Compilation of Funda Notes

FUNDAMENTALS OF NURSING
HISTORY OF NURSING
PERIODS OF NURSING
INTUITIVE NURSING/ PRIMITIVE NURSING/ INSTINCTIVE NURSING
(Primitive times – 6th century)
PRIMITIVE TIMES
- Women practice nursing because of low status in society.
- Took care of children and sick members of the family.
- Personalistic cause of disease.
- Sickness is due to active intervention of:
a. human – caused by witchcraft.
b. non human – caused by ghosts.
c. superhuman beings – caused by deities.
- Superstitious and believes in magic.
- Slave society “slave nurses”
- Wet nursing, take care of babies/children of their masters
- Women also practices midwifery.
- Masters/healers are the people who are responsible in decision making when
it comes to health.
6th CENTURY
- Founding of religious orders.
3 Attributes of Nurses
1. Self denial
2. Devotion to hard work and duty.
3. With spiritual calling.
Main Guiding Principles
1. “Love thy neighbor as thy self”.
Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010
2. Parable of the Good Samaritan.
- Beneficence (doing good to others).
2 Types of Beneficence
1. Ordinary – doing good to others.
2. Ideal – entails sacrifice.
APPRENTICE NURSING PERIOD (6th Century – 18th Century)

6TH CENTURY
- founding of religious orders.
- women practiced nursing.
- Daughters of Charity/Sisters of Charity founded by St. Vincent de Paul and
Augustinian Sisters.
CRUSADES
- Men practiced nursing.
- Knights of St. Lazarus
a. established a standard among hospitals in Europe.
b. took care of clients with skin problems like leprosy.
- Knights of St. John of Jerusalem
a. also known as Knights Hospitalers.
b. founded hospitals.
18TH CENTURY
1836
- Theodore Fleidner reestablished order of Deaconesses.
- Founded school of nursing in Kaisserwerth, Germany where Florence
Nightingale was the most known student.
1854-1856 (CRIMEAN WAR)
- Florence Nightingale was known as the Lady with a Lamp.

- Compiled the “Notes on Nursing: What it is and What is not” and became the
first nurse theorist.
EDUCATIONAL NURSING PERIOD (18th Century – 20th Century)

18TH CENTURY
- Florence Nightingale established a nursing school in St. Thomas Hospital in
London which adopted the Nightingale System.
- Made Florence Nightingale the mother of modern nursing.
Philosophy of Nightingale System
1. Government funds should be allotted to nursing education.
- earned her the title of being the first nurse political activist.
2. Training schools of nursing should be in close affiliation.
3. Professional nurses should train nurses.
4. Nursing students should be provided with residence near their training
hospitals.
- written orders of doctors insisted.
- nurses should go with doctors during rounds.
LATE 20TH CENTURY
- Specialization in medicine.
- Conceptualization of the role of clinical nurse specialist.
- Increase clinical content of education (1900’s).
CONTEMPORARY PERIOD (21st Century)

- Globalization of nursing.
- Period after world war II.
- Borderless nursing or transcultural nursing.
- Professionalization of nursing.
PROFESSION – a special calling that requires special, skills, knowledge and

attitudes.
7 CRITICAL ATTRIBUTES OF PROFESSION
1. Specialized education
2. Code of ethics
3. Research of orientation
4. Autonomy
5. Body of knowledge
6. Service orientation
7. Professional Organization
SOCIALIZATION – process where a person learns the ways and means or

skills, knowledge, attitudes of the group to which he belongs to.
BENNER LEVEL OF PROFICIENCY
1. Novice – student nurse entering a clinical setting where he has no
experience at all.
2. Advance – nurse who demonstrates a marginally acceptable performance:
depends on rules and maxims.
3. Competent – 2 – 3 years experience demonstrates organizational ability but
lacks speed and flexibility of a proficient nurse.
4. Proficient – concerned with long term goals, performance is fluid and
flexible compared to competent nurse
- has a wholistic view of the client.
5. Expert – no longer relies on maxims, performance is highly proficient, fluid
flexible and has a wholistic view.
- has high perceptual acuity or a clinical eye.
DIMENSIONS OF NURSING
1. Nursing Practice
2. Nursing Education
3. Nursing Research
FOCUS OF NURSING
1. Health Promotion – improve clients well being.
2. Health Maintenance
3. Health Instauration – help clients with illness to recover.
4. Care of the Dying – clients with cancer.
ROLE – patterns of behavior expected of person assuming a status/position in

society or a group.
TASK – specific activities required of a person.
PATIENT CLIENT
- Has a disease - Not necessarily sick
- Very dependent on health - Health promotion act till
professional disease prevention
- Client collaborates with
health professional

LEVELS OF CLIENTELE
1. Individual
2. Family
3. Community
4. Population Groups – special groups with special needs attributed to the
following:
a. Cultural characteristics – indigenous people.
b. Developmental stage
c. Occupation – commercial sex workers are more prone to STD’s.
ROLES OF NURSE
1. Nurse Educator
- 3 domains of learning
a. Cognitive – knowledge aspect
b. Psychomotor – skills
c. Affective – interest/emotion
2. Caregiver
- Attends to physical/emotional (mostly physical) needs of the client.
3. Nurses as Leader
- Process of influencing people to work towards the attainment of goals.
4. Manager
- Organizational goals/works within an organization.
PROCESS OF MANAGEMENT
a. Planning (resources)
b. Organizing (delegating tasks/tasking)
c. Directing (motivating people)
d. Controlling – evaluation of output against standards.
5. Client advocate – protects rights of clients.
6. Change agent – improvement in organization.
7. Researcher – research process
8. Facilitator
THEORIES – relationship between concepts

4 CONCEPTS OF NURSING THEORIES
1. Individual/Person
2. Nursing
3. Health
4. Environment
NURSING THEORIES
A. GENERAL THEORIES
1. NIGHTINGALE’S ENVIRONMENTAL THEORY
- What nursing has to do is to put the individual in best position for nature to
work on him.
- Nursing Action: manipulation of elements in the environment to contribute to
reparative process.
10 ELEMENTS FOUND IN ENVIRONMENT
1. Air – importance to have moving air in room of patient to contribute in
proper ventilation.
2. Light – patient should be near windows to be able to see sunlight and give
hope.
3. Health of houses – environmental sanitation.
4. Cleanliness
5. Beddings – change linens/beddings in patients room to promote comfort.
6. Nutrition
7. Variety – change in environment for patient.
8. Ventilation – promote warming.
9. Noise – due to nurses clothing or roaming around.
10. Chattering hopes – deals with social aspect; nurse should be cautious
with words when at bedside,
GOALS
talk about positive things.
2. VIRGINIA HENDERSON’S DEFINITION OF NURSING
INDEPENDENCE
- Assisting individualsKNOWLEDGE
sick or well in the performance of activity.
RESTORATION
- Role of nurse is complimentary. WILL
- Supplementary MAINTENANCE
STRENGTH
- Individual person is a whole, complete and individual being.
NURSE- PERSON INTERACTION
PEACEFUL DEATH

NURSES PERSON
ENVIRONMENT
14 BASIC COMPONENTS OF NURSING CARE

1. Breathe normally
2. Eat, drink adequately
3. Eliminate body waste
4. Move and maintain desirable posture
5. Sleep and rest
6. Select suitable clothes
7. Maintain body temperature
8. Keep body clean and well groomed
9. Avoid dangers in environment
10. Communicate with others
11. Worship according to ones faith
12. Work for accomplishment
13. Participate in recreation
14. Learn to satisfy the curiosity that leads to normal development
1-9 PHYSIOLOGIC
10 – 14 PSYCHOLOGICAL
12 – 13 SOCIOLOGIC
11 SPIRITUAL/MORAL
3. MARTHA ROGER’S SCIENCE OF UNITARY HUMAN BEINGS

A. Nursing is humanistic science
B. Parallel with Ludwig von Bertalanffy’s General System Theory
C. 5 assumptions about human beings
1. Man is a unified whole – whole not equal to sum of parts.
2. Individual and environment are continuously exchanging matter and
energy.
3. Lifecycle evolves irreversibly and uni-directionally along space and
time continuum.
4. Life patterns identify individuals.
5. Humans have the capacity for absorption and imagery, language and
thought, sensation and emotion.
GENERAL SYSTEM THEORY

- A set of interacting parts/ components with a boundary that filters the input
and output from and to the environment.
- Input and output: matter, energy, information.
- Whole: physical, psychological, spiritual, intellectual.
4. DOROTHEA OREM’S SELF CARE DEFICIT THEORY

- Man is an integrated whole, biologically, symbolically and socially.
- Man is self reliant and responsible for self care.
- Man is requisite for all.
- Nursing is a service, art and technology.
3 SUB THEORIES
1. Self Care – universal self care, developmental.
2. Self Care Deficit – demands, capabilities, deficits.
3. Theory of Nursing Systems – wholly compensatory, partly supportive-
educative.
UNIVERSAL SELF CARE REQUISITES
1. Sufficient intake of air
2. Sufficient intake of water
3. Sufficient intake of food
4. Satisfactory eliminative functions
5. Activity balanced with rest
6. Time spent alone balanced with time spent with others
7. Prevention of danger
8. Being normal
DEVELOPMENT OF SELF CARE REQUISITES

- Specialized expression of universal self-care requisites for development
process.
HEATH DEVIATION
- Additional demands for health care due to illness, disease or injury.
THEORY OF NURSING SYSTEM
1. Wholly compensatory – nurse acts for patient.
2. Partly compensatory – both nurse and patient.
3. Supportive-Educative – patient able to perform self care.
B. SYSTEM THEORIES
5. SISTER CALLISTA ROY’S ADAPTATION MODEL
- Grounded on humanism.
- Person is adaptive system with coping mechanism.
- Goal of nursing is to promote persons adaptation.
STIMULI
1. Focal - immediate
2. Contextual – other internal and external factors
3. Residual – may or may not have effect like attitudes and beliefs.
COPING MECHANISMS
1. Regulator – neural – chemical – endocrine.
2. Cognator – processed through cognition.
ADAPTIVE MODES
- Physiologic – adaptive mode
- Self concept mode
- Interdependence mode
- Role function mode
- Adaptive/effective response
- Maladaptive/ineffective response

6. IMOGENE KING’S GOAL-ATTAINMENT THEORY
- Nursing is a process of human interaction between the nurse, client, each
person perceive the other and situation and explore the means to achieve
them.
- Humans are open systems in constant interaction with their environment.
- Nursing focus: human interact with the environment.
- Nursing Goal: humanistic maintenance of individuals and groups.
- Interacting components are personal, interpersonal, social.
- Elements: interaction, communication, transaction role, stress.
COMPONENTS PERSONAL SYSTEM

- Perception, self, growth and development, image, space, learning time.
- Organization, authority, power, status, decision making.
7. BETTY NEUMAN’S HEALTH CARE SYSTEMS MODEL

- Based on 2 components stress, reaction to stress.
- Client (individual, group, community) is an open system in interaction with
environment.
4 CONCEPTS
A. CLIENT
Flexible – keeps system free from stressor reaction or symptom-matology.
Line of Resistance – consist of internal defensive processes. Ex. Immune
response.
B. ENVIRONMENT
- Environment has potential to alter system stability due to internal and external
stressors.

STRESSORS CAN BE
1. Extra personal – unemployment, microorganisms, peer pressure,
radiation.
2. Inter personal – between 2 or more individual (parent expectations).
3. Intra personal – anger, physical abilities, financial condition.
- Environment can also be source of resources that may help client
cope with stressors.
C. HEALTH
D. NURSING
- Primary: protection of normal line of defense.
- Secondary: protection of basic structure by strengthening internal line of
resistance.
Ex. Treatment of symptoms, energy conservation
- Tertiary: promotion of reconstitution by supporting existing strengths and
resources.
8. DOROTHY JOHNSON’S BEHAVIORAL SYSTEMS MODEL

Mans subsystem
- Behavioral subsystem: addressed by nursing intervention.
- Biological subsystem: addressed by medical intervention.
Goal of Nursing
a. demonstrate behavior commensurate to social demands.
b. modify behavior to support biological needs.
c. benefit from physicians skill and knowledge.
d. demonstrate behavior that does not give evidence of unnecessary trauma.
- Nursing focus: behavior modification to foster equilibrium.

C. INTERPERSONAL/CARING THEORIES
9. HILDEGARD PEPLAU’S INTERPERSONAL RELATIONSHIP IN
NURSING
- purpose of nursing is to educate and to be a nurturing force to a patient for
him to get a new view of himself.
- interaction is a maturing force.
Nurse Patient
Counselor – identify stressor (with a need)
Resource Person – health educator
Surrogate – acts as caregiver
Congruent Goals
PHASE OF NURSE – PATIENT RELATIONSHIP

1. Orientation – leveling off between nurse and client in term of expectation.
2. Identification – selective response of the client to those who can meet his
needs; affected by clients belief.
3. Exploitation – client takes control of the situation by extracting help from
nurse.
4. Resolution – evaluation of care and discharge of client.
10. MADELEINE LEININGER’S TRANSCULTURAL CARE THEORY

- Culture: way of life, total of all the material and non material’s produced by
the people at their level of social development.
- has universalities: same as other culture (hygiene, nutritional needs).
- diversities: cultural peculiarities (caring ).
11. IDA JEAN ORLANDO’S DYNAMIC NURSE-CLIENT RELATIONSHIP

- Types of nursing response: deliberate action(based on correct identification
of patients needs) and automatic action.
- nursing function is concerned with providing direct assistance to individuals in
whatever setting to avoid, diminish, relieve individual’s sense of helplessness.
- Nursing disciplined professional response.
12 JEAN WATSON’S PHILOSOPHY AND SCIENCE OF CARING

- Nursing is the science of caring.
- Caring is more healthogenic than caring.
- Main focus of nursing is on curative factors that are derived from humanistic
perspectives combined with a scientific base.
10 CARATIVE FACTORS
1. Formation of a humanistic-altruistic value system.
2. Faith – hope
3. Cultivation of sensitivity to self and others.
(First 3 factors are the foundations for caring)
4. Establishing a helping trust relation
5. Expression of feelings, both positive and negative.
6. Research and systematic problem solving.
7. Promotion of interpersonal teaching-learning.
8. Provisions for a supportive, protective and corrective mental, physical,
sociocultural and spiritual environment.
9. Assistance with the gratification of human.
10. Allowance for existential phenomenological factors.
D. CLIENT CENTERED THEORIES
13. FAYE GLEN ABDELLAH’S 21 NURSING PROBLEMS

- Nursing in the use of the problem solving approach
- Covert: psychological problem
- Overt: obvious (physical manifestations of health problems)
14. LYDIA HALL’S THEORY OF CORE, CARE, CURE

- Patient is composed of 3 elements: body, pathology, person
- Nursing is helping clients move in the direction of self awareness
- Nursing operates in all 3 elements
- Core: the person, therapeutic use of self
- Care: the body, intimate body care (nurturing component)
- Cure: the disease, medical care (client advocate)
15. MYRA ESTRINE LEVINE’S FOUR CONSERVATION PRINCIPLES OF

NURSING
- Promotion of the wholeness of the person
- By improving the clients patterns of adaptive response
CONSERVATION OF
- Energy
- Structural Integrity
- Personal Integrity
- Social Integrity
Promotion of “wholeness” of the client
towards health maintenance or health
restoration.
CONSERVATION
- Defends wholeness of living systems by ensuring their ability to confront
change
16. NOLA J. PENDER’S HEALTH PROMOTION MODEL

- Directed towards increasing the level of well being and self actualization of a
given individual or group
- Importance
Example: 6 – 8 hours of sleep
of health
- Disease prevention/Health protection: action directed towards decreasing

Perceived control of health Biologic
the probability of experiencing illness by active protection of the body against
pathological stressors.
Perceived self efficacy
Interpersonal influences
- Example: BCG vaccination

Depth of health Situational factors
COGNITIVE PERCEPTUALBehavioral MODIFYING

Perceived health status factor FACTORS
FACTORS
Perceived benefits of health Demographic character
promoting behaviors
Cues to
action
Perceived barriers of health
promoting behaviors
LIKELIHOOD IN
ENGAGING IN
HEALTH PROMOTING
BEHAVIORS
Ex. Mass media
HEALTHY LIFESTYLE
- Adequate nutrition 3 times a day
- Regular exercise 3 times a week
- Not smoking
- Moderate intake of alcohol

CONCEPT OF MAN
Atomistic – whole or sum of parts
Holistic – the whole is not equal to the sum of parts
Physiologic – genetic character, organs and functioning
Psychological – emotions, affect, rationality, merciful
Socio-cultural – socialization, family, language
Intellectual – perception, cognition
Spiritual – faith (unquestioning belief in someone, serves to unite humans),
hope, charity
Charity – outward expression of love for others
BASIC HUMAN NEEDS

1. Universal
2. Met in different ways
3. Stimulated by external and internal factors
4. Maybe differed
5. Interrelated
6. Priorities maybe altered
MASLOW’S HEIRARCHY OF NEEDS

- Need: anything that is essential to the survival of man
- Framework: basic need is something whose
- Absence: may cause illness
- Presence: prevent illness/signal health
- Meeting unmet needs restore health
Physiologic
- sex, nutrition, shelter, clothing, water, elimination, rest and sleep
Safety and Security
- physical freedom from harm, psychological knowing what to expect from
others and what others expect from you.
Love and Belongingness
- nurturance with affection
Self Esteem
- persons sense of achievement and independence, competence, confidence
and strength
Self Actualization
- not all people attain self actualization (attained by only 15%)
- Accepts himself
- Balance between rest and activity
- Open mind
- Positive outlook in life
HEALTH
- Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.
WELLNESS
- State of well being
- Subjective perception of balance, harmony and vitality engaging in attitudes
and behaviors that enhance the quality of life and maximizes personal
potential.

DIMENSION OF WELLNESS
- Physical: ADL, fitness of organ structures and functioning
- Spiritual: faith and hope
- Intellectual: use knowledge for personal, family, social, career development
- Emotional: able to manage stress, express feelings and emotions
appropriately
- Social: interact successfully with others, tolerant of people with different
beliefs
MODELS OF HEALTH AND WELLNESS

LEAVELL AND CLARKS AGENT – HOST ENVIRONMENT MODEL OR
ECOLOGICAL MODEL/EPIDEMIOLOGIC
Agent
Host Environment
DUNN’S HIGH LEVEL WELLNESS GRID

Very Favorable Environment

Protected poor health High level wellness
( in favorable environment) (in
favorable environment)
HEALTH AXIS
Death Peak
Wellness
Poor health Energetic, High level wellness
(in an unfavorable environment) (in an unfavorable
environment)
Environmental axis
Very Unfavorable Environment

Both physical and social cultural environment

TRAVIS ILLNESS – WELLNESS CONTINUUM
Wellness model
. . . . . .
Premature Death
Disability Symptoms/Signs Awareness/ Education/ Growth

High Level Wellness
Treatment Models

Neutral Point
(no discernable illness or wellness)
- Movement to the right of the neutral point indicates high level of health and
well being for an individual and this may be achieved through awareness and
education and growth. In contrast, movement to the left of the neutral point
indicates a progressively decrease state of health
HEALTH BELIEF MODEL

- Intended to predict whether individuals would or would not use preventive
measure
- Based on the motivational theory
- Assumption: Good health is a motivation common to all people
ILLNESS
- Highly personal state in which the person feels unhealthy or ill, may or may
not be related to disease
DISEASE
- Alteration in body function resulting in a reduction of capacities or a
shortening of the normal lifespan

CAUSES OF DISEASE
1. Genetic – inherited, genetic defects
2. Developmental – resulting to exposure to virus or chemicals during
pregnancy
3. Biologic – microorganisms (virus, bacteria, protozoa, fungi) and their
toxins and helminthes
4. Physical – temperature extremes, electricity, radiation
5. Chemical – alcohol, strong acid and base, drugs
6. Mechanical – generalized tissue response to injury or irritation (trauma
shearing force, friction)
7. Physiologic and Emotional reaction to stress
8. Faulty Chemical or Metabolic Processes – excessive or insufficient
production of hormones, enzymes
IGUN’S 11 STAGES OF HEALTH SEEKING

- Any activity undertaken by a person who feels ill in order to define his state of
health and seek a suitable remedy
Stage 1: Symptom experience
Stage 2: Self treatment or self medication
Stage 3: Communication to others
Stage 4: Assessment of symptoms
Stage 5: Sick-role assumption
Characteristics of Sick Role
a. Expected to seek competent help
b. Expected to get well in the shortest possible time
c. Person is not blamed for his disease
d. Exempted from usual task
Stage 6: Concern
Stage 7: Efficacy of treatment
Stage 8: Selection of treatment
Stage 9: Treatment
Stage 10: Assessment of effectiveness of treatment
Stage 11: Recovery and rehabilitation
SUCHMAN’S 5 STAGES OF ILLNESS

Stage I: Symptom Experience
- Person believes that something is wrong
- Physical experience of the symptoms
- Cognitive aspect: interpretation of the symptoms
- Emotional response: fear or anxiety
Stage II: Assumption of Sick Role
- People are excused from normal duties and role expectations
- Clients are not held responsible for their condition
- Clients are obliged to get well and resume normal activity
- Clients are obliged to seek competent help
Stage III: Medical Care Contact
- Seeking medical advice to ask for the following
o Validation of real illness
o Explanation of symptoms in understandable terms
o Reassurance that they will be fine or for a prediction of what the
outcome would be
- Client may accept or deny diagnosis
Stage IV: Dependent Client Role
- The client is dependent on the professional for help and give up their
independence

- Client accepts treatment plan
Stage V: recovery or Rehabilitation
- Client relinquishes role and resumes former role and responsibilities
- For permanent disability, this may require therapy to learn how to make
major adjustments in functioning.

CHARACTERISTICS OF NURSING PROCESS
1. Cyclic and dynamic rather than static
2. Client centered – nurse organizes plan of care according to client
problems rather that nursing goals
3. Interpersonal and collaborative – depends on open and meaningful
communication between client and the nurse
4. Universally applicable – can be used with clients of any age at any point
of the wellness – illness continuum and useful in a variety of settings
5. Adaptation of problem solving techniques and system theory based on
the scientific method
6. It can be viewed as parallel to but separate from the medical process
ASSESSMENT
- Objective (physical exam) and subjective (nursing history)
SOURCES OF DATA
1. Primary – client
2. Secondary – relatives, members of health team
FOR NURSING HISTORY USE GORDON’S TYPOLOGY OF 11

FUNCTIONAL PATTERN
1. Health perception – health management pattern – describes clients
perceived pattern of health and well being and how health is managed.

2. Nutritional – metabolic pattern – describes pattern of food and fluid
consumption relative to metabolic need and pattern indicators of local
nutrient supply.
3. Elimination – describes pattern of excretory function (bowel, bladder and
skin).
4. Activity – exercise – describes pattern of exercise, activity, leisure and
recreation
5. Cognitive perceptual – describes sensory perceptual and cognitive
system
6. Sleep rest – describes pattern of sleep, rest and recreation.
7. Self perception – self concept – self concept pattern and perceptions of
self (body comfort, body image, feeling state).
8. Role relationship – describes pattern of role engagements and
relationships
9. Sexual reproductive – client patterns of satisfaction and dissatisfaction
with sexuality: describes reproductive pattern
10. Coping stress tolerance – general coping pattern and effectiveness
of the pattern in terms of stress tolerance.
11. Value belief – patterns of values, beliefs (including spiritual) or
goals that guide choices of decisions.
NURSING DIAGNOSIS
- Clinical judgment about an individual, family or community responses to
actual and potential health problems
- Professional nurses are responsible for making nursing diagnosis.
- Nursing diagnosis describe a continuum of health states.

Actual Potential Health
Healthy
Problem
Responses
NURSING DIAGNOSIS MEDICAL DIAGNOSIS

- Focus on identifying human - Identifies disease
responses to health and illness - Describe problems for which the
- Describe problems treated by physician directs the primary
nurses within the scope of treatment
independent nursing practice
- Changes from day to day as - Remains the same for as long
client responses change as the disease is present
6 TYPES OF NURSING DIAGNOSIS

1. Actual nursing diagnosis – judgment about a clients response to a health
problem at the time of assessment and is signified by the presence of
associated signs and symptoms.
Format: 2 part (problem related to etiology)
3 part (problem, etiology and signs and symptoms format)
2. Risk nursing diagnosis – clinical judgment about a clients vulnerability to
develop a problem
Format: 2 part statement (diagnostic label related to risk factors)
3. Possible nursing diagnosis – evidence about a certain problem is unclear
and need to gather more data to support it
Format: 2 part statement

4. Wellness nursing diagnosis – clinical judgment about an individual, family
and community in transition from a specific level of wellness to a higher level of
wellness
Format: potential + desired higher level of wellness
Readiness for + higher level of wellness
5. Syndrome nursing diagnosis – comprises of a cluster of problems
Format: 1 part statement (rape trauma syndrome)
6. Alfaro’s rule for a collaborative problem – focus on potential
complications
Format: potential problem + related to + list of complications that may
occur
First Priority – is any threat to the vital functions of breathing, heart beat,
blood pressure.
Medium Priority – health-threatening problems that may result in delayed
development or cause destructive physical or emotional changes.
Low Priority – problems that arise from normal development needs or those
that require minimal nursing support.
OBJECTIVES
- Should be SMART, client centered, statement of a single human response
EVALUATION
- Conclusion and supporting data
- Goal met
- Goal partially met
- Goal not met
GROWTH
- Physical change
- Increase in size
- Periods of very rapid growth rate: pre – natal, neonatal, infancy, adolescence
DEVELOPMENT
- Increase in complexity of function and skill progression
- The behavioral aspect of growth
PRINCIPLES OF DEVELOPMENT
1 Growth and development are continuous orderly, sequential process
influenced by maturational environment and genetic factors
2. All humans follow the same pattern of growth
3. The sequence of each stage is predictable although the time of onset, the
length of the stage and the effects of each stage vary with the person.
4. Growth and development occur in cephalocaudal direction.
5. Growth and development occur in a proximal to distal direction
6. Development occurs from simple to complex or from single acts to
integrated acts.
7. Development becomes increasingly differentiated, begins with generalized
response and progresses to a skilled specific response.
8. The pace of growth and development is asynchronous or uneven.

KOHLBERG’S STAGES OF MORAL DEVELOPMENT
LEVEL AND STAGE
Level I: Pre Conventional
(Egocentric Focus)
Stage 1 - Activity is wrong if one is
Punishment and obedience punished, activity is right if one
orientation is not punished.
(toddler – 7 years)
Stage 2 - Action is taken to satisfy ones
Instrumental – Relativist Orientation needs.
(4 – 12 years)
Level II: Conventional (Societal

Focus) - Action is taken to please
Stage 3 another and gain approvals.
Interpersonal concordance, good
boy, nice girl (6 years thru adult - Right behavior is obeying the
years) law and follow the rules
Stage 4
Law and order orientation
(adolescent – adult)
- Standard of behavior is
Level III: Post Conventional or based on adhering laws that

Principled Level (Universal protect the welfare and rights
Focus) of others: violating the rights of
Stage 5 others is avoided: personal
Social contract, legalistic orientation values and opinions are
(middle age or older adult) recognized.
- Universal moral principles are

internalized, person respects
Stage 6 other humans and believes
Universal ethical principles (middles that relationship are based on
age or older adult) mutual trust.
TYPES OF OLDER ADULT

1. Young old (65 – 74) – adaptation to retirement and changing physical
abilities, chronic illness may develop.
2. Middle old (75 – 84) – adaptation to decline in speed of movement, reaction
time and sensory abilities: increasing dependence in others.
3. Old old (85 – over) – increase physical problems.

DEVELOPMENTAL TASK AND WHOLISTIC APROACH BY ROBERT
HAVIGHURST
AGE PERIOD DEVELOPMENTAL TASK

Infancy and Early Childhood - Learning to walk, to taste solid
foods, to talk, to control
elimination of body wastes, sex
differences and sexual modes
- Learning to relate emotionally to
parents, siblings and others
- Learning to distinguish right
from wrong and developing a

conscience
- Learning to form concepts of
Middle Childhood social and physical reality
- Learning physical skills for

ordinary games
- Building wholesome attitude
towards oneself
- Learning to get along with age
mates
- Learning an appropriate
masculine or feminine social role
- Developing fundamental skills in
Adolescence reading, writing and calculating
- Develop concepts necessary for
everyday living
- Achieving personal
independence
- Achieving new and more mature

relations with age mates of both
sexes
- Achieving masculine/feminine
social role
- Accepting ones physique and
using the body effectively
- Achieving emotional
Early Adulthood (20 – 40 yrs) independence from parents
- Selecting and preparing for an
occupation
- Preparing for marriage and
family life
- Developing intellectual skills
necessary for civic competence
- Acquiring a set of values and an
Middle Age (Emptiness Stage) ethical system as a guide to
behavior
- Selecting a mate
- Learning to live with a partner
- Starting a family and rearing
children
- Managing a home
- Getting started in an occupation
- Taking on civic responsibility
Late Maturity - Finding a congenial social group
- Achieving adult civic and social

responsibility
- Establishing and maintaining an
economic standard of living
- Assisting teenage children to
become responsible and happy
adults
- Developing adult leisure time
activity
- Accepting and adjusting the
physiologic changes of middle
age
- Adjusting to aging parent
- Adjusting to decrease physical

strength
- Adjusting to retirement and
reduced income
- Adjusting to death of a spouse
- Meeting social and civic
obligations
- Establishing satisfactory living
arrangements
NURSE – CLIENT RELATIONSHIP
- Helping relationship for growth
PHASES OF NURSE – CLIENT RELATIONSHIP

Phase I: Pre Interaction
- No face-to-face interaction with client
Phase II: Introductory/Orientation

- Rapport setting, contract setting, sets tone for rest of relationship
- Testing behavior (orientation) resisting behavior (non compliance)
Phase III: Working

- Implementation of nursing care plans
- View as unique individuals

- Employ decision-making and technical skills and communication skills
Phase IV: Termination

- Characterized by ambivalence on both nurse and client
- Discharge phase
- Evaluation of care given by nurse
COMMUNICATION
- Human function that enables people to relate with each other
MODES
Verbal – spoken language
Non-Verbal – symbols, sign language
ELEMENTS OF COMMUNICATION
1. Stimulus – reason why people communicate, motivation with each other
(object, ideas, feeling) referent
2. Message – idea, feelings and emotions
3. Sender – also known as encoder, one that sends the message
4. Channels – kinesthetic: tactile stimulus, visual: symbols, auditory: spoken
language
5. Receiver – decoder
6. Feedback – answer to questions, whether receiver understood or not
FACTORS THAT AFFECT COMMUNICATION PROCESS

1. Ability of communicator – ability to speak, hear, see and comprehend
stimulus
2. Perceptions – each has a unique trait, values, life experiences
3. Personal space – distance people prefer in interactions with one another
Four distances
a. Intimate
- Physical contact to 1 ½ feet characterized by body contact heightened
sensation of body heat and smell, low vocalization
- Threatening to client
b. Personal
- 1 ½ feet to 4 feet
- Less overwhelming than intimate distance
- Usual distance between nurse and client
- Best distance
c. Social
- 4 feet to 12 feet
- Communication is non-formal
- Allows more activity and movement back and forth
- Often misused by nurse
d. Public
- 12 feet and beyond
- Individuality is lost
- Mass health education
4. Territoriality – concept of space and things that an individual considers as
belonging to the self
5. Roles and Relationships
6. Time – events that precede and follow interactions
7. Environment – environment is comfortable, communication is more
effective
8. Attitudes
THERAPEUTIC COMMUNICATION RATIONALE
Using silence Accepting pauses or silences without
interjecting any verbal response
Providing general leads Using statements or questions that

a. encourage client to verbalize
b. choose a topic of conversation
Being specific and tentative Statements that are specific rather

than general and tentative rather than
absolute
Using open ended questions

Specify only topic to be discussed and
invite answers longer than one or two
Using touch words
Touch reinforces caring feelings,

however, nurse should be sensitive to
Restating/Rephrasing difference in attitude’s practice of
clients self
Actively listening for the client’s basic

Seeking clarification message then repeats those thoughts
and/or feelings in similar words.

Used when communication is rambling
Clarifying time or Sequence or when paraphrasing is difficult
Offering self Helping the client clarify an event

situation or happening with respect to
time
Giving information
Suggesting ones presence, interest or
Acknowledging wish to understand the client without
making any demands that could make
client comply to suggestion
Presenting reality A simple and direct manner, specific

factual information
Focusing
Giving recognition in a non judgmental
way of
Reflecting a. change in behavior
b. effort the client has made
c. contribution to a communicator
Helping client differentiate real from

Summarizing and Planning unreal
Helping the client expand on and

Perception checking develop a topic of importance
The focus may be an idea or a

feeling.Directing ideas, feelings,
questions or content back to clients to
enable them to explore their own
feelings
Stating the main points of discussion

to clarify relevant parts discussed
Verifies meaning of specific words

than overall meaning of a message
NON THERAPEUTIC RATIONALE

COMMUNICATION
Stereotyping Offering generalized and over
simplified beliefs about groups of
people
Agreeing and Disagreeing
Akin to judgmental responses implies
client is either right or wrong
Being defensive
Attempting to protect a person

Challenging
Giving response that makes client
prove their statement or point of view
Probing
Asking information chiefly out of
curiosity rather than intent
Testing
Question than make a client admit
Changing topic something
Unwarranted reassurance Directing communication into areas of

self intent
Passing judgment Using clichés or comforting

statements of advice as a means to
reassure the client
Giving common advice
Giving opinions and approving or
disapproving response
Telling client what to do
VITAL SIGNS
TEMPERATURE
1. Oral
- Most accessible and convenient
- Normal value: 37 o C – 98.6 o F

- 2 – 3 minutes
2. Rectal
- Most reliable
- Normal value: 37.7 o C – 99.6 o F
- 3 – 5 minutes
3. Axila
- Less accurate
- 5 – 10 minutes
4. Tympanic membrane
- Directly reflects core temperature
- Automatic results
CONVERSION
- Fahrenheit to Celsius = (F-32) x 5/9
- Celsius to Fahrenheit = (C x 9/5) + 32
PULSE SITE
1. Temporal 6. Femoral
2. Carotid 7. Popliteal
3. Apical 8. Posterior tibial
4. Brachial 9. Dorsalis pedis
5. Radial
 When palpating for pulse use 2 – 3 fingers except when taking the
apical pulse use stethoscope
 Apical pulse is in the 5th intercostals space
 Landmark is the angle of Louie

 4th intercostals space left mid clavicular line child apical pulse
 When using the stethoscope use the flat part when looking for high
pitch sounds like (lung and bowel sounds) and use the bell for
vascular or heart sounds
RESPIRATION
- Adult: 12 – 20 c/min
- Newborn – 30 – 60 c/min
ERRORS IN TAKING RESPIRATORY RATE

Patient Factor
 Insufficient rest before assessing
 Assessing immediately after a meal or while client smokes or has pain
Equipment Factor
 Stethoscope fits poorly or hearing impaired
 Bladder or cuff too wide
 Bladder or cuff too narrow
Errors in technique
 Arm unsupported
 Arm above heart level and not perpendicular to the body
 Cuff wrapped to loosely
 Deflating cuff to slowly
 Deflating cuff to quick
 Failure to identify auscultatory gap
Auscultatory gap
 Temporary cessation of sounds after initiation

 Gap of 10 – 40 mmHg
 Common among hypertensive
 Repeating assessment too quickly (wait for 2 – 3 minutes after taking
again the bp, and maximum of 3 takes same arm and if still inaudible
rest arm for 5 – 15 minutes)
 Multiple examiner using different Kortkoff sounds for diastolic readings
 Failure to use the same arm consistently Effects
 Erroneously high readings
False low systolic and false high diastolic

- False low reading
- False high reading
- Erroneously high readings
- Erroneously low readings
- False high readings
- False low diastolic reading
- False high diastolic reading
- False low systolic bp and diastolic bp
- False high systolic blood pressure, false low diastolic blood pressure
 Inaccurate interpretation

 Inconsistent measurements
 For a client who’s blood pressure is to be taken for the first time,
take the blood pressure of both arms
 Difference of blood pressure for both arms should only be 10 mm Hg
 Use higher value as baseline
PALPATORY SYSTOLIC PRESSURE
 Point of pulsation stops with the use of stethoscope
 Maximum pressure + 30 mmHg that is you limit when taking the blood
pressure
KOROTKOFF SOUNDS
Phases
1. Characterized by a thud, thump and tapping sound
2. Swooshing, whoosing sound
3. Sound decrease in intensity when compared to Korotkoff one
4. Muffling sound
5. Disappearance of sound
- in adults record Korotkoff 1 and Korotkoff 5 of able to hear Korotkoff 4
record also
- in children record Korotkoff 1 and Korotkoff 4
HYPERTENSION
Average of 2 or more diastolic reading on at least 2 subsequent visits is 90
mmHg or higher or when an average of 2 or more systolic readings on at
least 2 visits is higher than 140 mmHg
SYSTOLIC DIASTOLIC

Optimal/ Normal 120 – 129 80 – 84
Above Normal 130 – 139 85 – 89
Hypertension
Grade 1 (Mild) 140 – 159 90 – 99
Grade 2 160 – 179 100 – 109
(Moderate) Greater than 180 Greater than 110
Grade 3 Greater than Less 90
(Severe) 140Less 80

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FUNDAMENTALS OF NURSING

APPRENTICE NURSING PERIOD (6th Century – 18th Century)

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

EDUCATIONAL NURSING PERIOD (18th Century – 20th Century)

CONTEMPORARY PERIOD (21st Century)

PROFESSION – a special calling that requires special, skills, knowledge and

SOCIALIZATION – process where a person learns the ways and means or

ROLE – patterns of behavior expected of person assuming a status/position in

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

THEORIES – relationship between concepts

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

14 BASIC COMPONENTS OF NURSING CARE

3. MARTHA ROGER’S SCIENCE OF UNITARY HUMAN BEINGS

GENERAL SYSTEM THEORY

4. DOROTHEA OREM’S SELF CARE DEFICIT THEORY

DEVELOPMENT OF SELF CARE REQUISITES

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

COMPONENTS PERSONAL SYSTEM

7. BETTY NEUMAN’S HEALTH CARE SYSTEMS MODEL

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

8. DOROTHY JOHNSON’S BEHAVIORAL SYSTEMS MODEL

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

PHASE OF NURSE – PATIENT RELATIONSHIP

10. MADELEINE LEININGER’S TRANSCULTURAL CARE THEORY

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

11. IDA JEAN ORLANDO’S DYNAMIC NURSE-CLIENT RELATIONSHIP

12 JEAN WATSON’S PHILOSOPHY AND SCIENCE OF CARING

D. CLIENT CENTERED THEORIES

13. FAYE GLEN ABDELLAH’S 21 NURSING PROBLEMS

14. LYDIA HALL’S THEORY OF CORE, CARE, CURE

15. MYRA ESTRINE LEVINE’S FOUR CONSERVATION PRINCIPLES OF

16. NOLA J. PENDER’S HEALTH PROMOTION MODEL

- Disease prevention/Health protection: action directed towards decreasing

- Example: BCG vaccination

COGNITIVE PERCEPTUALBehavioral MODIFYING

Ex. Mass media

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

BASIC HUMAN NEEDS

MASLOW’S HEIRARCHY OF NEEDS

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

MODELS OF HEALTH AND WELLNESS

DUNN’S HIGH LEVEL WELLNESS GRID

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Very Unfavorable Environment

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Disability Symptoms/Signs Awareness/ Education/ Growth

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

HEALTH BELIEF MODEL

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

IGUN’S 11 STAGES OF HEALTH SEEKING

SUCHMAN’S 5 STAGES OF ILLNESS

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

FOR NURSING HISTORY USE GORDON’S TYPOLOGY OF 11

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

NURSING DIAGNOSIS MEDICAL DIAGNOSIS

6 TYPES OF NURSING DIAGNOSIS

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Level II: Conventional (Societal

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Universal moral principles are