FUNDAMENTALS OF NURSING Nursing Theories and Theorists Florence Nightingale (Environmental Theory) a persons health was the direct

ct result of the environmental influences specially cleanliness, light, pure air, pure water and efficient drainage. Through manipulating the environment, nursing aims to discover the laws of nature that would assist in putting the patient in the best possible condition so that nature can effect a cure. Hildegard Peplau (Theory of Interpersonal Relations) defined the concepts and stages involved in the development of the nurse-client relationship. She identified the roles of the nurse as stranger, resource person, teacher, leader, surrogate and counselor. Virginia Henderson (14 basic needs) defined nursing as, The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he has the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. Henderson attempted to identify the basic human needs as the basis of nursing care. The 14 basic needs are as follows: breathing normally eating and drinking adequately eliminating body waste moving and maintaining a desirable position sleeping and resting selecting suitable clothes maintaining normal body temperature by adjusting clothing and modifying the environment keeping the body clean and well groomed to promote integument avoiding dangers in the environment and avoiding injuring others communicating w/others in expressing emotions ,needs,fears or opinions worshipping accdg. to one's faith working in such a way that one feels a sense of accomplishment playing or participating in various forms of recreation learning , discovering or satisfying the curiosity that leads to normal development and health, and using available health facilities Faye Abdellah (21 nursing problems) "Nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people , sick or well, cope with their health needs." o To promote good hygiene and physical comfort o To promote optimal activity, exercise, rest, and sleep o To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection o To maintain good body mechanics and prevent and correct deformities o To facilitate the maintenance of a supply of oxygen to all body cells o To facilitate the maintenance of nutrition of all body cells o To facilitate the maintenance of elimination o To facilitate the maintenance of fluid and electrolyte balance o To recognize the physiologic responses of the body to disease conditions o To facilitate the maintenance of regulatory mechanisms and functions o To facilitate the maintenance of sensory function o To identify and accept positive and negative expressions, feelings, and reactions

To identify and accept the interrelatedness of emotions and organic illness To facilitate the maintenance of effective verbal and nonverbal communication To promote the development of productive interpersonal relationships To facilitate progress toward achievement of personal spiritual goals To create and maintain a therapeutic environment To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs o To accept the optimum possible goals in light of physical and emotional limitations o To use community resources as an aid in resolving problems arising from illness o To understand the role of social problems as influencing factors in the cause of illness Joyce Travelbee (Existentialism/ Human-to-human relationship model) a theory that is centered on individual existence in an incomprehensible world and the role that free will plays in it, and searched ti find meaningin lifes experiences. Jospehine Paterson and Loreta Zderad ((Humanistic NUrsing Theory) a humanistic nurse has a different frame of reference that places her relationship with the patient at the center of her focus, with the patient's health benefiting from that relationship rather than solely from medical or educational experience. Myra Estrine Levine (4 Conservation Principles) Levine believed in the wholeness of the human being and the primary focus of conservation is to maintain that wholeness. o Conservation of Energy the individual requires a balance of energy and a constant renewal of energy to maintain life activities. o Conservation of Structural Integrity structural integrity is concerned with the process of healing to restore wholeness and continuity after injury or illness. o Conservation of Personal Integrity everyone seeks to defend his or her identity as a self, in both that hidden, intensely private person that dwells within and in the public faces assumed as individuals move through their relationship with others. o Conservation of Social Integrity No diagnosis should be made that does not include the other persons intertwined with that of the individual. Dorothea Orem (Self-care /Self-care deficit theory ) self-care is a learned behavior and a deliberate action in response to a need. Self-care deficit purports that nursing care is needed when people are affected by limitations that do not allow them to meet their self-care needs. These theories define three types of nursing systems: o Wholly Compensatory Nursing System the nurse supports and cares for the client, compensates for the clients inability to care for self, and attempts to provide care for the client. o Partly Compensatory Nursing System both the nurse and the client perform care measures. o Supportive-Educative Nursing System the nurses actions are to help the clients develop their own self care activities. Sister Callista Roy (Adaptation Theory) the person has coping mechanisms that are broadly categorized in either the regulator of cognator subsystem. The regulator subsystem functions through the autonomic nervous system, which responds automatically through neural,chemical, and endocrine coping processes. The cognator subsystem enables the person to respond to stimuli through processing stimuli, learning, judgment, and emotion. All input into the system (the person) is channeled through the regulator and cognator subsystems. If the regulator or cognator subsystem fails, there is ineffective adaptation. Jean Watson (Theory of Human Caring) focuses on the art and science of human caring. Watsons theory is composed on 10 carative factors which are defined as nursing actions or caring processes. These carative factors are:

o o o o o o

Formation of a humanistic-altruistic system of values Nurturing of faith-hope Cultivation of sensitivity to ones self and to others Developing a helping-trusting, human caring relationship o Promotion and acceptance of the expression of positive and negative feelings o Use of creative problem-solving method processes o Promotion of transpersonal teaching and learning o Provision for a supportive, protective, or corrective mental, physical, sociocultural, and spiritual environment o Assistance with gratification of human needs o Allowance for existential-phenomenological forces Martha Rogers (Science of Unitary Human Beings) the person is a unified whole and seen as greater than and different from the sum of the parts. The whole person cannot be known by examining any particular aspect or dimension of the person because all aspects together combine to form an entity different from the collection of parts. It is the characterization of the person as a human energy field that unites all aspects of the person into a unified whole. The whole of the persons energy field interacts with the whole of the environmental energy field, which results in the process of life. Rosemarie Rizzo Parse (Theory of Human Becoming) o The first theme, MEANING, is expressed in the first principle of humanbecoming, which states that "Structuring meaning is the imaging and valuing of languaging. This principle means that people coparticipate in creating what is real for them through self-expression in living their values in a chosen way. o The second theme, RHYTHMICITY, is expressed in the second principle of humanbecoming, which states that "Configuring rhythmical patterns of relating is the revealing-concealing and enabling-limiting of connecting-separating". This principle means that the unity of life encompasses apparent opposites in rhythmic patterns of relating. It means that in living moment-to-moment one shows and does not show self as opportunities and limitations emerge in moving with and apart from others. o The third theme, TRANSCENDENCE, is expressed in the third principle of humanbecoming, which states that "Cotranscending with possibles is the powering and originating of transforming". This principle means that moving beyond the "now" moment is forging a unique personal path for oneself in the midst of ambiguity and continuous change.

o o o o

Imogene King (Goal Attainment Theory) Madeleine Leninger (Transcultural Nursing) Margaret Newman (Health as an expanding Consciousness) Patricia Benner Betty Neumann (Healthcare Systems Model) Lydia Hall (The Nursing Process)

Types of Healthcare Services Basically, health care services can be categorized into three levels: Primary, Secondary and Tertiary. The complexity of care caries according to the individuals need, providers expertise, and delivery set ting

PRIMARY: HEALTH PROMOTION AND ILLNESS PREVENTION Goal: To decrease the risk to a client (individual or community) for disease or dysfunction) Examples: Teaching, Lifestyle modifications for health, referrals, immunizations, promotion of a safe environment SECONDARY: DIAGNOSIS AND TREATMENT Goal: Early intervention to alleviate disease and prevent further disability Examples: Screenings/Diagnosis, Acute Care, Surgery TERTIARY: REHABILITATION Goal: to minimize effects and permanent disability of chronic or irreversible condition Examples: Education and retraining, provision of direct care, environmental modifications THE NURSING PROCESS The nursing process is a framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection and disease prevention and is used by nurses in every practice, setting and specialty. OVERVIEW OF THE NURSING PROCESS Assessment Assessment is the first step in the nursing process and includes collection, verification, organization, interpretation and documentation of data. The completeness and correctness of the information obtained during the assessment are directly related to the accuracy of the steps that follow. Primary Source of Data the major provider of information. As much information as possible should be gathered from the client, using both interview techniques and physical examination Secondary Source of Data - sources of data other than the client. and may include family members, other health care providers and medical records. Subjective Data subjective data are data from the clients point of view and include feelings, perceptions, and concerns. The method of collecting the data is primarily the interview. Objective Data objective data are observable and measurable data that can be obtained through both standard assessment techniques performed during the physical examination and diagnostic tests. Diagnosis The second step in the nursing process involves further analysis and synthesis of the data that have been collected. Formulation of the list of nursing diagnoses is the outcome of this process. According to NANDA, nursing diagnosis is a clinical judgment about the individual, family or community responses to actual, or potential health problems/life processes. Below is a table of comparison between Medical and Nursing Diagnoses.

Medical Diagnosis Focuses on the illness, injury or disease process Remains constant until a cure is effected Identifies conditions the health care practitioner is licensed and qualified to treat Types of Nursing Diagnoses

Nursing Diagnosis Focuses on the responses to actual or potential health problems or life processes Changes as the clients response and/or the health problem changes Identifies situations in which the nurse is licensed and qualified to intervene

Actual Nursing Diagnosis indicates that a problem exists and is composed of a diagnostic label, related factors and signs and symptoms Risk Nursing Diagnosis indicates that a problem does not yet exist, but special risk factors are present. A risk diagnosis is a diagnostic label preceded by the phrase risk for with the specific risk factor listed. Possible Nursing Diagnosis indicates a situation in which a problem could arise unless preventive action is taken. In addition, a possible diagnosis may state a hunch or intuition by the nurse that cannot be confirmed or eliminated until more data have been collected Wellness Nursing Diagnosis indicates that the clients expression of a desire to attain a higher level of wellness in some area of function. It is composed of the diagnostic label preceded by the phrase potential for enhanced Collaborative problems are defined as physiologic complications monitored by nurses to assess changes in the client status. Collaborative problems are managed through the use of interventions prescribed by other health care practitioners and/or nurses

Planning Planning is the third step of the nursing process and includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses. Client-centered goals are established in collaboration with the client whenever possible. A Goal is an aim, intent or end. Goals are broad statements that describe the intended or desired change in the clients behavior Expected Outcomes are specific objectives related to the goals that are used to evaluate the nursing intervention. Outcomes have to be SMART A Nursing Intervention is the activity that the nurse will execute for and with the client to enable accomplishment of the goals. Implementation The fourth step of the nursing process is implementation. It involves the execution of the nursing plan of care derived during the planning phase. It consists of performing nursing activities that have been planned to meet the goals set with the client. Evaluation The fifth step in the Nursing Process, involves determining whether the client goals have been met, partially met and not met. Evaluation is an ongoing process. Nurses continually evaluate data in order to make informed decisions during other phases of the nursing process.

ASSESSMENT Purpose: to establish a database concerning a clients physical, psychosocial and emotional health in order to identify health promoting behaviors as well as actual and/or potential problems Review of Systems Review of systems is a brief account from the client of any recent signs or symptoms associated with any of the body systems. This allows the client to communicate any deviations from normal that have been otherwise identified. Relevant data in the review of systems shall include: Location: the area of the body in which the symptom (such as pain) can either be pointed or described in detail Character: the quality of the feeling or sensation (e.g., sharp, dull, stabbing) Intensity: the severity or quantity of the feeling or sensation and its interference with functional abilities. The sensation can be rated on a scale of 1 to 10 Timing: the onset, duration, frequency and precipitating factors of the system Aggravating/alleviating factors: the activities or actions that make the symptom worse or better PHYSICAL EXAMINATION Inspection - Involves careful visual observation. The client is observed first from a general point of view and then with specific attention to detail Palpation - uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses and tenderness. - Palpation uses a calm, gentle approach and is used systematically with light palpation preceding deep palpation and palpation of tender areas performed last Percussion - Uses short, tapping strokes on the surfaces of he skin to create vibrations of underlying organs. It is used for assessing the density of structures or determining the location and size of organs in the body Auscultation - Involves listening to sounds in the body that are created by movement of air or fluid. MEASURING VITAL SIGNS MEASUREMENT OF HEIGHT AND WEIGHT Height Measurement of height is expressed in inches (in), feet, (ft), or meters (m)

CONVERSION EQUIVALENTS FOR HEIGHT MEASUREMENT 1 in. = 2.5 cm 1 cm = 0.4 in. 1 in. = 2.5 cm 1 cm = 0.4 in. 1 ft = 30.5 cm or 0.3 m 1 m = 39.4 in. or 3.28 1 ft = 30.5 cm or 0.3 m 1 m = 39.4 in. or 3.28

Guidelines in taking the height: - When measuring an infants length, the nurse should place the child in a firm surface. Extend the knees with the feet at right angles to the table. Measure the distance form the vertex (top) of the head to the soles of the feet with a measuring tape. - Height increases gradually from birth to the prepubertal growth spurt - Girls usually reach their adult height between the ages of 16 and 17whereas boys continue to grow until the ages 18 to 20 years Weight ` Measurement in weight is usually expressed in ounces (oz), pounds (lbs) and kilograms (kg) CONVERSION EQUIVALENTS FOR WEIGHT MEASUREMENT

1 lb = 0.45 kg 1 kg = 2.2 lb 1 oz = 28.4 g 1 g = 0.35 oz

1 lb = 0.45 kg 1 kg = 2.2 lb 1 oz = 28.4 g 1 g = 0.35 oz

Guidelines in taking the weight: - When the client has an order for daily weights, the weight should be obtained at the same time of the day on the same scale, with the client wearing the same type of clothing. - Standing scales are used for clients who can carry their own weight. - Accurate reading of weights are imperative because they are used in drug dosage calculations and to evaluate the effectiveness of drug, fluid and nutritional therapy. BODY TEMPERATURE Frequent monitoring is required for clients who have or are at risk for infection CENTIGRADE AND FAHRENHEIT CONVERSION FORMULAS

Centigrade to Fahrenheit conversion: multiply the centigrade reading by 9/5 and add 32: F = (C 9/5) + 32 Fahrenheit to centigrade conversion: deduct 32 from the Fahrenheit reading and multiply by 5/9: C = (F 32) 5/9
Sites for Body Temperature taking Traditional sites for measuring the bodys internal (core) temperatures are Oral, Rectal and Axillary using either glass (obsolete) or electronic thermometers. Advances in clinical thermometry provide other devices and sites, such as thermistors for pulmonary artery temperature and infrared thermometers for Ear Canal Temperature. Oral and rectal measurements are higher than the axillary because the measuring device is in contact with a mucous membrane. The axilla is a commonly used site for infants and children with disabilities because it is the safest, even though least accurate method. Axillary or rectal sites are used for clients who are uncooperative, comatose or who have a nasogastric tube in place. *Rectal temperature measurements is contraindicated in clients with cardiovascular alterations because the thermometer may stimulate the vagus nerve and cause an irregular cardiac rhythm. It is also contraindicated in leukemia and rectal surgery clients because the insertion of the thermometer may traumatize the mucosa or the incision line, causing bleeding. *

Alterations in thermoregulation Alteration Heat exhaustion Definition An increase in body temperature (3840C; 100.4104.0F) in response to environmental conditions that, in turn, causes diaphoresis (profuse perspiration) A critical increase in body temperature, (41-44 C) resulting from exposure to high environmental temperatures Characteristics Loss of excessive amounts of water and sodium from perspiring leads to thirst, nausea, vomiting, weakness, and disorientation. Dry, hot skin is the most important sign. The person becomes confused, or delirious and experiences thirst, abdominal distress, muscle cramps and visual disturbances. Loss of consciousness occurs if untreated Decrease in metabolism leads to impaired mental functioning and depressed pulse, respirations and blood pressure; can result in cardiac arrest if untreated Circulatory impairment may be followed by gangrene

Heat stroke

Hypothermia

A body temperature of 35 C or lower resulting from cold weather exposure or artificial induction

Frostbite

Freezing of the bodys surface areas (earlobes, fingers and toes) in extremely low temperatures

PULSE Pulse assessment is the measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta. There are multiple pulse points. The most accessible are the radial and carotid sites. Pulse Characteristics A normal pulse has defined characteristics, quality, rate, rhythm and volume. Pulse Quality refers to the feel of the pulse, its rhythm and forcefulness. Pulse Rate is an indirect measurement of cardiac output by counting the number of apical or peripheral pulse wave over a pulse point. A normal pulse rate for for adults is between 60 to 100 beats per minute. Bradycardia is a heart rate less than 60 beats per minute in an adult. Tachycardia is a heart rate in excess of 100 beats per minute in an adult Electrocardiogram (ECG) provides an electrical representation of the hearts activity. The primary pacemaker of the heart is the Sinoatral (SA) node. If another site within the heart initiates the electrical activity, the ECG tracing will identify the area serving as the pacemaker. Cardiac Telemetry transmits the hearts electrical activity to a site for continuous monitoring A Holter monitor is a portabledevice worn for a 24 hour interval to identify the dysrhythmia pattern.

RESPIRATIONS Respirations is the measurement of the breathing pattern. Characteristics of Normal and Abnormal Breath Sounds Different Respiratory patterns are characterized by their rate, rhythm and depth. Eupnea refers to easy respirations with a normal rate of breaths per minute that are age-specific

Bradypnea is a respiratory rate of 10 or fewer breaths per minute Hypoventilation is characterized by shallow respirations Tachypnea is a respiratory rate greater than 24 breaths per minute Hyperventilation is characterized by deep, rapid respirations Dyspnea refers to difficulty in breathing as observed by labored or forced respirations through the use of accessory muscles in the chest and neck to breathe. *Dyspneic clients should never be placed flat on bed; maintain them in a semi-fowlers or fowlers position. To facilitate maximum lung expansion, place the client in a forward-leaning position (orthopneic) over a padded, raised, overbed table with arms and head resting on a table.* BLOOD PRESSURE Blood pressure measurement is performed during a physical examination, at initial assessment and as part of routine vital signs assessment. Depending on the clients condition, the blood pressure is measured by either a direct or indirect technique. The direct method requires an invasive procedure in which an intravenous catheter with an electronic sensor is inserted into an artery and the artery-transmitted pressure on an electronic display unit is read. The indirect method requires the use of the sphygmomanometer and stethoscope for auscultation and palpation as needed. The most common site for indirect blood pressure measurement is the clients arm over the brachial artery. When the clients condition prevents auscultation of the brachial artery, the nurse should assess the blood pressure in the forearm or leg sites. When pressure measurements in the upper extremity are not accessible, the popliteal area, located behind the knee, becomes the site of choice. Auscultation A stethoscope is used to auscultate the blood pressure. The blood pressure is inflated 30 mm Hg higher than the palpated pressure so that the inflated pressure causes the artery to collapse; blood flow ceases and sound is absent on auscultation. As the pressure is released form the bladder, blood begins to flow through the artery and creates the first sound, which is the systolic pressure. Contraindications For Brachial Artery Blood Pressure Measurement When the client has any of the following, do not measure blood pressure on the involved side: Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal dialysis Surgery involving the breast, axillas, shoulder arm or hand Injury or disease to the shoulder, arm, or hand such as trauma, burns or application of a cast or bandage

HYPOTENSION Refers to a systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the clients normal systolic pressure. Hypotension is caused by a disruption in hemodynamic regulation, such as: Decreased blood volume Decreased cardiac output Decreased peripheral vascular resistance HYPERTENSION Refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. Diagnosis of hypertension is based on the average of two or more readings taken at each of two or more visits after an initial screening.

Nursing Considerations Before checking a blood pressure, review the clients chart for brachial artery contraindications and make sure that the client has not exercised or eaten for the past 30 minutes. Clients who have recently eaten, ambulated, or experienced an emotional upset will have a falsely high blood pressure reading. When the vital signs are taken correctly in sequence (T-P-R and BP), the client should be calm from sitting or lying quietly. Faulty techniques that constrict blood flow will produce a false high pressure reading: A cuff too narrow for the extremity A cuff that does not fit snugly around the extremity A cuff that is deflated too slowly Other false high readings occur when the mercury column in the manometer is not positioned flat on a firm surface or is read above eye level or the extremity is below the hearts apex level. False low readings occur when the extremity is above the hearts apex level, the cuff is too wide for the extremity, or the mercury column in the manometer is read below eye level. If the nurse fails to recognize the auscultatory gap, the temporary disappearance of sounds at the end of Korotkoff phase I and beginning of phase II, the systolic pressure is read at a false low pressure.