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Emillie Grace D. Tombucon, RN, MSNc
Is the diagnosis and treatment of human
responses to actual or potential health problems (ANA, 1980)
Is an interpersonal process whereby professional
nitse practitioner assists an individyal, family or community to prevent or to cope with experience of illness and suffering and if necessary to find meaning in these experiences (Joyce Travelbee) RA 9173, Philippine Nursing Act of 2002
Roles and responsibilities of Nurses
Educator Counselor Manager Change Agent Leader Clinician Advocate
Pres Carlos P Garcia.Nursing Hx Nightingale Pledge.FNA was founded with 150 nurses Proclamation 539.Written by Lystra Grette of Farrand Nursing School Ilo ilo Mission Hospital Training school for nurses. nurses week .Dean and pioneer of Philippine Nursing September 2. 1909 Anna Dahlgen.5% Act 2493-first law affecting the nursing practice Act of 2808-the first nursing law Miss Anastacia Giron Tupas. 1922.first top notcher with 93.
Components of Nursing Process Assessment Diagnosis Planning Implementation Evaluation .
focuses on clinical judgment about trasitioning from s specific level to a ahigher level of wellness Syndrome Nursing Diagnosis.NANDA Actual Nursing Diagnosis.based on clinical judgment of the nurse on review of validated data Risk Nursing Diagnosis.cluster of actual or high-rsik diagnosis that are predicted to be present because of certain situation .Based on clinical judgment of the client‟s degree of vulnerability Wellness Nursing Diagnosis.
any hypothesis or opinion not based upon actual knowledge.Theory a set of related statements that describes or explains phenomena in a systematic way. a formulated hypothesis or. a provisional statement or set of explanatory propositions that purports to account for or characterize some phenomenon. . loosely speaking. the doctrine or the principles underlying an art as distinguished from the practice of that particular art.
and /or prescribing. relationships. systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing. definitions. and assumptions or propositions derived from nursing models or from other disciplines and project a purposive. explaining.Nursing theory A nursing theory is a set of concepts. predicting. .
and influences affecting the person Health. characteristics and attributes of person giving care. spiritual.Degree of wellness or illness experienced by the person Nursing. or community Environment.All internal and external conditions. family. and sociocultural components.Actions. psychological.METAPARADIGMS IN NURSING Person. . circumstances.Individual. including physical.Recipient of care.
Patients require help towards achieving independence. . .Identified 14 basic human needs on which nursing care is based. Florence Nightingale’s Legacy of caring- Focuses on nursing and the patient environment relationship Ernestine Wiedenbach: The helping art of clinical nursing Virginia Henderson’s Definition of Nursing .Derived a definition of nursing .
Cure. Jean Watson’s Philosophy and Science of caring. Hall :Care. social phenomenon that is only effective when practiced interpersonally considering humanistic aspects and caring. Faye G. Core model-Nursing care is person directed towards self love.Abedellah’s Typology of twenty one Nursing problems -Patient‟s problems determine nursing care Lydia E. Patricia Benner’s Novice to Expert .Caring is a universal.
Dorothea E. Orem’s Self care deficit theory in
nursing-Self–care maintains wholeness.
Three Theories: Theory of Self-Care Theory of Self-Care Deficit Theory of Nursing Systems Nursing Care: Wholly compensatory (doing for the patient) Partly compensatory (helping the patient do for himself or herself) Supportive- educative (Helping patient to learn
self care and emphasizing on the importance of nurses‟ role
Myra Estrin Levine’s: The conservation model Martha E.Roger’s: Science of unitary human
beings Dorothy E.Johnson’s Behavioural system modelIndividual as a behavioural system is composed of seven subsystems: the subsystems of attachment, or the affiliative, dependency, achievement, aggressive, ingestive-eliminative and sexual. Sister Callista: Roy‘s Adaptation model- The individual is a biopsychosocial adaptive system within an environment.The individual and the environment provide three classes of stimuli-the focal, residual and contextual.
Betty Neuman’s : Health care systems model-
Neuman‟s model includes intrapersonal, interpersonal and extrapersonal stressors. Nursing is concerned with the whole person. Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on the variables affecting the client‟s response to stressors. Imogene King’s Goal attainment theory-
Exploitations 4. Orientation 2. Identification 3. Peplau: Psychodynamic Nursing Theory-nterpersonal process is maturing force for personality. Hildegard E. The four phases of nurse-patient relationships are: 1. Resolution . Stressed the importance of nurses’ ability to understand own behaviour to help others identify perceived difficulties.
Counselor Interpersonal process alleviates distress. . Leader 5. Surrogate 6. Teacher 4. Resource person 3. The six nursing roles are: 1. Stranger 2.
Therapeutic human relationships. . Ida Jean Orlando’s Nursing Process Theory- Elements of nursing situation: Patient Nurse reactions Nursing actions Joyce Travelbee’s Human To Human Relationship Model. Nursing is accomplished through human to human relationships that began with the original encounter and then progressed through stages of emerging identities.
culture. caring. culture-care theory.Clients are open. Major concepts include care. Madeleine Leininger’s Transcultural nursing. cultural values and cultural variations Rosemarie Rizzo Parse’s :Theory of human becoming. mutual and in constant interaction with environment.Caring is universal and varies transculturally. .
Health Is the extent to which an individual or group is able to relize aspirations and satisfy needs and change or cope with environment. It is the complete physical. mental and social well being and not merely the absence of disease or infirmity .
Prevention Primary Prevention Secondary Tertiary Assuming the Sick Role Experience of symptom Assumption of dependent role Recovery and rehabilitation .
Resistive .Exercise Isotonic-dynamic Isometric-Static Isokinetic.
A person in the Trendelenberg position is lying supine with their head slightly lower than their feet.Someone in the prone position is lying face down. Left Lateral Recumbent. SIM'S POSITION -This position is a variation of lateral position with the patient on the left side. Their legs may either be straight or bent. means that the patient is lying on their right side. means that the patient is lying on their left side. or LLR. Fowler's Position -A person in the Fowler's position is sitting straight up or leaning slightly back.Positioning Supine. or RLR. This position is often used for rectal examination and treatments and enemas. left leg extended and right leg flexed. Trendelenberg Position.The Right lateral recumbent. Right Lateral Recumbent. . Prone.Someone in the supine position is lying on his or her back. A „high fowlers‟ position is somewhat who is sitting upright. A „low fowlers‟ position is someone whose head is only slightly elevated.The left lateral recumbent.
Supine position .
Prone Position This prone position can be used to prevent contractures in knees and hips. . Prone position counter indicated with spinal cord clients.
flex knees. chin to chest. HOB down---don‟t move up hill. Have patient flex knees. .Positioning/Moving a Client Up in Bed Allow patient to move himself if he can. moving patient. bed in low position. Nurses shift weight. Position height of bed for nurses‟ comfort. Reposition HOB. arms folded across chest Nurses tightens abdominal girdles.
far leg over near one. flex knees. . Position patient supine on far side of bed. Patient arms across chest.Turning a Patient Determine what patient can do. find assistance if it is needed. Tighten girdles. Position height of bed for nurses‟ comfort.
Turning Patient (con‟t)
Place one hand on patient shoulder, other on hip.
Roll patient toward you. Position patient for comfort, support with pillows if
need be. Raise side rails, lower bed.
The patient is unable
to move independently and someone else manipulates body parts.
The nurse provides minimal support as the patient moves through ROM.
Active ROM The patient moves independently through a full ROM for each joint. .
strength and improves cardiac and pulmonary functioning.Only active ROM increases muscle tone. mass. .
2-3 minutes very accurate CI wih MI.6-9 minutes.6) Oral-3-5 minutes Rectal. hemorrhoids Tympanic.Vital signs Temperature – 37 C (98.temperature fluctuates and normal on fluctuation Constant fever.temperature fluctuates and is nonnormal Relapsing-short febrile periods of a few days Intermittent.careful fo rinjury. perforation Axillary.41 C Remittent fever.Hyperythermia is temperature 38-41 C Hyperpyrexia. safe and none invasive Pyrexia.temperature that fluctuates minimally .
Basal metabolic rate 2. Muscle Activity 3. Conduction 3.Factors affecting Heat production 1. Thyroxine Output 4. Fever Factors Affecting Heat Loss 1. Vaporization . Symathetic Stimulation 5. Radiation 2. Convection 4.
8 Conversion: 41 C= ___ F .Celsius to Fahrenheit F= (Temp in C) X1.8 + 32 C=(Temp in F-32)/1.
Factors Affecting Body Temperature Circadian Rhythms Age Exercise Sex Hormone levels Stress Environment .
is controlled by the hypothalamus (control center in the brain) – maintained within a narrow range. . of heat lost to external environment The body‟s tissues & cells function best between the range from 36 deg C to 38 deg C Temperature is lowest in the morning. highest during the evening.Body Temperature Core temperature – temperature of the body tissues. Skin temperature rises & falls in response to environmental conditions & depends on bld flow to skin & amt.
Infrared Tympanic (Ear) – sensor probe shaped like an otoscope in external opening of ear canal. (reads in seconds) there is a probe for oral/axillary use (red) & a probe for rectal use (blue). .Thermometers – 3 types Glass mercury – mercury expands or contracts in response to heat. Ear canal must be sealed & probe sensor aimed at tympanic membrane – ret‟n to charging unit after use. Relies on battery power – return to charging unit after use. (just recently non mercury) Electronic – heat sensitive probe. There are disposable plastic cover for each use.
insert lubricated bulb (1-11/2 inch adult) (1/2 inch infant) Ear Close to hypothalmus – sensitive to core temp. Less accurate (no major bld vessels nearby) Leave in place 3 min Leave in place 5-10 min. Not for small children (bite down) Non invasive – good for children.Pull pinna up & back Child – pull pinna down & back No hot or cold drinks or smoking 20 min prior to temp.Sites Oral Posterior sublingual pocket – under tongue (close to carotid artery) Axillary Bulb in center of axilla Lower arm position across chest Rectal Side lying with upper leg flexed. changes Adult . Measures 0. Leave in place 2-3 min. Measures 0. Must be awake & alert.5 C higher than oral When unsafe or inaccurate by mouth (unconscious.5 C lower than oral temp. disoriented or irrational) Side lying position – leg flexed Rapid measurement Easy assessibility Cerumen impaction distorts reading Otitis media can distort reading 2-3 seconds .
Pulse Number of pulsations/minute over a peripheral artery Rate: Beats per minute 60-100 Beat per minute Bradycardia Tachycardia Rhythm: regular or irregular (dysrhythmia) Amplitude 0 to 4+ .
strength – can assess by using palpation & auscultation.Assessing Radial Pulse Left ventricle contracts causing a wave of bld to surge through arteries – called a pulse. popliteal. . dorsalis pedis Assess: rate. Atrial fibrillation. posterior tibial. rhythm.is the difference between the systolic an diastolic pressure Pulse deficit – the difference between the radial pulse and the apical pulse – indicates a decrease in peripheral perfusion from some heart conditions ie. radial. Carotid. femoral. Pulse Pressure. Felt by palpating artery lightly against underlying bone or muscle. brachial.
and then apically for full minute. Do not use your thumb (feel pulsations of your own radial artery). Apical – beat of the heart at it‟s apex or PMI (point of maximum impulse) – 5th intercostal space. 3rd & 4th fingers lightly on skin where an artery passes over an underlying bone. just below lt. if irregular – count radial for 1 min.Procedure for Assessing Pulses Peripheral – place 2nd. midclavicular line. Count 30 seconds X 2. nipple – listen for a full minute “Lub-Dub” Lub – close of atrioventricular (AV) values – tricuspid & mitral valves Dub – close of semilunar valves – aortic & pulmonic valves .
average 80 bpm Tachycardia – greater than 100 bpm Bradycardia – less than 60 bpm Rhythm – the pattern of the beats (regular or irregular) Strength or size – or amplitude.Assess: rate. the volume of bld pushed against the wall of an artery during the ventricular contraction weak or thready (lacks fullness) Full. strength & tension Rate – N – 60-100. rhythm.3+ ----------------4+ Absent Weak NORMAL Full Bounding . bounding (volume higher than normal) Imperceptible (cannot be felt or heard) 0----------------.1+ -----------------2+--------------.
Normal Heart Rate Age Infants Toddlers Preschoolers School agers Adolescent Adult Heart Rate (Beats/min) 120-160 90-140 80-110 75-100 60-90 60-100 .
apply bell lightly (hint think of Bell with the “L” for Low) . is pulse obliterated by slight pressure (low tension or soft) Stethoscope Diaphragm – high pitched sounds.) Tension – or elasticity. lung & heart sounds – tight seal Bell – low pitched sounds. the compressibility of the arterial wall. heart & vascular sounds.Assess (cont. bowel.
Apical Pulse Site: PMI at 5th ICS at left MCL A/R rate correspond usually Pulse Deficit is the difference between the A/R rate .
Peripheral Sites Temporal Carotid Brachial Radial Femoral Popliteal Posterior tibial Dorsalis pedis .
Dorsalis Pedis .Common Pulse Points Central Pulses Carotid Femoral Peripheral Pulses Radial Brachial (children under 1) Posterior Tibial.
Pulse Assessment Stethoscope for apical pulse using bell side to hear low frequency sounds of heart and blood Doppler Ultrasound Cardiac Monitor Palpation of peripheral arterial pulse .
Factors Influencing Pulse Rates Exercise Temperature Emotional States Drugs Hemorrhage Postual Changes Pulmonary Conditions .
Respirations Passive process regulated by brain stem Ventilation regulated most importantly by high arterial CO2 (hypercarbia) COPD regulation is by hypoxemia (low 02 levels) via chemoreceptors in carotid artery and aorta Respiratory Rate Eupnea: 12 to 20 breaths/min Tachypnea Bradypnea .
Factors influencing Respirations Exercise Acute pain Anxiety Smoking Body Position Medications Neurological Injury Hemoglobin Levels .
so pt is unaware you are counting respiratons . rhythm & depth Inspiration – inhalation (breathing in) Expiration – exhalation (breathing out) I&E is automatic & controlled by the medulla oblongata (respiratory center of brain) Normal breathing is active & passive Women breathe thoracically. while men & young children breathe diaphramatically ***usually Asses after taking pulse. while still holding hand.Respirations Assess by observing rate.
of air inhaled/exhaled normal (deep & even movements of chest) shallow (rise & fall of chest is minimal) SOB shortness of breath (shallow & rapid) Regularity of inhalation/exhalation Normal (very little variation in length of pauses b/w I&E Depth Rhythm Character Digressions from normal effortless breathing Dyspnea – difficult or labored breathing Cheyne-Stokes – alternating periods of apnea and hyperventilation.Eupnea – normal rate & depth breathing Abnormal increase – tachypnea Abnormal decrease – bradypnea Absence of breathing – apnea Amt. .Assessing Respiration Rate # of breathing cycles/minute (inhale/exhale-1cycle) N – 12-20 breaths/min – adult . with period of apnea at the end of each cycle. gradual increase & decrease in rate & depth of resp.
Pulse Oximetry Spo2 Spo2 acceptable ranges: 90%-100% Sp02 85%-89% acceptable for chronic diseases Spo2 less than 85% is unacceptable .
Factors influencing Respirations Exercise Acute pain Anxiety Smoking Body Position Medications Neurological Injury Hemoglobin Levels .
Pressure of bld within the arteries of the body – lt.Blood Pressure Force exerted by the bld against vessel walls.medications . smaller arteries & capillaries Systolic. ventricle contracts & pumps bld into the aorta – max. when the heart is filling.force exerted against the arterial wall as lt. minimum pressure in arteries. Factors affecting B/P lower during sleep Lower with bld loss Position changes B/P Anything causing vessels to dilate or constrict . Diastolic – arterial pressure during ventricular relaxation. pressure exerted on vessel wall. ventricle contracts – bld is forced out into the aorta to the lg arteries.
o Electronic – cuff with built in pressure transducer reads systolic & diastolic B/P .B/P (cont.) P&P p. 240 see table 9-3 Measured in mmHg – millimeters of mercury Normal range syst 110-140 dias 60-90 Hypertensive . stethoscope 3 types of sphygmomanometers o Aneroid – glass enclosed circular gauge with needle that registers the B/P as it descends the calibrations on the dial.>160. >90 Hypotensive <90 Non invasive method of B/P measurement Sphygmomanometer. o Mercury – mercury in glass tube .more reliable – read at eye level.
240. rt mastectomy.e.) Cuff – inflatable rubber bladder.B/P (cont. palm turned upward . rt arm . important to have correct cuff size (judge by circumference of the arm not age) Support arm at heart level. P&P p.above heart causes false low reading Cuff too wide – false low reading Cuff too narrow – false high reading Cuff too loose – false high reading Listen for Korotkoff sounds – series of sounds created as bld flows through an artery after it has been occluded with a cuff then cuff pressure is gradually released. tube connects to the manometer. Do not take B/P in Arm with cast Arm with arteriovenous (AV) fistula Arm on the side of a mastectomy i. another to the bulb.
Hypertension Asymptomatic Diastolic 80-89 mm Hg on 2 subsequent visits Systolic 120-139 mm Hg on 2 subsequent visits HTN greater than 140/90 Greater peripheral vascular resistance with decrease in blood flow to heart. brain and kidneys .
Hypotension Systolic B/P falls below 90 mm Hg Hemorrhage Pump failure of heart Pallor Mottling of skin Clamminess Confusion Increase in HR Decrease in urinary output .
Hypotension Orthostatic (Postual) Risk Factors Dehydration Anemia Prolonged bedrest Recent blood loss .
5-8 Liters average .Blood Pressure Variations in B/P Peripheral resistance and compliance Wall elasticity Neural and humoral mechanisms Renin-angiotensin-aldosterone Increase per vascular resitance Increase Na and H2O retention Cardiac Output 3.
Blood Pressure Assessment Non-invasive Monitoring Equipment: stethoscope and sphygmomanometer Select appropriate cuff size Sites Brachial artery Popliteal if brachial artery inaccessible .
What factors may influence accuracy of B/P measurement? Exercise Caffeine Smoking Cuff size Too rapid or too slow release of valve Release so descent is 2-3mm Hg .
Korotkoff Sounds Phase I = 1st thump sound Phase II = whooshing sound Phase III = softer thump than Phase I Phase IV = soft blowing that fades Phase V = silence .
opiod analgesics.B/P Variation Factors Age Diurnal Rhythms Stress Ethnicity Weight Gender Body Position Exercise Medications [anti-HTN. contraceptives] . cardiac.
Physical Assessment Inspection Palpation Percussion Auscultation Skin Pallor Cyanosis Jaundice Erythema .
petichiae Patch-vitiligo Palpable elevated solid mass Papule.localized skin edeme (hive) .2 cm deeper than papule Tumor.Circumscribed. flat.elevated nevus Plaque-psoriasis Nodule.larger 1-2 cm Wheal. non palpable change in skin color Macule-freckles.
athlete foor Crust.impetigo Scale.dandruff Scar Keloisd-hypertrophied scar Excoriation-scratch mark Lichenification-rough thickened (dermatitis) .scratch mark chicken pox Ulcer-pressure sores Fissure. Eroison.
Eyes and Vision PERRLA Anisocoria N pupil size 3-7 mm in diameter Snellen‟s Chart.20/20 Myopia Hyperopia Presbyopia Astigmatism .
Tonometry PerimetryOpthalmoscopy Gonioscopy .
3 ossicles (incus malleus stapes.auricle pinna.Cochlea. external canal and tympanic membrane Middle. Eustachian tube) Inner.Ears and Hearing Outer. vestibule and semicircular canal .
lateralization test that compares right and left ear Rinne.compares air conduction with bone conduction Schwabach-compares client hearing with examiner . Tuning fork Weber.
Nose and paranasal sinuses Nasal speculum Penlight .
stensen‟s duct Submandibular.Mouth and pharynx Central lower incisor 5-8 mos 20 temporary teeth 32 permanent teeth Parotid.wharton duct Sublingual .
Thorax and Lungs Barrel Chest. protruding sternum Funnel Cheststernum is depressed with narrowing Kyphosis .when the AP diameter is wider than the transverse diameter Pigeon Chestpermanent deformity with narrow transverse diamter.
consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. As stated earlier. these sounds are NOT produced by air moving through the terminal bronchioles and alveoli but rather are the result of attenuation of breath sounds produced in the bronchi at the hilar region of the lungs.Normal breath sound Bronchial Sounds. almost silent expiratory phase. They are normally heard over the hilar region in most resting animals and should be quieter than the tracheal breath sounds. wispy inspiratory phase followed by a short. Vesicular breath sounds consist of a quiet. They are heard over the periphery of the lung field. . They are normally heard over the trachea and larynx Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase.
Abnormal Breath Sounds Crackles Wheezes Rhonchi Friction Rub Dull.emphysema Tactile Fremitus .Pneumonia Hyper-resonance.
Cardiovascular system Systole Diastole Tricuspid Valve Mitral Pulmonic Valve Aortic Valve .
use warm hands and stethoscope. supine position.Abdomen Empty bladder. slow approach Skin Umbilicus Contour Symmetry Enlarged Organs Masses Peristalsis Pulsation .
Bowel sounds.5 to 34 per minute Borborygmi Bruits Light palpation-note for tenderness or superficial pain Deep palpation-note masses and structure of underlying content. 4-5 cm in depth .
shortening of tendons Muscle tone Muscle strength Fasculation.abnormal contraction Tremor-involuntary trembling of a limb or body part. intentional and resting .Musculoskeletal Muscle size.atrophy Contractures.
Joint movement .
Inflammatory Response .
Abnormal Spinal Curvature .
Nervous System .
Confusion Disorientation Lethargy Obtundation Stupor Coma DysarthriaDysphonia.abnormal Aphasia Agnosia .
Crisis Maturational or Developmental Situational Crisis Coping mechanisms Primary appraisal Secondary appraisal Pre crisis Impact Crisis Resolution Post Crisis .
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