “I am
afraid to go to the bathroom because I might
bleed.”
2. Presence of thick, copious secretions, with
difficulty expectorating, RR 24, BP 130/90, PR
88, complained of shortness of breath.
Diagnosis: pneumonia
3. A 30-year old mother of 3 children underwent
bilateral mastectomy. Diagnosis : Breast Ca
Outcome Identification
-refers to formulating & documenting
measurable, realistic, client-focused goals
-PURPOSES:To provide individualized care,
promote client participation, plan care that
is realistic & measurable, allow
involvement of support people
ACTIVITIES DURING OUTCOME
IDENTIFICATION
1. ESTABLISH PRIORITIES
- life-threatening situations takes highest
priority(something that takes precedence in position)
- use principle of ABC’s, airway should
always be given highest priority.
- use Maslow’s hierarchy of needs.
Physiologic needs are given priority over
psychosocial needs
- consider something that is important to
the client
-Clients with unstable condition should be
given priority over those with stable
condition
-Consider amount of time,materials,
equipment required to care for clients
-Actual problems take precedence over
potential problems
-Attend to client before equipment
CLASSIFICATION OF NURSING DIAGNOSIS
High–Priority- those that are potentially
life-threatening & require immediate
attention
Medium-Priority- those that could result
in unhealthy consequences but are not
life-threatening
Low-Priority- those that can be resolved
easily with minimal interventions &
unlikely to cause significant dysfunction
2. ESTABLISH CLIENT’S GOALS & OUTCOME
CRITERIA
-client goal (educated guess, made as BROAD
STATEMENT, about what the client’s state will be after
nursing intervention)

-Must be written to indicate a desired

state. Contains an action verb & a
qualifier that will indicate the level of
performance that needs to be achieved
-Example:”Ambulates safely with one-
person assistance along the
hallway”,”Reduces temperature by at least
37-37.5 C after continuous TSB”
GOALS
Short Term – may be met in relatively short
period of time
Long Term – requires more time
OUTCOME CRITERIA
-are SMART statements of goal attainment
SAMPLE 1:
-GOAL: The client will report a decreased
anxiety level regarding surgery
-OUTCOME CRITERIA:
(1)During client teaching, the client
discusses fears & concerns regarding
surgical procedure
(2) After client teaching, the client
verbalizes decreased anxiety
SAMPLE 2
-GOAL: The client will demonstrate safety
habits when performing ADL’s and injury
prevention
- POSSIBLE OUTCOME CRITERIA:
(1)The client uses call light system for
assistance at each need to use the
bathroom immediately after instruction
by the nurse
(2) The client uses over-the-bed lights, non-
skid slippers when transferring to chair.
Planning
Involves determining the strategies or
course of actions to be taken before
implementing nursing care
PURPOSES: To identify client’s goals &
appropriate nursing interventions, to direct
client care activities, to promote continuity
of care
ACTIVITIES DURING PLANNING
1. PLAN NURSING INTERVENTION
- to direct activities to be carried out
- Nursing Interventions are independent,
dependent & interdependent
2. WRITE A NURSING PLAN OF CARE
- NCP is a written summary of care. A
“blueprint” of the nursing process
- plan of care is nursing centered
- is a step-by-step process
SAMPLE OF NURSING PLAN OF CARE
Nursing Diagnosis:
Risk for injury R/T sensory & integrative
dysfunction manifested by altered mobility
& faulty judgment
Client Goal:
Client will demonstrate safety habits when
performing ADLs & injury prevention
Client Outcome Criteria
-Client uses nurse call light system for
assistance for each need to use bathroom
immediately after instruction by the nurse
-Client demonstrates safety practices in
dressing & hygiene
-Client uses overbed lights, non-skid slippers
when transferring to chair or out of bed
-Client identifies modification for home
safety 12 hours after instruction.
NURSING INTERVENTIONS / RATIONALE
INTERVENTION RATIONALE
1. Position bed in lowest 1. Low bed position
level minimizes distance to
floor if client falls
2. Place call light system 2. Call light allow client to
within reach of hand & call for help easily
give instruction
3. Explain all safety 3. Client & family will feel
modifications of client’s safer if they are aware
room:removal of of safety promotion
clutter,placement & strategies
use of call/night light,
installing brakes on
bed & chairs
Implementation
- Putting your nursing care plan into action
PURPOSE: To carry out planned nursing
interventions to help client attain goals &
achieve optimal level of health
ACTIVITIES DURING IMPLEMENTATION:
1. Reassessing
2. Set priorities
3. Perform nursing interventions
4. Record actions
Evaluation
Assessing client’s response to interventions
& comparing response to predetermined
standards or outcome criteria
PURPOSE: To appraise extent to which goals
& outcome criteria of care are met
ACTIVITIES DURING EVALUATION:
1. Collect data about client’s response
2. Compare response to goals/outcome
criteria
3. Four possible judgments:
- Goal was completely met
- Goal was partially met
- The goal was completely unmet
- New problems or nursing diagnoses
have developed
4. Analyze reasons for the outcomes
Vital Signs
 BODY TEMPERATURE
The balance between heat production and
heat loss
* Body heat is primarily produced by
metabolism & regulated by hypothalamus
TYPES OF BODY TEMPERATURE
1. Core Temperature-temperature of deep
tissues of the body (oral/rectal)
2. Surface Temperature- temperature of
the skin, subcutaneous tissue and fat
(Axilla)
 FACTORS AFFECTING BODY HEAT
PRODUCTION

1. Basal Metabolic Rate (BMR)

2. Muscle Activity
3. Thyroxine Output
4. Epinephrine, norepinephrine &
sympathetic stimulation
5. Increased temperature of body cells
 PROCESSES INVOLVED IN HEAT LOSS
1. Radiation – transfer of heat from one
surface to another without contact
2. Conduction – transfer of heat from one
surface to another with difference of
temperature
3. Convection –dissipation of heat by air
currents
4. Evaporation – continuous vaporization of
moisture from the skin, oral mucous,
respiratory tract
 FACTORS AFFECTING TEMPERATURE
1. Age
2. Diurnal Variations
3. Exercise
4. Hormones
5. Stress
 ALTERATIONS IN BODY TEMPERATURE

1. PYREXIA – body temperature above

normal range
2. HYPERPYREXIA – very high fever,
41degrees & above
3. HYPOTHERMIA – subnormal core body
temperature
 TYPES OF FEVER
1. INTERMITTENT FEVER
2. REMITTENT FEVER
3. RELAPSING FEVER
4. CONSTANT FEVER

DECLINE OF FEVER

1. CRISIS or FLUSH or DEFERVESCENT STAGE

2. LYSIS
 NURSING INTERVENTIONS FOR FEVER
1. Monitor VS, assess skin color/temperature
2. Monitor WBC, Hct & other pertinent labs
3. Remove excessive clothing when pt. feels
warm & provide warmth when with chills
4. Adequate foods and fluids
5. Measure I & O
6. Maintain IV as prescribed
7. Promote rest
8. Good oral hygiene
9. Provide cool, circulating air
10. Ensure dry clothing & bed linens
11. TSB and antipyretics as ordered
METHODS OF TEMPERATURE TAKING

ORAL ROUTE
-Most accessible & convenient method
-allow 15 mins when pt took food, drank
hot/cold beverage or smoked
-Wash thermometer before & after use
utilizing proper technique
-Take temperature 2-3 minutes
CONTRAINDICATIONS TO ORAL TEMP:
-Oral lesions / surgery
-Dyspnea
-Cough
-Nausea & vomiting
-Presence of NGT,ET tubes, oral airway, etc
-Seizure prone
-Very young children
-Unconscious, restless, disoriented,
confused
RECTAL ROUTE
-Most accurate measurement
-Assist in assuming lateral position
-Lubricate before insertion, do not force.
-Insert 0.5-1.5 inches
-Instruct to take deep breath during
insertion
-Let stay for 2 mins
CONTRAINDICATIONS:
-Anal / rectal conditions
-Diarrhea
-Quadriplegic clients
AXILLARY ROUTE
-Safest & non-invasive
-Pat dry the axilla before placing
thermometer. Do not rub.
-Place arm tightly for 9 minutes
Normal Adult Temperature Ranges

Methods Ranges
Oral 36.5-37.5 C
(97.6-99.6 F)
Axillary 35.8-37 C
(96.6 – 98.6 F)
Rectal 37.0 – 38.1 C
(98.6 – 100.6 F)
Tympanic 36.8 – 37.9 C
(98.2 – 100.2 F)
 PULSE RATE
- Wave of blood created by contraction of
the LV of the heart, regulated by ANS
FACTORS AFFECTING PULSE RATE
1. Age
2. Sex/gender
3. Exercise
4. Fever
5. Medications
6. Hemorrhage
7. Stress
8. Position changes
PULSE SITES
1. Temporal
2. Carotid
3. Apical
4. Brachial
5. Radial
6. Femoral
7. Posterior tibial
8. Popliteal
9. Pedal
 ASSESSMENT OF THE PULSE
RATE – Normal Pulse Rate are as follows:
Newborn - 1 month 80 – 180 bpm
1 year 80- 140 bpm
2 years 80 – 130 bpm
6 years 75 – 120 bpm
10 years 60 – 90 bpm
adult 60 – 100 bpm

Tachycardia- above 100 bpm (adult)

Bradycardia – below 60 bpm (adult)
RHYTHM – pattern & intervals of beat
VOLUME – strength of pulse
* Normal – felt with moderate pressure
* Full / Bounding – obliterated with
great pressure
* Thready – easily obliterated
ARTERIAL WALL ELASTICITY- artery feels
straight, smooth, soft & pliable
PRESENCE/ABSENCE OF BILATERAL
EQUALITY- absence indicates CV disorder
 RESPIRATORY RATE
-Act of breathing
PROCESSES:
1. Ventilation
** Inhalation
** Exhalation
2. Diffusion
3. Perfusion
RESPIRATORY CENTERS
1. Medulla Oblongata – primary
2. Pons – contains:
*Pneumotaxic Center-responsible for
rhythmic quality
*Apneustic Center- responsible for deep,
prolonged inspiration
3. Carotid & Aortic bodies-contains
peripheral chemoreceptors
4. Muscle & joints – contains
proprioreceptors
FACTORS AFFECTING RESPIRATORY RATE
1. Exercise
2. Stress
3. Environment
4. Altitude
5. Medications
COMMON TERMS:
Eupnea – normal respiration
Tachypnea – rapid respirations, above 20
Bradypnea – slow breathing, below 12
Hyperventilation – deep, rapid RR, CO2
excessively exhaled(respiratory alkalosis)
Hypoventilation – slow, shallow RR, CO2
excessively retained (respiratory acidosis)
Dyspnea – difficult / labored breathing
Orthopnea – DOB when lying flat
Apnea – absence of RR
 ASSESSMENT OF THE
RESPIRATORY RATE
RATE – Normal is 12-20 in adult
DEPTH – may be normal, deep or shallow
RHYTHM – observe for regularity of
exhalations and inhalations
QUALITY / CHARACTER – respiratory effort
& sound of breathing
 BLOOD PRESSURE
-Measure of pressure exerted by blood as it
pulsates through arteries
Systolic Pressure- pressure of blood due to
contraction of ventricles
Diastolic Pressure – pressure when ventricles are at
rest
Pulse Pressure – difference bet. Systolic & diastolic
pressures
Hypertension – abnormally high BP over 140 systolic
or over 90 diastolic for at least 2 consecutive readings
Hypotension – abnormally low BP, below 100/60
DETERMINANTS OF BLOOD PRESSURE
1. BLOOD VOLUME- hypervolemia raises BP
2. PERIPHERAL RESISTANCE-
vasoconstriction elevates BP, vasodilation
lowers BP
3. CARDIAC OUTPUT – if pumping action of
heart is weak (low CO), BP decreases
4. ELASTICITY/COMPLIANCE OF BV-less
elastic,higher BP
5. BLOOD VISCOSITY-increased
viscosity,higher BP
FACTORS AFFECTING BLOOD PRESSURE
1. Age
2. Exercise
3. Stress
4. Race
5. Obesity
6. Sex/ gender
7. Medications
8. Diurnal variations
9. Disease process
ASSESSMENT OF BLOOD PRESSURE
1. Ensure client is rested
2. Allow 30 mins after exercise,
smoking,caffeine intake before taking
BP
3. Use appropriate size of BP cuff
4. Position in supine or sitting
5. Arm must be at the level of the heart
6. Apply cuff 1 inch above antecubital
space snugly and smoothly
7. Use bell of the stethoscope
8. The sound during BP taking is called
KOROTKOFF sound
9. Read lower meniscus of mercury level of
sphygmomanometer at eye level to prevent
Error of Parallax
ERROR OF PARALLAX – if eye level is higher than level of
lower meniscus of mercury, it may cause false low reading
 Physical
Examination &
Health Assessment
PHYSICAL EXAMINATION
-CEPHALOCAUDAL approach
-Determine mental status and LOC
-Protect client’s privacy during entire
procedure
-Prepare needed materials before starting
procedure
MODES OF EXAMINATION:
1. INSPECTION – uses sense of sight
2. PALPATION – uses sense of touch
3. PERCUSSION – tapping body parts to
produce sounds
4. AUSCULTATION – listening to body sounds
with a stethoscope
POSITIONS
1. DORSAL RECUMBENT – back-lying
position with knees flexed, hips
externally rotated
2. DORSAL/SUPINE- back-lying with or
without pillow
3. SITTING OR SEATED- back unsupported
& legs hanging freely
4. LITHOTOMY- back-lying with feet
supported in stirrups
5. FOWLER’S-
a. Semi-Fowler’s – head of bed elevated at
15-45 degrees angle
b. High Fowler’s – head of bed raised at 80-
90 degrees angle
6. GENUPECTORAL/KNEE-CHEST- kneeling
with torso at 90 degrees angle to hips
7. LATERAL – side-lying position
8. SIM’S – semi prone
9. PRONE-face lying position with head
turned to sides/abdomen-lying position
NURSING CONSIDERATIONS
1. Sequence of PE of abdomen is IAPP
2. No abdominal palpation among clients
with tumor of liver or kidneys
3. During PE of abdomen:flex knees to relax
abdominal muscles
- sequence: RLQ, RUQ, LUQ, LLQ
4. Best position when examining chest is
sitting/upright position
5. The best position when examining the
back is standing position.
6. To palpate neck for lymphadenopathy or
enlargement of thyroid gland, nurse stands
behind patient.
7. If ophthalmoscopy is to be done, darken
room for better illumination.
8. If vaginal exam is required, pour warm
water over speculum before use.
9. If female client is examined by male
doctor, female nurse must be present.
 Patient
Admission ,
Transfer and
Discharge
Patient Admission and Transfer

CLASSIFICATIONS:
1. Admission from Emergency Room
2. Direct Admission
ADMISSION THRU EMERGENCY DEPARTMENT
PURPOSES:
1. Give immediate care
2. Prompt and proper evaluation of patient’s
management & placement
WORKFLOW:
1. Assist in examining table & accomplishing
forms
2. Assess vital signs
3. Inform AMD stat, prepare materials & assist as
needed
4. Carry out stat orders
ADMISSION TO GENERAL UNIT
PURPOSES:
1. Ensure patient & relatives a courteous
welcome
2. Assist patient & family to hospital setup
3. Provide immediate care of patients upon
admission
CHECK FOLLOWING FROM E.R.
DOS, patient’s data & PIN, name tag, adm. Kit,
Kardex, ready made chart, chart cover
WORKFLOW:
1. Receive from Admission Office/ER:
- receive preliminary telephone
endorsement
2. Prepare room for completeness
3. Receives patient : ht., wt., allergies,
DOS, patient data, name tag, PIN
4. Usher to room
5. Render preliminary nursing care
6. Retrieve old chart & document care
TRANSFER TO ANOTHER UNIT
PURPOSES: transfer patient with all possible
safety
WORKFLOW:
1. Receive written transfer order from the
doctor
2. Prepare client transfer
3. Document procedure
4. Transfer patient
TRANSFER TO ANOTHER HOSPITAL
WORKFLOW:
1. Receive written transfer out orders
2. Prepare patient for transfer
3. Arrange transportation system
Patient Discharge
DISCHARGE PLANNING: systematic process
of preparing patient to leave the healthcare
agency & continuity of care
® Discharge planning starts upon admission.
PATIENT DISCHARGE WORKFLOW
1. Ensure that patient has discharge order
2. If leaving against medical advice, ensure
proper forms are filled up
3. Ensure discharge instructions are given
& understood both by the patient &
family
4. Check if all needed equipment/supplies
are ready for the patient
5. financial statements should be
counterchecked
6. Assist patient in dressing up & packing
7. Help transport patient & belongings
8. Document all pertinent events & data
before closing the charting ensuring that
the date & time & status/condition of the
patient upon discharge is clearly written.
 Medication
Administration
Definition of Terms
Medications – substance administered for
diagnosis, cure, treatment, relief or
prevention of disease. AKA as drug
Prescription Name – name given to a drug
before it becomes official
Official Name – name after which the
drug is listed in one of the official
publications
Chemical Name- name that describes
precisely the constituents of drugs
Brand name- name given to a drug by the
manufacturer. AKA trademark.
Pharmacology – study of effects of drugs
on living organisms
Posology – study of dosage or amount of
drugs given in the treatment of diseases
Types of Doctor’s Orders
Standing Order – carried out until the
specified period of time or until
discontinued by an order
Single Order – carried out for only once
STAT Order –carried out at once
PRN Order – only as patient requires or
needed
Parts of A Legal Doctor’s Order
1. Name of Patient
2. Date and Time
3. Name of Drug
4. Dose of Drug
5. Route of Administration
6. Time or Frequency
7. Signature of Physician
Effects of Drug
Therapeutic Effect – intended primary
effect. AKA desired effect.
Side Effect – Unintended effect of the
drug. AKA secondary effect.
Drug Allergy – immunologic reaction to
the drug
Anaphylactic Reaction – severe allergic
reaction
Drug Tolerance – decreased physiologic
response to repeated administration of a
drug
Cumulative Effect – increased response
to repeated doses of drug that occurs when
the rate of administration exceeds the rate
of metabolism or excretion
Idiosyncratic Effect- unexpected
peculiar response to the drug
Drug Abuse – inappropriate intake of a
substance, either continually or
periodically
Drug Dependence – person’s reliance to
take a drug/substance which will produce
an intense reaction upon withdrawal
Addiction – due to biochemical changes
in body tissues esp. of the nervous system.
Tissues come to require the substance to
function normally. AKA physical
dependence.
Habituation – emotional reliance on a
drug to maintain sense of well being. AKA
psychological dependence.
Drug Interaction – effects of one drug are
modified by the prior or concurrent
administration of another drug, thereby
increasing or decreasing the
pharmacological action
Drug Antagonism – conjoint effect of two
drugs is less that the drugs acting
separately
Summation – combined effect of two drugs
produces result that equals the sum of the
individual effects of each agent
Synergism – combined effects of drugs is
greater than the sum of each individual
agent acting independently
Potentiation – concurrent administration
of two drugs in which one drug increases
the effect of the other drug
Therapeutic Actions of Drugs
Palliative – relieves symptoms of disease but
does not affect the disease itself
Curative – treats the disease condition
Supportive – sustains body functions until
other treatment of the body’s response can
take over
Substitutive – replaces body fluids /
substances
Chemotherapeutic – destroys malignant cells
Restorative – returns/repairs body to health
General Properties of Drugs
1. Drugs do not confer any new function on
a tissue or organ. They only modify
existing functions.
2. Drugs in general exert multiple actions
rather than single effect.
3. Drug interaction results from
physiochemical interaction between drug
& a functionally important molecule in
the body
Pharmacokinetic Factors in Drug Therapy
I. ABSORPTION
Is the process by which a drug passes from its site
of administration to bloodstream
Factors Affecting Drug Absorption:
1. Blood Flow 7. Solubility of Drug
2. Pain 8. pH
3. Stress 9. Drug Concentration
4. Foods 10. Dosage Form
5. Exercise
6. Nature of absorbing surface
II. DISTRIBUTION
Is the transport of drug from its site of absorption
to site of action
Factors Affecting Drug Distribution
1. Plasma-Protein Binding
2. Volume Distribution
3. Barriers to Drug Distribution
A. Blood Brain Barrier – drug must be lipid soluble &
loosely attached to plasma proteins
B. Placental Barrier- shields from possibility of adverse
drug effects
4. Obesity
5. Receptor Combination
III. METABOLISM or BIOTRANSFORMATION
- Sequence of chemical events that change a drug
to less active form after entering the body. AKA
detoxification.
- LIVER – principal site of drug metabolism
Factors Affecting Drug Metabolism
1. Age
2. Nutrition
3. Insufficient amounts of major body hormones
IV. EXCRETION
- Process by which drugs are eliminated from the
body
- KIDNEYS – most important route of excretion of
drugs
Factors Affecting Drug Excretion
1. Renal Excretion
2. Drugs can affect elimination of other drugs
3. Blood concentration levels
4. Half life
Principles of Drug Administration
1. Observe the “7 Rights” of drug
administration.
-RIGHT drug,dose,time,route,patient,
recording, approach
2. Practice asepsis.
3. Nurses administering medications are
responsible for their own actions.
4. Be knowledgeable about the meds you
administer.
5. Keep narcotics locked.
6. Use only medications that are clearly
labeled.
7. Return liquid that are cloudy in color.
8. Identify patient correctly before
administering medications.
9. Do not leave medications at the bedside.
10. The nurse who prepares the drug must
be the one to administer it.
11. If patient vomits, report to nurse in
charge or physician.
12. Preoperative meds are usually
discontinued during postop unless ordered
to be continued.
13. When meds is omitted for any reason,
record the fact & the reason.
14. When med error is made, report ASAP.
Routes of Drug Administration
I. ORAL
ADVANTAGES: most convenient, less
expensive, safe & does not break the skin
barrier
DISADVANTAGES: inappropriate for those
with nausea & vomiting, dysphagia,
reduced GIT motility, seriously ill
May give unpleasant odor/taste, discolor
teeth, irritate gastric mucosa
Oral Drug Forms
1. SOLID – tablet, capsule, pill, powder
2. LIQUID – syrup, suspension, emulsion,
elixir, milk, other alkaline substance
SYRUP-sugar-based
SUSPENSION-water-based
EMULSION- oil-based
ELIXIR- alcohol-based
** Never crush enteric-coated or sustained-
release medication
II. SUBLINGUAL

-Drugs placed under the tongue

ADVANTAGES: for local effect, rapid
absorption in the bloodstream
DISADVANTAGES: if swallowed, may be
inactivated by gastric juices, must remain
under the tongue until dissolved/absorbed
III. BUCCAL
-held in the mouth against mucous
membranes of the cheek. Should not be
chewed, swallowed or placed under the
tongue
ADVANTAGES: local effect, greater potency
because drug directly enters blood & bypass
the liver
DISADVANTAGES: if swallowed, may be
inactivated by gastric juices
IV. TOPICAL
-application of medications to a
circumscribed area of the body
1. Dermatologic-lotions,liniments,ointment
• Pat dry area, use surgical asepsis, thin
layer needed, use gloves over large
areas
2. Ophthalmic – instillations, irrigations
* Instillations-provides meds, Irrigations-
flush eye of noxious/foreign material
3. Otic – instillations, irrigations
•Instillations-softens earwax, reduce
inflammation & treat infection, relieve
pain
•Irrigations- remove cerumen, apply heat,
remove foreign body
4. Nasal – for astringent effect, loosen
secretions, facilitate drainage, treat
infections
** Parkinson’s position-frontal/maxillary
** Proetz position-ethmoid/sphenoid
5. Inhalation- nebulizers, MDI
6. Vaginal – local therapeutic effect but
has limited use
FORMS: tablet, liquid, cream, jelly, foam &
suppository
•Vaginal Irrigation – washing of vagina by
liquid at low pressure. AKA douche.
•Empty bladder first, position
•Irrigating can shld be 12 in higher
•Remain in bed for 5-10 mins after
V. RECTAL

ADVANTAGE: Used when odor/taste is not

favorable
DISADVANTAGE: absorption is unpredictable
REMINDERS: needs refrigeration, use gloves
for insertion, position- lie on left & breathe
thru mouth, must remain on the side for 20
minutes for absorption
VI. PARENTERAL
- Administration by needle
1. INTRADERMAL – thru the dermis beneath
epidermis
SITES: inner lower arm, upper chest & back,
beneath the scapulae
INDICATIONS: for allergy & tuberculin
testing & vaccinations
• Needle at 10-15 degrees angle, bevel up
• Inject over 3-5 sec to form a wheal/bleb
• Do not massage the site
2. SUBCUTANEOUS –
SITES: outer aspects of UA, anterior aspect of
thighs, abdomen, scapular area of the back,
ventrogluteal & dorsogluteal areas
INDICATIONS: vaccines, preoperative meds,
narcotics, insulin, heparin
•Small doses only – 0.5-1 ml & rotate sites
•Use 5/8 needle for adults when given at 45
degrees (thin pts.), ½ for 90 degrees (obese
pts)
•Insulin Injection- do not massage & give at
90*
3. INTRAMUSCULAR – use 1” – 2” needle to
reach the muscle layer
SITES: ventrogluteal, dorsogluteal (<3 y/o),
vastus lateralis, rectus femoris, deltoid,
Z-track
General Principles in Parenteral
Administration
1. Check orders, identify pt properly.
2. Practice ASEPSIS.
3. Use appropriate needle size.
4. Locate injection site properly.
5. Use separate needles for aspirating &
injecting
6. Introduce air to the vial before
aspirating.
4. INTRAVENOUS – direct IV, IV push or infusion
- Most rapid route, predictable
INDICATIONS: pts with compromised GI
function, rapid introduction of medications
TYPES OF IV FLUIDS:
A. Isotonic Solution- same concentration as
body fluids (D5W, NaCl 0.9%, plain LR, plain
NM)
B. Hypotonic –has lower concentration than
body fluids (NaCl 0.3%)
C. Hypertonic – has higher concentration than
body fluids (D10W, D50W, D5LR, D5NM)
Nursing Interventions:
1. Know the type, amount, indications of IV.
2. Inform client & explain purpose of IV
therapy.
3. Prime IV tubing to expel air.
4. Change IV tubing every 72 hours.
5. Change /alter IV needle insertion site
every 72 hours.
6. Regulate every 15-20 minutes.
7. Observe for complications.
Complications of IV Infusion:
1. Infiltration – needle out of vein, fluids
accumulate in the subcutaneous tissues
S/S: pain, swelling, cold skin, pallor at site,
IV rate decreases/stops, no backflow
NSG.INT: change IV site, apply warm
compress
2. Circulatory Overload – from administration
of excessive volume of IV fluids
S/S: headache, flushed skin, increased
PR,BP,RR, weight, SOB, syncope, cough,
increased venous pressure, pulmonary
edema, shock
NSG. INT: slow IV infusion (KVO), high
fowler’s position, administer diuretic,
bronchodilator as ordered
3. Drug Overload – excessive amount of
drugs in the fluids
S/S: dizziness, fainting, shock
NSG. INT.: slow IV infusion (KVO), inform
physician
4. Superficial Thrombophlebitis – due to
overuse of vein, irritating soln/drugs, clot
formation, large bore catheter
S/S: pain along the vein, vein feels hard &
cordlike, edema & redness over site,
affected arm warmer than the other
NSG. INT: change IV site every 72H, use
large veins for irritating fluids, stabilize
area, apply cold compress immediately
then warm compress after
5. Air Embolism - air enters the system (at
least 5 ml or more)
S/S: chest/shoulder/back pain,
hypotension, dyspnea, tachycardia,
cyanosis, increases venous pressure, LOC
NSG.INT: do not allow bottle to “run dry”,
prime tubings before starting IV, turn to left
side in Trendelenburg position
6. Nerve Damage – due to overly tight tying
of the splint
S/S: numbness of fingers/hands
NSG.INT: massage area & move shoulders
thru ROM, open/close hands several times
each hour, PT if required
7. Speed Shock – D/T rapid administration
of IV fluids
NSG.INT: to avoid speed shock & cardiac
arrest, give most IV push meds over 3-5
minutes
PURPOSES:
1. Administer required blood component
2. Restore blood volume
3. Improve oxygen-carrying capacity of the
blood
NURSING INTERVENTIONS:
1. Verify order, inform patient/relatives of
purpose, identify patient properly.
2. Check for cross-matching & blood typing
3. Obtain baseline VS
4. Practice strict ASEPSIS.
5. Ensure blood is counterchecked by 2
nurses: serial#, blood component/type, Rh
factor, expiration date, tests done
6. Warm the blood at room temperature.
7. Use needle gauge 18,19 or 20.
8. Use BT set with filter.
9. Start at slow rate (10 gtts/min)& remain
at bedside for 15-30 mins
10. Monitor VS
11. Do not mix meds with BT
12. Administer 0.9% NaCl before, during or
after BT. Never administer IV with dextrose.
13. Administer BT for 4 hours for WB & PRBC
and 20 minutes for plasma, platelets,
cryoprecipitate.
14. Observe for complications.
COMPLICATIONS OF BT:
1. ALLERGIC REACTION – caused by
sensitivity to plasma protein/donor
antibody that reacts with recipient
antigen
S/S: flushing, rash, hives, pruritus,
laryngeal edema, DOB
2. FEBRILE, NON-HEMOLYTIC – caused by
hypersensitivity to donor white cells,
platelets or plasma proteins.
** most symptomatic complication
S/S: sudden chills & fever, flushing,
headache, anxiety
3. SEPTIC REACTION – D/T transfusion of
contaminated blood/components
S/S: rapid onset of chills, vomiting,
marked hypotension, high fever
4. CIRCULATORY OVERLOAD – D/T rapid
administration of blood
S/S: dyspnea, crackles/rales, distended
neck vein, cough, elevated BP
5. HEMOLYTIC REACTION – D/T transfusion
of incompatible blood products
S/S: chills, low back pain, feeling of
fullness, increased RR,PR, hypotension,
flushing, bleeding, vascular collapse or
acute renal failure
NURSING INTERVENTIONS FOR BT
COMPLICATIONS:
1. Stop BT immediately.
2. Start IV line (0.9% NaCl)
3. Collect urine specimen.
4. Monitor VS
5. Send unused blood & BT set to blood
bank.
6. Administer antihistamine, diuretics &
bronchodilators as ordered.
 Asepsis
& Infection Control
TERMINOLOGIES:
INFECTION – invasion of body tissue by
microorganisms
ASEPSIS – absence of disease-producing
microorganisms; being free from infection
MEDICAL ASEPSIS – practices designed to
reduce number & transfer of microorganisms
SURGICAL ASEPSIS – practices that render &
keep objects/areas free from microorganisms;
sterile technique
SEPSIS – presence of infection
SEPTICEMIA – transport of infection
throughout the body or blood
CARRIER – person / animal, with or without
signs of illness but who harbors pathogens
within his body that can be transferred to
another
CONTACT – person / animal known or
believed to have been exposed to a disease
RESERVOIR – natural habitat for growth &
multiplication of microorganisms
TRANSIENT FLORA – microorganisms picked
up as a result of normal activities & can be
removed easily.
RESIDENT FLORA – microorganisms that
normally live on a person’s skin
STERILIZATION – process by which all
microorganisms including spores are destroyed
DISINFECTANT – substance that destroys
pathogens but generally not including spores
ANTISEPTIC – substance that inhibits growth
of pathogens but does not necessarily destroy
them
BACTERICIDAL – chemical that kills
microorganisms
BACTERIOSTATIC – agent that prevents
bacterial multiplication but does not kill all
forms of organisms
CONTAMINATION – process by which
something is rendered unclean / unsterile
DISINFECTION – process by which pathogens
but not their spores are destroyed
COMMUNICABLE DISEASE – results if
infectious agent can be transmitted to another
by direct/indirect contact thru vector/vehicle
INFECTIOUS DISEASE – results from invasion
& multiplication of microorganisms in a host
PATHOGEN – disease-producing
microorganism
PATHOGENICITY – ability to produce a
disease
VIRULENCE – vigor with which the organism
can grow & multiply
SPECIFICITY – organism’s attraction to a
specific host
OPPORTUNISTIC PATHOGEN – causes disease
only in susceptible individuals
NOSOCOMIAL INFECTION – hospital-
acquired infection
ISOLATION – separation of persons with
communicable disease from another so that
transmission is prevented
ISOLATION TECHNIQUES – practices
designed to prevent transfer of specific
microorganisms
ETIOLOGY – study of causes
STAGES OF INFECTIOUS PROCESS
Incubation Period – from entry of
microorganism to the body to onset of S/S
Prodromal Period – from onset of non-specific
S/S to appearance of specific S/S
Illness Period – specific S/S develop & become
evident
Convalescent Period – S/S start to abate until
client returns to normal state of health
THE CHAIN OF INFECTION
ETIOLOGIC/INFECTIOUS AGENT
(MICROORGANISMS)

RESERVOIR
SUSCEPTIBLE HOST
(SOURCE)
CHILDREN/ELDERLY/ILL, WITH
TRAUMA/INJURY

PORTAL OF ENTRY PORTAL OF EXIT

(M.MEMBRANE,SKIN,GIT,RESP. (SPUTUM, EMESIS,STOOL,BLOOD)
TRACT)

MODES OF TRANSMISSION
(CONTACT,VEHICLE,AIRBORNE,
VECTOR)
ETIOLOGIC AGENT – may be bacteria, virus,
fungi or parasites
RESERVOIR – humans, animals, plants,
environment
PORTAL OF EXIT – (from reservoir)
-Respiratory Tract- droplet,sputum
-GIT- vomitus, feces, saliva, drainage tubes
-Urinary Tract – urine, urethral catheter
-Reproductive Tract- semen, vaginal discharge
-Blood – needle puncture, open wound
 MODES OF TRANSMISSION
CONTACT TRANSMISSION – direct/indirect
DROPLET TRANSMISSION – when MM are
exposed to secretions of an infected personwho
is coughing, sneezing, laughing within 3 feet
VEHICLE TRANSMISSION – transfer by way of
vehicles or contaminated items (food, water,
milk, utensils, pillows, mattress)
AIRBORNE TRANSMISSION – when fine
particles are suspended in the air for a long time
& dispersed by air current then
inhaled/deposited to a host
VECTOBORNE TRANSMISSION – vectors can
be biologic or mechanical
Biologic – animals (rats, snails, mosquitoes)
Mechanical – infected inanimate objects
(contaminated needles/syringes)
PORTAL OF ENTRY – permits organism to
enter host
- Through body orifice such as mouth, nose,
vagina, rectum OR breaks in the skin or MM
SUSCEPTIBLE HOST – host is a person who is
at risk for infection, whose body defense
mechanism are unable to withstand the
invasion of the pathogen
 TYPES OF IMMUNIZATION
ACTIVE IMMUNIZATION- antibodies are
produced by the body in response to infection
NATURAL – antibodies formed in presence of
active infection in the body. It is lifelong.
ARTIFICIAL – antigens (vaccines/toxoid) are
administered to stimulate Ab production
PASSIVE IMMUNIZATION – antibodies are
produced by another source (animal/human)
NATURAL – Ab from mother to baby
ARTIFICIAL – Immune serum (antibody) from an
animal or another human is injected
 ASEPTIC PRACTICES
1. HANDWASHING
Handwashing is the single most important
infection control practice.
Handwashing for medical asepsis is done by
holding hands lower than the elbows
Use running water, soap & friction for 15-30
seconds each hand
Wash hands before and after client contact
2. CLEANING, DISINFECTION &
STERILIZATION
-Cleaning – physical removal of dirt & debris
by washing, dusting or mopping
-Disinfection – chemical or physical process to
reduce number of potential pathogens on a
surface but not necessarily the spores
-Sterilization – complete destruction of all
microorganisms including spores
 METHODS OF STERILIZATION
STEAM STERILIZATION – autoclaving uses
supersaturated steam under pressure
-non-toxic , inexpensive, sporicidal &
penetrates fabric
-Color indicator strips change color to indicate
sterilization
GAS STERILIZATION – ethylene oxide is
colorless gas that can penetrate plastic, rubber,
cotton or other subs. Used for oxygen, suction
gauges, BP apparatus, stethoscope, catheter
-Expensive & requires 2-5 hours
-Ethylene oxide is toxic to humans
RADIATION – ionizing radiation penetrates deeply
to objects
-Used for drugs, food & other heat-sensitive items
CHEMICALS – are effective disinfectants
-Attacks all types of microorganisms rapidly,
inexpensive & stable in light & heat. Chlorine is
used.
BOILING WATER – least expensive, at least 15
minutes
TYPES OF DISINFECTION
Concurrent – during
Terminal - after CATEGORIES OF WASTES:
3. USE OF BARRIERS Infectious

a. Masks Injurious
Hazardous
b. Gowns
c. Caps & shoe covers
* Most agencies use color
d. Gloves coding

e. Private rooms
f. Equipment & refuse handling
4. ISOLATION SYSTEMS
CLASSIFICATIONS:
A. Standard Precautions
- Universal Precaution & Body-Substance
Isolation
- Prevent transmission of bloodborne & moist
body substance pathogens
1. Wear clean gloves
2. Perform handwashing
3. Wear masks, goggles, face shield if sprays/splashes
are expected
4. Wear gown if soiling & splashes are expected
5. Remove soiled protective items immediately
6. Clean & reprocess all equipment
7. Discard all single-used items
8. Prevent injuries
9. Use private room or consult with Infection
Control Department
B. Transmission-Based Precautions
1. AIRBORNE PREC – for small-particle
droplet that may remain suspended in the air
& dispersed by air current (varicella, TB,
measles
- Private room, negative airflow, wear masks
2. DROPLET PREC – for large-particle droplet
& dispersed by air current (H. influenza,
diphtheria, rubella, mycoplasma
pneumoniae)
- Private room, wear masks within 3 ft.
3. CONTACT PREC – for those transferred by
hand-or skin-to-skin contact (clostridium
difficile, shigella, impetigo)
- Private room, use gloves, gowns & other
protective barriers when exposure to infected
material is likely
C. Protective Isolation – prevent infection for
people with compromised resistance
(leukopenia, undergoing chemoRx, extensive
burns)
- Private room, restrict visitors, no fresh
fruits/flowers, raw foods, potted plants
allowed, only cooked/canned foods allowed
5. SURGICAL ASEPSIS
PRINCIPLES:
a. Moisture causes contamination.
b. Never assume that an object is sterile.
c. Always face the sterile field.
d. Sterile articles may touch only sterile
surface/articles to maintain sterility.
e. Sterile equipment/areas must be kept above
the waist & on top of the sterile field.
f. Prevent unnecessary traffic & air currents
around sterile area
g. open, unused sterile articles are no longer
sterile after the procedure
h. A person who is considered sterile who
becomes contaminated must reestablish
sterility
i. Surgical technique is team effort.
Wound Care
TYPES OF WOUNDS: accdg. to contamination
1. Clean Wounds – uninfected, minimal inflammation,
closed
- respiratory, GIT & urinary tract are not entered
2. Clean-contaminated Wounds – also surgical wounds,
no infection
- respiratory, GIT & urinary tract entered
3. Contaminated Wounds- open, fresh, accidental
wounds, with evidence of inflammation
4. Dirty/Infected Wounds – with dead tissue & evidence
of infection
TYPES OF WOUND: accdg to cause
1. Incision
2. Contusion
3. Abrasion
4. Puncture
5. Laceration
6. Penetrating wound
TYPES OF WOUND HEALING
1. Primary Intention healing
2. Secondary Intention healing
PHASES OF WOUND HEALING
1. Inflammatory Phase – immediate, 3-6 days
2. Proliferative Phase – 3rd to 21 days
3. Maturation Phase – 21 days to 2 years
STAGES OF PRESSURE ULCER FORMATION
Stage 1 – non-blanchable erythema signaling
potential ulceration
Stage 2 – partial-thickness skin loss (abrasion,
blister or shallow crater) involving epidermis &
dermis
Stage 3 – full-thickness skin loss involving damage
or necrosis of subcutaneous tissue that may extend
down but not thru fascia. Deep crater.
Stage 4 – full-thickness skin loss with necrosis or
damage to muscle, bone, structures, tendon, joints
KINDS OF WOUND DRAINAGE
EXUDATE – material that escapes from blood
vessels during the inflammatory process
1. SEROUS EXUDATE – blister from burns
2. PURULENT EXUDATE
3. SANGUINEOUS (Hemorrhagic)
EXUDATE
COMPLICATIONS OF WOUND HEALING

1. Hemorrhage – massive bleeding, greatest on

the 1st 48 hours
2. Infection
3. Dehiscence with possible evisceration
FACTORS AFFECTING WOUND HEALING
1. Developmental Considerations
2. Nutrition
3. Lifestyle
4. Medications
NURSING INTERVENTIONS:
1. Supporting wound
healing 6. Maintaining good
hygiene
2. Nutrition & fluids
7. Avoid trauma
3. Preventing infection
8. Provide supportive
4. Positioning device
5. Preventing pressure
ulcers
TREATING PRESSURE ULCERS - The RYB
CODE

RED – (PROTECT) - on late regeneration phase

& needs protection to avoid disturbance to
regenerating tissue
-(1) Gentle cleansing, (2) avoid dry gauze,
(3) apply topical antimicrobial agent, (4) apply
appropriate dressing (gauze, transparent film,
hydrocolloid), (5) changing infrequently
YELLOW – (CLEANSE) - characterized by liquid
to semiliquid “slough” with purulent drainage
-(1) apply wet-to-damp dressing, (2) irrigation,
(3) use exudate absorbers as dressings, (4) topical
antimicrobials

BLACK – (DEBRIDE) - covered with thick

necrotic tissue/eschar
- Require debridement
Loss, Grieving &
Death
DEFINITION OF TERMS
LOSS – actual or potential situation where a
valued object, person or the like is inaccessible
or changed & no longer perceived as valuable
BEREAVEMENT – subjective response to loss
thru death of a person with significant
relationship
GRIEF – total response to experience of loss
thru thoughts, feelings & behavior
MOURNING – behavioral process thru which
grief is resolved & altered
DEVELOPMENTAL CONCEPT OF DEATH
Infancy to 5 years – does not understand
death
-believes death is reversible, temporary sleep
5- 9 yrs - understands death is final
-Believes own death can be avoided
-Associates death with aggression or violence
9-12 yrs – understands death as inevitable
end of life
- Begins to understand own mortality
12-18 yrs – fears of lingering death
-Fantasize death can be defied, acting out thru
violence
-Views death in religious/philosophical terms
18-45 yrs – attitude influenced by religious &
cultural beliefs
45-65 yrs – accepts own mortality
-Encounters several deaths of loved ones
-Experiences peak of death anxiety
65 above- fears prolonged illness, has multiple
meanings of death
 STAGES OF GRIEVING
Kubler-Ross Stages of Grieving
1. Denial – refuse to believe the loss, may
assume artificial cheerfulness
2. Anger – directed at others
3. Bargaining – to avoid loss, express feeling of
guilt/punishment of past sins
4. Depression – may talk freely or withdraw
5. Acceptance – comes to terms, decreased
interest in surroundings, wish to begin plans
MARTOCCHIO’S FIVE CLUSTER OF GRIEF
1. Shock & disbelief
2. Yearning & protest
3. Anguish, disorientation & despair
4. Identification in bereavement
5. Reorganization & restitution
 CARE OF THE DYING CLIENT
SIGNS OF IMPENDING CLINICAL DEATH
Loss of Muscle Tone
Slowing of Circulation
Changes in Vital Signs
Sensory Impairment
NURSING INTERVENTIONS
1. Assist to achieve dignified & peaceful death
2. Maintain physiologic & psychologic comfort
3. Provide spiritual support
 CARE OF THE DEAD PATIENT
BODY CHANGES
Rigor Mortis – stiffening about 2-4 hrs after death
Algor Mortis – gradual decrease of body temperature
Livor Mortis – discoloration of the skin
NURSING INTERVENTIONS
1. Clean the body, change into clean gown
2. Place absorbent pads/cotton balls on orifice
3. Remove all jewelries, log & endorse properly
4. Allow family to view the body if needed
5. Apply identification tags & transfer to morgue
 Meeting
Physiologic
Needs
*Oxygenation*
 MEASURES TO PROMOTE ADEQUATE
RESPIRATORY FUNCTION
1. Adequate oxygen supply from
environment
2. Deep breathing & coughing exercises
3. Positioning
4. Patent airway
5. Adequate hydration
6. Avoid environmental pollutants, alcohol &
smoking
7. Chest physiotherapy (CPT)
Kinds of Chest Physiotherapy
1. Percussion (clapping)
2. Vibration
3. Postural drainage
Bronchial Hygiene Measures
1. Steam Inhalation – semifowler’s
position & position spout 12-18 inches
away from nose
2. Aerosol Inhalation
3. Medimist Inhalation
SUCTIONING
1. Assess indications for suctioning.
2. Position properly:
conscious: semi-fowlers
unconscious: lateral position

3. Apply proper pressure

4. Use appropriate size of catheter
Adult: Fr 12-18
Child: Fr 8-10
Infant: Fr 5-8
5. Don sterile gloves
6. Insert proper length of catheter
7. Lubricate catheter
8. Apply suction during withdrawal of catheter
9. Apply suction for 5-10 seconds (max 15)
10. Hyperventilate 100% before & after
11. Allow 20-30 sec interval between each suction
12. Provide oral & nasal hygiene
13. Dispose contaminated equipment/matls safely
14. Assess effectiveness / document
INCENTIVE SPIROMETRY
Enhance deep inspiration
INTERMITTENT POSITIVE PRESSURE
BREATHING
Administer oxygen at pressures higher
than the atmospheric pressure
OXYGEN SYSTEMS
1. Low flow administration devices
2. High flow administration devices
ADMINISTRATION OF OXYGEN
Indications: hypoxemia
Signs of Hypoxemia:
Restlessness
Increased pulse rate
Rapid, shallow breathing, DOB, nasal flaring
Light headedness
Substernal / intercostals retractions
Cyanosis
LOW FLOW ADMINISTRATION
DEVICES
NASAL CANNULA 24-45%
2-6 LPM
SIMPLE FACE MASK 40-60%
5-8 LPM
PARTIAL REBREATHING 60-90%
MASK 6-10 LPM
NON-REBREATHING 95-100%
MASK 6-15 LPM
CROUPETTE

OXYGEN TENT
HIGH FLOW ADMINISTRATION
DEVICES

VENTURI MASK LOW CONCENTRATION

VENTURE-TYPE
(is preferred for clients with COPD
because it provides accurate
amount of O2)
FACE MASK

OXYGEN HOOD Can be used for low & high flow

concentration
INCUBATOR / Can be used for low & high flow
ISOLETTE concentration
Nursing Implications in the
Administration of Oxygen Therapy
•Oxygen is colorless, odorless, tasteless
gas & leakage cannot be detected.
•Since oxygen is dry gas, it can irritate
mucus membranes of airways.
•Oxygen supports combustion, it can
cause fire.
•Place a “No Smoking” sign at the bedside
•Avoid use of oil, grease, alcohol & ether
near client with O2
•Check electrical appliances before use.
•Avoid materials that can generate statis
electricity such as woolen blanket &
synthetic fabrics.
•Humidify oxygen
•Provide good oronasal hygiene
•Assess efectiveness of oxygen therapy
ALTERATIONS IN RESPIRATORY FUNCTION
HYPOXIA
Insufficient oxygenation of tissues
CLINICAL SIGNS:
Early Signs Late Signs
Tachycardia Bradycardia
Increased rate & depth of Dyspnea
respirations Decreased systolic BP
Slight increase in systolic Cough
BP hemoptysis
RHYTHM
CHEYNE-STOKES – marked rhythmic waxing &
waning of respirations from very deep to very
shallow and temporary apnea
KUSSMAUL’S (Hyperventilation) – increased
rate & depth of respiration
APNEUSTIC – prolonged gasping inspiration
followed by very short inefficient expiration
BIOT’S – shallow breaths interrupted by apnea