Professional Documents
Culture Documents
NUR SING
CONC EPT OF MA N
MAN
Establish a family
Establish a territory
Biopsychosocial Being
Open System
Unified Whole
By Martha Rogers
By Martha Rogers
Man is composed of
certain parts
By Florence Nightingale
Man is passive in
influencing the nurse or
the environment
MAN IS A WHOLE. MAN IS COMPLETE
By Virginia Henderson
Universal
Interrelated
In order to prioritize
nursing actions
ABRAHAM MASLOW’S HIERARCHY OF NEEDS
Physiologic needs
Food
Air
Drink
Shelter
Warmth
Sex
Sleep
Maintenance of
homeostasis
ABRAHAM MASLOW’S HIERARCHY OF NEEDS
Protection
Security
Order
Law
Limits
Stability
ABRAHAM MASLOW’S HIERARCHY OF NEEDS
Family
Affection
Relationships
Work group
ABRAHAM MASLOW’S HIERARCHY OF NEEDS
Self-esteem
Feeling good about
one’s self
Two factors affecting
Self-esteem
Yourself
• Sense of
adequacy
• Accomplishment
Others
• Appreciation
• Recognition
• Admiration
ABRAHAM MASLOW’S HIERARCHY OF NEEDS
Self-actualization
Additional needs:
Aesthetic needs
Transcendence
ABRAHAM MASLOW’S MODIFIED HIERARCHY
OF EIGHT NEEDS (1990)
Need to know and
understand or Cognitive
needs is supported by
Richard Kalish who says
that:
Man needs stimulation
Needs to explore
Sex
Activity
Novelty
• Stimulator
• Desire to come
up with
something of
your own
ABRAHAM MASL OW’ S M OD IF IE D
HIE RARC HY OF EIGH T N EE DS ( 1990 )
Aesthetic needs:
Beauty
Balance
Form
ABRAHAM MASL OW’ S M OD IF IE D
HIE RARC HY OF EIGH T N EE DS ( 1990 )
Transcendence:
Superior perception
Decisive
Capable of making decisions
It is impossible to attain
Acute Illness
Chronic Illness
ACUTE ILLNESS
Alcoholism
A disease rather than a social problem
WELLNESS
World Health
Object 5
Organization
A high-level wellness!
DEFINITIONS OF HEALTH
Claude Barnard
Ability to maintain
internal milieu
DEFINITIONS OF HEALTH
Walter Cannon
Ability to maintain
homeostasis
A dynamic equilibrium
A state of balance of
the internal
environment while
external environment is
changing
DEFINITIONS OF HEALTH
Florence Nightingale
Being well
Can be maintained by
manipulating the
environment
DEFINITIONS OF HEALTH
Virginia Henderson
Viewed in terms of
ability to perform the
fourteen (14)
fundamental needs or
components of nursing
care UNAIDED
DEFINITIONS OF HEALTH
Martha Rogers
Positive health
symbolizes wellness
Dorothea Orem
Characterized by
soundness and
wholeness of
DEVELOPED HUMAN
STRUCTURES and
FUNCTIONS
DEFINITIONS OF HEALTH
Imogene King
Illness is interference in
the life cycle
DEFINITIONS OF HEALTH
Betty Neuman
Dorothy Johnson
1. Clinical Model
3. Adaptive Model
4. Eudaemonistic Model
American Nurses
Association
Florence Nightingale
Virginia Henderson
Martha Rogers
Nursing is a
HUMANISTIC
SCIENCE dedicated to
compassionate concern
for the promotion of
health, prevention of
illness and
rehabilitation of the sick
DEFINIT ION S OF NU RSING
Nursing is a
THEORETICAL
SYSTEM OF
KNOWLEDGE that
prescribes analysis and
action related to the
care of the sick or ill
It is a set of knowledge
DEFINIT ION S OF NU RSING
Dorothea Orem
Nursing is a helping
service to any individual
who is sick
It comprises of wholly
dependent or partly
dependent care when
the person is unable to
do so.
Defines nursing in
terms of a NEED!
DEFINIT ION S OF NU RSING
Imogene King
Nursing is a helping
profession that assists
a person (same with
Henderson) towards a
DIGNIFIED DEATH
DEFINIT ION S OF NU RSING
Betty Neuman
Nursing is a profession
that is concerned with
INTRAPERSONAL,
INTERPERSONAL,
and
EXTRAPERSONAL
VARIABLES affecting a
person’s response to
stressors
DEFINIT ION S OF NU RSING
Dorothy Johnson
Nursing is an
EXTERNAL
REGULATORY
FORCE that regulates
the ACTION or
BEHAVIOR of a person
when such behavior
constitutes a threat, in
order to preserve his
organization
DEFINIT ION S OF NU RSING
Dorothy Johnson
Example:
In a COPD patient
who remains a
smoker, the nurse
who encourages
the patient not to
smoke, serves as
an external
regulatory force
DEFINIT ION S OF NU RSING
Faye Abdella
Nursing is a service to
individuals, families…
and therefore, to
society
Conceptualized nursing
as an ART and
SCIENCE of MOLDING
THE INTELLECT,
ATTITUDE and SKILLS
of the nurse
Nursing in terms of
providing education
DEFINIT ION S OF NU RSING
Hildegard Peplau
Nursing is the
INTERPERSONAL
process of
THERAPEUTIC
INTERACTION
between the nurse and
the patient.
NURSING THEORIES
1) FLOREN CE NIG HTIN GALE:
EN VIRON MENT AL NU RS ING
THEORY
Often considered the first
nurse theorist
Nightingale’s theory
remains an integral part
of nursing and healthcare
today.
1) FLOREN CE NIG HTIN GALE:
EN VIRON MENT AL NU RS ING
THEORY
5 Environmental Factors:
Ventilation
Cleanliness
Quiet
Warmth
Diet
CONC EPT
Seven Subsystems
Attachment and
Affiliative
Dependency
Ingestive
Eliminative
Sexual Achievement
Aggressive
3) VIRGI NIA H EN DERS ON:
FOU RT EEN F UNDAMENTA L NEE DS
Fourteen (14)
Fundamental Needs
focusing on
PHYSIOLOGIC SOCIAL
RECREATION
3) VIRGI NIA H EN DERS ON:
FOU RT EEN F UNDAMENTA L NEE DS
1) Breathing normally
2) Eating and drinking
adequately
3) Eliminating body waste
4) Moving and
maintaining a desirable
position
5) Sleeping and resting
6) Selecting suitable
clothes
7) Maintaining body
temperature within
normal range by adjusting
clothing and modifying
the environment
3) VIRGINIA HENDERSON:
FOURTEEN FUNDAMENTAL NEEDS
9) Avoiding dangers in
the environment and
avoiding injuring others.
11) Worshipping
according to one’s faith
3) VIRGI NIA H EN DERS ON:
FOU RT EEN F UNDAMENTA L NEE DS
12) Working in a such
way that one feels a
sense of accomplishment
13) Playing or
participating in various
forms of recreation
Health perception
Nutritional / Metabolic
Elimination
Activity and Exercise
Pattern
Cognitive Perceptual
Pattern
5) M ARJORIE GORDON :
HUMAN F UNC TI ONA L H EALTH
PATT ERNS
Eleven Functional Health
Patterns
Sleep and Rest
Self perception / Self
concept
Role Relationship
Pattern
Sexuality /
Reproductive
Coping-Stress-
Tolerance
Value Belief Patterns
6) IM OG ENE KING :
GOA L A TT AINM EN T TH EO RY
Individuals / Personal
systems
Group systems /
Interpersonal systems
fraternity
Social systems
7) MADELEINE LEH NING ER:
TRA NS CULTURA L NU RSING
THEORY
Nursing is a
HUMANISTIC and
SCIENTIFIC mode of
helping through
CULTURE-SPECIFIC
PROCESS
8) MYRA LEVINE:
FOUR CONSERVATION
PRINCIPLES OF NURSING
1. Conservation of
Energy
Example: complete bed
rest without bathroom
privileges
2. Conservation of
Structural Integrity
Example: turn patient
from side to side every
two hours to avoid bed
sores
8) MYRA LEVINE:
FOUR CONSERVATION
PRINCIPLES OF NURSING
3. Conservation of
Personal Integrity
Example: maintain
patient’s privacy
4. Conservation of Social
Integrity
Example: maintenance
of patient’s
relationships
9) BETTY NE UMAN:
HEALTH CARE SYST EM S M OD EL
2. Wholly Compensatory
or Total Compensatory
For paralyzed patients,
for ICU patients
3. Supportive-Educative
For up and about
patient
11) H IL DEGA ARD P EP LAU:
INT ERP ERS ONA L MODEL
1. Orientation
Nurse and patient
test the role each
one assumes
Prepares patient
for termination
Patient identifies
areas of difficulty
11) H IL DEGA ARD P EP LAU:
INT ERP ERS ONA L MODEL
2. Identification Phase
Patient identifies
with the personnel
who can satisfy his
needs
3. Exploitation Phase
Nurse maximizes
all the resources to
benefit the patient
11) H IL DEGA ARD P EP LAU:
INT ERP ERS ONA L MODEL
4. Resolution Phase or
Termination Phase
Occurs when
patient’s needs
have been met
CONC EPT S!
Pre-Interaction Phase
In psychiatric setting, this consists of gathering data
Pre-Entry Phase
In community health nursing, this consists of a
courtesy call
12) MART HA ROG ERS:
SCIENC E OF UNIT ARY HUMAN
BEINGS
Man is composed of
energy fields, which are
in constant interaction
with the environment
CON CEP T!
Man is a
BIOPSYCHOSOCIAL
BEING
Four (4) modes of
Adaptation
Physiologic Mode
Compatible with
Hans Selye
Self Consent
Role Function
Interdependence
14) LYDIA HALL:
CARE, CORE, CURE
Care
Comfort measures given by the nurse to a
patient
Nurturance aspect of Nursing
Core
Therapeutic use of self
Cure
Activities in relation to doctors’ orders
Dependent orders
15) JEA N WATSON :
HUMAN CARING MODEL
Emphasis is to encourage
and engage the patient
and the family to actively
participate in learning
about health
28 ) KATH RYN B ARNARD :
PA RENT -CHIL D IN TE RA CTIO N
MOD EL
In order to produce a
healthy person, the
baby’s need should be
ADDRESSED AT ONCE!
Application: Bonding
29) A LFRE D ADLER:
THEORY OF PE RSON ALIT Y
Primary Prevention
Secondary Prevention
Tertiary Prevention
PRIM ARY PREV ENT ION
Emphasis on:
Generalized health promotion and specific protection
Recipients are GENERALLY HEALTHY PEOPLE
When given:
Before onset of illness or before onset of disease
PRIM ARY PREV ENT ION
Examples:
Generalized health education
Prevention of accidents
Standards of nutrition
Immunizations
Specific preventions
Risk Assessment for specific disease
Family Planning Services and Marriage Counseling
Environmental Sanitation
Recreation and Housing
SE COND ARY PRE VEN TION
When given:
During illness
SE COND ARY PRE VEN TION
Examples:
Screening survey
Encouraging regular check-ups
Complying with regular check-ups
Teaching Breast-self-examination
Teaching Testicular-self-examination
CON CEP T!
When given:
Begins after the illness or when a defect or disability is
fixed or irreversible
TERT IA RY PREV ENT ION
Examples:
Referring a client to support groups
Teaching a diabetic client how to inject insulin
ROLES OF A NURSE
ROLES OF A NU RSE
Activities:
Support and comfort measures (mothering aspect of
nursing / nurturance aspect of nursing)
ROLES OF A NU RSE
2. Counselor
Focuses on:
Helping client establish capacity for successful
interpersonal relations
Helping the patient develop new coping skills
CON CEP T!
3. Client Advocate
Activity:
Speaking on behalf of the patient
ROLES OF A NU RSE
4. Change Agent
5. Teacher
Teaching
Imparting of knowledge
ROLES OF A NU RSE
6. Leader
7. Manager
Decision-making
Planning
Giving directions
Monitoring operations
Facilitating staff development
Therefore, this is done on the supervisory level of
organization
ROLES OF A NU RSE
8. Researcher
Basic Guidelines
Basic Guidelines
Knowledge – cognitive
Skills – motor
Attitude – emotional
TEA CHING ST RA TE GIE S
2. One-to-one Discussion
3. Answering Questions
Cognitive
TEA CHING ST RA TE GIE S
4. Demonstration
Motor
TEA CHING ST RA TE GIE S
5. Discovery
6. Group Discussion
7. Practice
Motor
TEA CHING ST RA TE GIE S
9. Role-playing
10. Modeling
Online review
NURSING PROCESS
TH E NU RSING PROC ES S
Definition:
To establish plans
Concepts:
Both the nurse and the patient benefit from the nursing
process
Remember:
Nursing process is CLIENT-CENTERED or
PATIENT-CENTERED and NOT NURSE-
CENTERED
BENEFITS DERIVED FROM
THE NURSING PROCESS
Assessment Phase
Diagnosing Phase
Planning Phase
Intervention Phase
Evaluation Phase
ASSESSMENT PHASE
OF THE
NURSING PROCESS
ASSESSMENT PHASE OF
THE NURSING PROCESS
Data Collection
Data Organization
Data Validation
Data Recording
IMPORTANT CONCEPT!
Initial Assessment
Emergency Assessment
Time-Lapsed Assessment
FOUR TYPES OF ASSESSMENT
1. Initial Assessment
When performed:
At specified time after admission
Where done:
Done at the ward
Where Admitted:
At the ward
Purpose of Initial Assessment:
To create a data base for problem identification
For reference and future comparison
FOUR TYPES OF ASSESSMENT
When performed:
Integrated throughout the nursing process
3. Emergency Assessment
When done:
During acute physiologic and psychologic crisis
Where done:
Emergency Room
Comfort Room
Anywhere!!!
On site!!!
Purpose of Emergency Assessment
To identify life-threatening condition
FOUR TYPES OF ASSESSMENT
3. Emergency Assessment
4. Time-Lapsed Assessment
When done:
Several months after initial assessment
Concept:
1. Primary Source
2. Secondary Source
Patient’s record
Health care members
Related literature or journals
Significant others (they become primary source when
patient is unconscious)
Family or relatives
The person who brought the patient to the hospital
SOURCES OF DATA
Example:
Patient with diabetes mellitus exhibits acetone
breath
• Assess for diabetic ketoacidosis
METHODS OF DATA COLLECTION
Observing
Interviewing
Examining
METHODS OF DATA COLLECTION: OBSERVING
It should be deliberate
Exert effort!!!
METHODS OF DATA COLLECTION: OBSERVING
Structured
When used:
When you need to elicit specific data
When there is little time available
CONCEPT!
Yes or No questions
Open-Ended Questions
Closed-Ended Questions
Neutral Questions
TYPES OF INTERVIEW QUESTIONS
1. Open-Ended Questions
2. Closed-Ended Questions
Leading Questions
3. Neutral Questions
Concepts:
Concepts:
When is it done?
When patient is available
When patient is comfortable
1. Opening Stage
Key Concept!!!
This is the most important part of the interview
Rationale
What was said and done during the opening stage
sets the tone all throughout the interview
THE INTERVIEW
3. Closing Stage
To ensure the:
Correctness
Completeness
Accuracy of the data
GUIDELINES IN VALIDATION OF DATA
Compare subjective and objective data
Concepts:
Concept:
Key Concept!
1. Problem Statement
Example:
Fluid Volume Deficit
2. Presumed Etiology
Example:
…related to frequent loss of bowel movement
3. Defining Characteristics
Example:
…as manifested by decreased skin turgor
ADVANTAGES OF USING A STANDARDIZED
DIAGNOSTIC TERMINOLOGY
Concept:
Planning means:
Determining ahead of time
Forecasting a course of action
PLANNING PHASE OF
THE NURSING PROCESS
Key Concept!!!
IMPORTANT CONCEPT!!!
1. Initial Planning
When done:
At specified time upon or after admission of the
patient
TYPES OF PLANNING
2. On-going Planning
2. On-going Planning
Purposes of On-going Planning
To determine if the client’s health status has
changed
To decide which problems to focus on during the
shift
To set priorities for client care during the shift
To coordinate the patient care and activities so
that more than one problem can be addressed at
the same time
TYPES OF PLANNING
3. Discharge Planning
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time bound
ACTIVITIES DURING
THE PLANNING PROCESS
Set priorities
Set goals
To set direction
Implementation
Purpose of Implementation
Concept!!!
Adequate knowledge
Technical Skills
Communication skills
Therapeutic use of self
Right attitude as a requirement
NURSING ACTIVITIES DURING THE
IMPLEMENTATION PHASE
Understand orders
Clarify / verify doctors’ orders
It should be holistic
1. On-going Evaluation
When done:
During or immediately after the intervention
Importance:
Allows the nurse to decide and make on-the-spot
modification/s in an intervention
TYPES OF EVALUATION
2. Intermittent Evaluation
When done:
At a specified time
Purpose:
It shows the extent of progress of the patient
Importance:
Enables the nurse to correct deficiencies and modify
the nursing care plan
TYPES OF EVALUATION
3. Terminal Evaluation
When done:
At or immediately before discharge
Importance:
States the status of a health problem at the time of
discharge
It determines whether the goals are:
• Met
• Partially met
• Unmet
DOCUMENTATION
DOCUMENTATION
Planning Care
Communication
For legal documentation purposes
For research
For education
Reimbursements
For statistics, reporting, epidemiology
Accreditation, licensing
GUIDELINES ON DOCUMENTATION
Timing
Document patient care as soon as possible
Observe confidentiality
Observe permanence
Use non-erasable ink
Do not use sign pen
GUIDELINES ON DOCUMENTATION
Signature
Sign full name and append R.N.
Accuracy
Ensure that data is correct
Avoid biases
Avoid ambiguous terms
Appropriateness
Write only appropriate information
GUIDELINES ON DOCUMENTATION
Completeness
Brevity
Make it concise yet meaningful
Legal Awareness
Cross out erroneous entry
Write “Error”
Countersign
TYPES OF RECORDS
Face Sheet
Therapeutic Sheet
PROBLEM-ORIENTED
CLINICAL RECORD
1. Baseline Data
2. Problem List
4. Progress Notes
Includes:
Nurses’ narrative notes (SOAPIE)
Flow sheets
Discharge Notes and Referral Summaries
Formats:
SOAPIE – for revisions
COMMON METHODS OF COMMUNICATION AMONG
NURSES
1. Referring
2. Confer
Verifying information
COMMON METHODS OF COMMUNICATION AMONG
NURSES
3. Reporting
It is a reminder
It is not a record
IMPORTANT CONCEPT
1. Message
Data
2. Sender
Encoder
3. Receiver
Decoder
4. Feedback
5. Context
Setting
Overall environment where the communication takes
place
MODES OF COMMUNICATION
1. Verbal
Oral
Spoken
Written communication
Text communication
Cable communication
Telex communication
Facsimile communication
MODES OF COMMUNICATION
2. Non-verbal communication
Facial expression
Grimacing
Posture
Gait
Adornment
Make-up
Gestures
FACTORS AFFECTING COMMUNICATION
Territoriality
One person believes that the space and all the things in
that space belongs to him
Do not enter abruptly; this may result in breach of
privacy
Using Silence
Supplement with non-verbal communication
Open-ended questions
THERAPEUTIC COMMUNICATION
IN NURSING
Use Touch
But assess the culture of the patient
If the patient is a child, touch the patient on the top of
the head
If the patient is an elderly, touch the patient on the hand
If the patient is of the same age level, touch the patient
on the shoulder
Offering yourself
For autistic child
Stay nearby or stay beside the patient
THERAPEUTIC COMMUNICATION
IN NURSING
Presenting Reality
Example:
“You are in the hospital”
Reflecting
Example:
“What do you think will make you happy”
Never agree nor disagree
Reflect it back or throw it back
NON-THERAPEUTIC COMMUNICATION
A biological rhythm
A biological clock
Characterized by:
Vivid dreams
Easily recalled upon awakening
TYPES OF SLEEP: REM SLEEP
Irritability
Restlessness
Poor concentration
TYPES OF SLEEP
Physical exhaustion
Avoid shabu
Do something HOT!
Cholecystectomy
Incision site on diaphragm
Patient does not want to breathe
Predisposed to hypostatic pneumonia
BASAL DEEP BREATHING
Same procedure
Rationale:
If pain is already present, it would be difficult for patient
to follow
BASAL DEEP BREATHING
When done:
Purpose
To expand the lungs
To facilitate expectoration of secretions
Procedure
Purpose
To avoid drying and
irritation of the mucosal
lining
Also traps particulates
from the tank
Iron oxide may be
present in the tank
(iron plus oxygen
produces iron oxide or
rust)
CONCEPTS!
Fire Precaution
Place ‘NO SMOKING’ sign at the door or at the head
part of the patient
A physiologic solution
Water liquefies secretions
Sodium chloride stimulates coughing
Salbutamol is a bronchodilator
Purpose:
For expectoration of secretions
NURSING PRE-THERAPY ASSESSMENT PRIOR TO
NEBULIZATION
Percussion
Vibration
Postural Drainage
THREE COMPONENTS OF
CHEST PHYSIOTHERAPY
1. Percussion
2. Vibration
3) Postural Drainage
Drain secretions by gravity
Change positions
POSTURAL DRAINAGE POSITIONS
IMPORTANT CONCEPT!
When done:
Before meals
Two (2) hours after meals
Question:
If you have only one (1) suction catheter, which will you
suction first, the nose or the mouth?
Answer:
If the patient is an infant or a newborn:
Start on the mouth then proceed to the nose
Rationale:
If you start on the nose, you will trigger the sneezing
reflex and this would result into aspiration
CONCEPTS ON SUCTIONING
Question:
If you have only one (1) suction catheter, which will you
suction first, the nose or the mouth?
Answer:
If the patient is an adult, suction the mouth first, then
proceed to the nose
Rationale:
This is done for aesthetic reasons
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
OROPHARYN WHILE PASS OF
-GEAL SUCTIONING SUCTION
SUCTIONING
If the patient is Fowler’s (high or 10 – 15 cm Not more than 20 – 30 Not more than
conscious moderate); 10 – 15 seconds 5 minutes
Head turned to seconds
one side (towards
the nurse)
If the patient is Place on one side 10 – 15 cm Not more than 20 – 30 Not more than
unconscious (facing the nurse); 10 – 15 seconds 5 minutes
Tilt neck to move seconds
head slightly
forward towards
the basin to avoid
aspiration during
suctioning
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
NASOPHA- WHILE PASS OF
SUCTIONING SUCTION
RYNGEAL
SUCTIONING
If the patient is Neck should be From tip of Not more than 20 – 30 Not more than
conscious hyperextended; the nose to 10 – 15 seconds 5 minutes
Fowler’s position tip of the seconds
earlobe
If the patient is Flat on bed with From tip of Not more than 20 – 30 Not more than
unconscious head turned to the the nose to 10 – 15 seconds 5 minutes
nurse tip of the seconds
Lateral position earlobe
may be assumed
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
OROTRA- WHILE PASS OF
SUCTIONING SUCTION
CHEAL
SUCTIONING
If the patient is Low to semi- Measure Not more than 20 – 30 Not more than
conscious fowler’s position from 10 seconds seconds 5 minutes
mouth to
mid-
sternum
If the patient is Flat on bed; Measure Not more than 20 – 30 Not more than
unconscious Suction trachea from 10 seconds seconds 5 minutes
through the mouth mouth to
mid-
sternum
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
NASOTRA- WHILE PASS OF
SUCTIONING SUCTION
CHEAL
SUCTIONING
If the patient is Low to semi- From tip of Not more than 20 – 30 Not more than
conscious fowler’s position the nose to 10 seconds seconds 5 minutes
earlobe to
dominating
side of
neck to the
thyroid
cartilage
If the patient is Flat on bed; From tip of Not more than 20 – 30 Not more than
unconscious Suction trachea the nose to 10 – 15 seconds 5 minutes
through the nose earlobe to seconds
dominating
side of
neck to the
thyroid
cartilage
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
WHILE PASS OF
SUCTIONING SUCTION
ENDOTRA- Semi-Fowler’s if 12.5 cms. 5 – 10 2 – 3 minutes Not more than
CHEAL TUBE not or 6 seconds 5 minutes
SUCTIONING contraindicated inches;
Insert as
far as it
goes until
you meet
resistance
or until
patient
coughs
TRACHEOS- Semi-Fowler’s if Insert as 5 – 10 2 – 3 minutes Not more than
TOMY TUBE not far as it seconds 5 minutes
SUCTIONING contraindicated gets until
you meet
resistance
or until the
patient
coughs
IMPORTANT CONCEPTS ON SUCTIONING!!!
Nursing Alert!
During insertion, if you encounter resistance,
withdraw the catheter about one centimeter (1 cm)
before applying suction
Rationale:
To avoid trauma on the mucous membrane
GENERAL CONDITIONS FOR SUCTIONING
Do suctioning intermittently
Nursing Alert!
If the patient has thick, tenacious secretions, DO NOT
USE AN AMBUBAG
Use an OXYGEN INSUFFLATION SUCTION
CATHETER instead!!!
This is a two-lumen catheter (one lumen brings oxygen
to the patient, the other lumen brings out secretions
from the patient)
HOW TO HYPEROXYGENATE THE PATIENT
Oral Temperature
Axillary Temperature
Rectal Temperature
ORAL TEMPERATURE
Most convenient
Most accessible
Nursing Alert!
Procedure
Nothing Per Orem for about thirty (30) minutes before
taking temperature
No food intake
No drinks
No smoking
No chewing gum
No whistling
No gargling
Rationale
Any of the above would alter the results
ORAL TEMPERATURE
Placement:
Under the tongue, beside the frenulum (right or left)
Total Time:
Two (2) to three (3) minutes
AXILLARY TEMPERATURE
Least reliable
Safest method
Nursing Alert!
Nursing Alert!
Do not RUB!
Rationale
This increases heat due to friction
Rubbing increases blood supply to the area
Therefore, there will be increase in temperature
reading
Rubbing provides a false-positive elevation of
temperature reading
AXILLARY TEMPERATURE
Duration:
Concept!
If tympanic method is used using a tympanic
thermometer, the rectal method is only second most
reliable and second most accurate
RECTAL TEMPERATURE
Disadvantage:
Placement on a different site yields a different reading
Therefore, ensure that the bulb of the rectal
thermometer rests on the mucous membrane.
Contraindications:
Hemorrhoids
Rectal Surgery
Certain Cardiac ailments due to stimulation of the vagus
nerve; valsalva maneuver leads to arrhythmias
RECTAL TEMPERATURE
Duration:
Two (2) minutes
TEMPERATURE SCALES
Centigrade = (5/9)F – 32
Centigrade = (F/1.8) – 32
TEMPERATURE SCALES
Fahrenheit = (9/5)C + 32
Fahrenheit = (1.8)C + 32
CONCEPTS ON HUMAN BODY TEMPERATURE
Key Concept!!!
Patient complains of feeling cold
Sweating will stop because body will minimizes heat
loss
Also called:
Onset Stage
Chill Stage
Cold Stage
This stage is characterized by low febrile temperatures
FIRST STAGE OF FEVER
Nursing Management:
Question:
When will you start application of TSB?
Answer:
If there is a 1°C to 2°C increase in body temperature
SECOND STAGE OF FEVER
Also called:
Coarse Stage of Fever
Peak Stage of Fever
Key Concepts!
Patient does not feel hot or cold
Skin is warm to touch
Skin is flushed
Fever blisters are present
Herpetic lesions
Absence of shivering
Possible dehydration
SECOND STAGE OF FEVER
Important Concept!!!
For every increase of temperature, there is a
corresponding increase in pulse rate
Rationale:
Increase in temperature results in an increase in pulse
rate due to increased metabolic rate
Increased metabolic rate increases oxygen demand
Due to increased oxygen demand of susceptible brain
cells, CONVULSIVE SEIZURES may occur. These may
also be due to irritation of nerve cells – FEBRILE
CONVULSIONS
SECOND STAGE OF FEVER
Nursing Management
Tepid Sponge Bath
Cooling Bed Bath
TEPID SPONGE BATH
How to apply:
Done by patting
Rationale:
To avoid friction, which increases temperature
TEPID SPONGE BATH
Important Concept!
Do NOT use ALCOHOL when applying TSB
Rationale:
Alcohol dries the skin and leads to irritation
Key Concept!
TSB should not be done hurriedly
Rationale:
When done hurriedly, TSB will stimulate shivering
Shivering would lead to increased muscle activity
Increased muscle activity would lead to increased
temperature
COOLING BED BATH
1. Intermittent Fever
2. Remittent Fever
3. Relapsing Fever
4. Constant Fever
Concepts!
1+ - Weak or thready
2+ - Normal
3+ - Bounding
BLOOD PRESSURE
BLOOD PRESSURE
Systolic
Produced by ventricular contraction
Pressure on blood vessels during depolarization or
ventricular contraction
Diastolic
Pressure that remains in the walls of the blood vessels
during relaxation or repolarization or resting
BLOOD PRESSURE
Direct
By insertion of a catheter
Indirect Method
Auscultatory method
Palpatory method
Flush Method
AUSCULTATORY METHOD
A popping sound
NOT the heart beat
It is a phenomenon – an unknown phenomenon!
AUSCULTATORY METHOD
Concepts!!!
Take systolic on loudest sound if patient is an adult
If patient is pediatric or up to ten (10) years old, take the
first sound, whether it is faint or loud
If, for example, first sound is at 190 mmHg and there is
silence up to 140 mmHg and then there is a sound at
130 mmHg down to 80 mmHg then…
Use the PALPATORY METHOD in combination with
the AUSCULTATORY METHOD because there is an
auscultatory gap
Repeat using:
Auscultatory method
Palpatory method
HOW TO DO THE PALPATORY METHOD
Inflate
Determine up to what point to inflate
Palpate pulse
If pulse is absent, add 30 – 40 mmHg
Deflate
First palpable pulse is true systolic pressure
When done:
How done:
Normal is 30 – 40 mmHg
HYPERTENSION
Ventilation
The movement of gases in and out of the lungs
Involves inhalation or inspiration and exhalation or
expiration
Diffusion
The exchange of gases from an area of higher
pressure to an area of lower pressure
It occurs at the alveolo-capillary membrane
Perfusion
The availability and movement of blood for transport
of gases, nutrients, and metabolic waste products
ASSESSING RESPIRATIONS
Rate
Normal is 12 – 20 cycles per minute in an adult
Depth
Observe the movement of the chest.
May be normal, deep, or shallow
ASSESSING RESPIRATIONS
Rhythm
Observe for regularity of exhalations and inhalations
Quality or Characteristic
Refers to respiratory effort and sound of breathing
MAJOR FACTORS AFFECTING THE
RESPIRATORY RATE
Exercise
Increases respiratory rate
Stress
Increases respiratory rate
Environment
Increased temperature of the environment decreases
RR; Decreased temperature, increases RR
Increased altitude
Increases RR
Medications
(e.g., narcotics decrease RR)
SKIN INTEGRITY
DECUBITUS ULCERS
Localized ischemia
Shearing force
Predisposing Factors:
Unconsciousness
Incontinence
Loss of Sensation
Hypoproteinemia
Decreased lean muscle mass
Increase in fluid shifting leads to edema
Dependent position is the skin attached to or facing
the bed
Emaciation
STAGES OF DECUBITUS ULCER FORMATION
Stage 1
Involves the epidermis
Manifestation
Non-blanchable erythema of INTACT SKIN
This is the first heralding sign of decubitus ulceration
STAGES OF DECUBITUS ULCER FORMATION
Stage 2
Partial Thickness Skin Loss
Involves epidermis and dermis
Manifestation
Blister formation
Shallow craters
Shallow abrasion and ulceration
STAGES OF DECUBITUS ULCER FORMATION
Stage 3
Full Thickness Skin Loss Ulceration
There is skin loss already
Involves necrosis of the skin and subcutaneous tissues
EXTENDING TO but NOT THROUGH the underlying fascia
STAGES OF DECUBITUS ULCER FORMATION
Stage 4
Formations and manifestations of Stage 3 plus…
Involvement of bones, supporting structures (tendons),
joint capsules
Massive damage
TOOLS TO ASSESS RISK OF ULCERATION
Nursing Alert!
If edema is due to Congestive Heart Failure (Right
Sided), NEVER ELEVATE THE LOWER
EXTREMITIES
Rationale:
This increases the workload of the right side of the
heart
Concept!
If edema is due to prolonged standing, DO THE
ELEVATION
MANAGEMENT OF EDEMA
Rationale:
Vasoconstriction and vasodilation causes re-
circulation of fluid
Concept!
This is contraindicated if there is inflammation
ASSESSMENT OF EDEMA
Induration
1+ - 1 cm induration
2+ - 2 cm induration
3+ - 3 cm induration
4+ - 4 cm induration
5+ - 5 cm induration
PAIN MANAGEMENT
PAIN
1) Cutaneous
Skin
2) Deep Somatic
Tendons, ligaments
Bones
Blood Vessels
3) Visceral Pain
Organs of the body
CATEGORIES OF PAIN BASED ON CAUSE
1) Acute
Due to trauma or surgery
Persists for less than six (6) months
1) Radiating Pain
Felt on the source and is extending to nearby tissues
2) Referred Pain
Felt on other parts detached from the source
Example:
Pain on a lacerated liver may be felt on the right
shoulder and not on the right upper quadrant
CATEGORIES OF PAIN ACCORDING TO WHERE IT
IS EXPERIENCED
3) Intractable Pain
Highly resistant to pain-relief methods
4) Phantom Pain
Pain that is felt on a MISSING BODY PART or a PART
THAT IS PARALYZED by SPINAL CORD INJURY.
PAIN THRESHOLD
1) Pharmacologic Methods
Narcotics
NSAIDs
Adjuvants or Co-analgesics
2) Non-Pharmacologic Methods
Physical Interventions
Cognitive / Behavioral Interventions
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN
1) Cutaneous
Stimulation
1A) Massage
Effleurage
Soft massage
Gentle stroking
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN
1) Cutaneous
Stimulation
1B) Petrissage
Hard massage
Large and quick
pinches
Also done by
striking
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS
TO PAIN
1) Cutaneous Stimulation
1) Cutaneous Stimulation
1) Cutaneous Stimulation
1F) Accupressure
Pressure on
certain points of the
body
Stimulates release
of endorphins,
which have natural
analgesic effects
This started in
Ancient China
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN
1) Cutaneous
Stimulation
1F) Accupuncture
Insertion of long
slender needles on
certain chemical
pathways
Origin is also
Ancient china
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS
TO PAIN
1) Cutaneous Stimulation
2) Immobilization
Application of splints
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN
3) Transcutaneous
Electrical Nerve
Stimulation
Composed of
electrodes
Operated by battery
Electrodes are applied
on painful site or over
the spinal cord
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS
TO PAIN
4) Administration of a Placebo
Relieves pain because of its intent and not because of
physical or chemical properties
COGNITIVE AND BEHAVIORAL
NON-PHARMACOLOGIC INTERVENTIONS TO PAIN
Purpose:
1) Distraction
Purpose is to divert attention from pain
Slow Rhythmic Breathing
Stare at a certain object
Take deep breath slowly
Release or exhale slowly
Concentrate on breathing
Picture a peaceful scene
Establish a rhythmic pattern
COGNITIVE AND BEHAVIORAL
NON-PHARMACOLOGIC INTERVENTIONS TO PAIN
4) Guided Imagery
Imagine that you are
walking along a
peaceful shore
Eyes are closed and
suggestions are given
COGNITIVE AND BEHAVIORAL
NON-PHARMACOLOGIC INTERVENTIONS TO PAIN
5) Hypnosis
The success of
hypnosis depends on
the ability of the
patient to concentrate
and the capacity of the
hypnotist to suggest
Based on suggestion
Progressive relaxation
URINARY ELIMINATION
URINARY ELIMINATION
Oliguria
Renal output of less than 500 ml per day
Anuria
Renal output of less than 100 ml per day
Retention
Positive for distended bladder
May also occur in the absence of bladder distention
ALTERED URINARY ELIMINATION
Enuresis
Common among pediatric patients
Age 4 – 5 years old child has adequate bladder control
Primary Enuresis
Never had a dry period
Secondary Enuresis
Acquired enuresis
At age 7, bladder control is present for at least one
year
Then, enuresis comes back
Urinating could NOT be controlled again
ALTERED URINARY ELIMINATION
Incontinence
Involuntary passage of urine
TYPES OF INCONTINENCE
1) Functional Incontinence
Involuntary passage
Unpredictable time
TYPES OF INCONTINENCE
2) Reflex Incontinence
3) Stress Incontinence
4) Total Incontinence
5) Urge Incontinence
1) Kegel’s Exercises
Also called:
Pubococcygeal Muscle Exercises
Pelvic Floor Muscle Exercises
Applicable for:
Functional Incontinence
Stress Incontinence
How done:
Advise patient to stand with legs slightly apart
Concentrate on perineum
Draw perineum upward slowly
MANAGEMENT OF INCONTINENCE
1) Kegel’s Exercises
Alternative way:
When urinating, try to stop in the middle of flow or try
to stop diarrhea from flowing
2) Clean Intermittent
Self Catheterization
How done:
Use a mirror for:
• Obese male
patients
• Female patients
MANAGEMENT OF INCONTINENCE
3) Crede’s Maneuver
Nursing Alert!
Do not use if there is OBSTRUCTION (i.e. renal
obstruction in the form of renal stones)
This is done only for patients who are no longer
expected to regain control (Reflex incontinence and
retention)
MANAGEMENT OF INCONTINENCE
6) Catheterization
MIDSTREAM CLEAN CATCH URINE SPECIMEN
If patient is a Female…
Let patient wash genitals
Dry the genitals
Get to bed
Place patient in semi-Fowler’s position when she is
ready to void
Clean and spread labia with two fingers
Remain holding labia
Then let patient urinate
Let go of first flow
Collect next flow
CATHETERIZATION
TYPES OF URINARY CATHETERS
1) Coude Catheter
2) Robinson Catheter
Straight catheter
TYPES OF URINARY CATHETERS
Multi-Lumen Retention
Catheter
Foley catheter
One lumen is for
inflation
One lumen is for
drainage of urine
One lumen is for
irrigation
A three-way catheter
Aspirate using syringe
and needle
This is made with a
self-sealing rubber
CONCEPTS IN MALE CATHETERIZATION
Rationale:
To avoid scrotal excoriation
Tape on the inner thigh (with penis sideways either on
left or right and follow the normal contour of the penis
CONCEPTS IN MALE CATHETERIZATION
Length of Catheter
40 centimeters
Depth of Insertion
While inserting, the point at which urine starts to flow,
insert further by five (5) centimeters and then inflate the
balloon – KOZIER
Insert up to a the Y-point, retract after inflating (this
method is more prone to infection
CONCEPTS IN FEMALE CATHETERIZATION
Area of Insertion
Insert at female Urethra
Length of Catheter
22 centimeters
Depth of Insertion
Point at which urine starts to flow, insert further by five
(5) centimeter before inflating balloon
GIT – FECAL ELIMINATION
WELLNESS TEACHINGS
Regular exercise
Eat papaya
1) Guiac Test
To determine the presence of occult blood
Concepts!!!
Have a meat-less diet three (3) days before
examination
Withhold oral iron supplements
Injectable iron is allowed
Avoid any food that discolors the stool.
SPECIAL GASTRO-INTESTINAL LABORATORY
PROCEDURES
2) GI SERIES
2A) Upper GI Series – Barium Swallow
Nursing Considerations:
• Elimination of contrast medium
How:
• Increase fluid intake
• Increase fiber in the diet
Rationale:
• To offset the risk of constipation
Inform patient that the color of the stool will be
WHITE
SPECIAL GASTRO-INTESTINAL LABORATORY
PROCEDURES
2) GI SERIES
1) Cleansing Enema
Soap suds enema
Alkaline solution
Nursing Alert!
Contraindicated in patients with liver cirrhosis and
with increased ammonia in the blood
Rationale:
Alkaline solution facilitates transfer of ammonia from
the GI tract to the bloodstream
Therefore, use lemon juice or dilute vinegar
instead!!!
DIFFERENT TYPES OF ENEMA
1) Cleansing Enema
Nursing Alert!
Also
contraindicated in
possible
appendicitis or
appendicitis
patients
Rationale:
Can lead to rupture
of the appendix
DIFFERENT TYPES OF ENEMA
2) Carminative Enema