Nursing

Tutorial

Emillie Grace D. Tombucon, RN, MSNc

Nursing
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

Caregiver

Communicator
Educator Counselor Manager Change Agent Leader Clinician Advocate

Nursing Hx
Nightingale Pledge- Written by Lystra Grette of

Farrand Nursing School Ilo ilo Mission Hospital Training school for nurses, 1909 Anna Dahlgen- first top notcher with 93.5% Act 2493-first law affecting the nursing practice Act of 2808-the first nursing law Miss Anastacia Giron Tupas- Dean and pioneer of Philippine Nursing September 2, 1922- FNA was founded with 150 nurses Proclamation 539- Pres Carlos P Garcia, nurses week

Components of Nursing Process

Assessment

Diagnosis
Planning Implementation Evaluation

NANDA
Actual Nursing Diagnosis- based on clinical

judgment of the nurse on review of validated data Risk Nursing Diagnosis- Based on clinical judgment of the clients degree of vulnerability Wellness Nursing Diagnosis- focuses on clinical judgment about trasitioning from s specific level to a ahigher level of wellness Syndrome Nursing Diagnosis- cluster of actual or high-rsik diagnosis that are predicted to be present because of certain situation

Theory
a set of related statements that describes or

explains phenomena in a systematic way. the doctrine or the principles underlying an art as distinguished from the practice of that particular art. a formulated hypothesis or, loosely speaking, any hypothesis or opinion not based upon actual knowledge. a provisional statement or set of explanatory propositions that purports to account for or characterize some phenomenon.

Nursing theory
A nursing theory is a set of concepts,

definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing.

METAPARADIGMS IN NURSING
Person- Recipient of care, including physical,

spiritual, psychological, and sociocultural components.Individual, family, or community Environment- All internal and external conditions, circumstances, and influences affecting the person Health- Degree of wellness or illness experienced by the person Nursing- Actions, characteristics and attributes of person giving care.

 Florence Nightingales Legacy of caring-

Focuses on nursing and the patient environment relationship Ernestine Wiedenbach: The helping art of clinical nursing Virginia Hendersons Definition of Nursing - Patients require help towards achieving independence. - Derived a definition of nursing - Identified 14 basic human needs on which nursing care is based.

 Faye G.Abedellahs Typology of twenty one

Nursing problems -Patients problems determine nursing care Lydia E. Hall :Care, Cure, Core model-Nursing care is person directed towards self love. Jean Watsons Philosophy and Science of caring- Caring is a universal, social phenomenon that is only effective when practiced interpersonally considering humanistic aspects and caring. Patricia Benners Novice to Expert

 Dorothea E. Orems Self care deficit theory in

nursing-Selfcare 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 Levines: The conservation model Martha E.Rogers: Science of unitary human

beings Dorothy E.Johnsons 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: Roys 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 Neumans : Health care systems model-

Neumans 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 clients response to stressors. Imogene Kings Goal attainment theory-

 Hildegard E. Peplau: Psychodynamic Nursing

Theory-nterpersonal process is maturing force

for personality. Stressed the importance of nurses ability to understand own behaviour to help others identify perceived difficulties. The four phases of nurse-patient relationships are:
1. Orientation 2. Identification 3. Exploitations 4. Resolution

 The six nursing roles are: 1. Stranger 2. Resource person 3. Teacher 4. Leader 5. Surrogate 6. Counselor Interpersonal process alleviates distress.

 Ida Jean Orlandos Nursing Process Theory-

Elements of nursing situation:

Patient Nurse reactions

Nursing actions

Joyce Travelbees Human To Human

Relationship Model- Therapeutic human relationships. Nursing is accomplished through human to human relationships that began with the original encounter and then progressed through stages of emerging identities.

 Madeleine Leiningers Transcultural nursing,

culture-care theory- Caring is universal and varies transculturally. Major concepts include care, caring, culture, cultural values and cultural variations Rosemarie Rizzo Parses :Theory of human becoming- Clients are open, mutual and in constant interaction with environment.

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

Exercise
Isotonic-dynamic

Isometric-Static
Isokinetic- Resistive

Positioning
Supine- Someone in the supine position is lying on his or her

back. Prone- Someone in the prone position is lying face down. Right Lateral Recumbent- The Right lateral recumbent, or RLR, means that the patient is lying on their right side. Left Lateral Recumbent- The left lateral recumbent, or LLR, means that the patient is lying on their left side. Fowler's Position -A person in the Fowler's position is sitting straight up or leaning slightly back. Their legs may either be straight or bent. A high fowlers position is somewhat who is sitting upright. A low fowlers position is someone whose head is only slightly elevated. Trendelenberg Position- A person in the Trendelenberg position is lying supine with their head slightly lower than their feet. SIM'S POSITION -This position is a variation of lateral position with the patient on the left side, left leg extended and right leg flexed. This position is often used for rectal examination and treatments and enemas.

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.

Positioning/Moving a Client Up in Bed

Allow patient to move himself if he can.

HOB down---dont move up hill.

Position height of bed for nurses comfort. Have patient flex knees, chin to chest, arms

folded across chest Nurses tightens abdominal girdles, flex knees. Nurses shift weight, moving patient. Reposition HOB, bed in low position.

Turning a Patient
Determine what patient can do, find assistance if

it is needed. Position height of bed for nurses comfort. Position patient supine on far side of bed. Patient arms across chest, far leg over near one. Tighten girdles, flex knees.

Turning Patient (cont)

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.

Passive ROM

The patient is unable

to move independently and someone else manipulates body parts.

Active-Assistive ROM

The nurse provides minimal support as the patient moves through ROM.

Active ROM

The patient moves independently through a full ROM for each joint.

Only active ROM increases muscle tone, mass, strength and improves cardiac and pulmonary functioning.

Vital signs
Temperature 37 C (98.6)

Oral-3-5 minutes Rectal- 2-3 minutes very accurate CI wih MI, hemorrhoids Tympanic- careful fo rinjury, perforation Axillary- 6-9 minutes, safe and none invasive Pyrexia- Hyperythermia is temperature 38-41 C Hyperpyrexia- 41 C Remittent fever- temperature fluctuates and is nonnormal Relapsing-short febrile periods of a few days Intermittent- temperature fluctuates and normal on fluctuation Constant fever- temperature that fluctuates minimally

Factors affecting Heat production 1. Basal metabolic rate 2. Muscle Activity 3. Thyroxine Output 4. Symathetic Stimulation 5. Fever Factors Affecting Heat Loss 1. Radiation 2. Conduction 3. Convection 4. Vaporization

Celsius to Fahrenheit
F= (Temp in C) X1.8 + 32

C=(Temp in F-32)/1.8

Conversion: 41 C= ___ F

Factors Affecting Body Temperature

Circadian Rhythms

Age
Exercise Sex Hormone levels Stress Environment

Body Temperature
Core temperature temperature of the body tissues,

is controlled by the hypothalamus (control center in the brain) maintained within a narrow range.
Skin temperature rises & falls in response to

environmental conditions & depends on bld flow to skin & amt. of heat lost to external environment
The bodys 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.

Thermometers 3 types
Glass mercury mercury expands or contracts in

response to heat. (just recently non mercury)

Electronic heat sensitive probe, (reads in seconds)

there is a probe for oral/axillary use (red) & a probe for rectal use (blue). There are disposable plastic cover for each use. Relies on battery power return to charging unit after use.
Infrared Tympanic (Ear) sensor probe shaped like

an otoscope in external opening of ear canal. Ear canal must be sealed & probe sensor aimed at tympanic membrane retn to charging unit after use.

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, insert lubricated bulb (1-11/2 inch adult) (1/2 inch infant) Ear Close to hypothalmus sensitive to core temp. changes Adult - Pull pinna up & back Child pull pinna down & back No hot or cold drinks or smoking 20 min prior to temp. Must be awake & alert. Not for small children (bite down) Non invasive good for children. Less accurate (no major bld vessels nearby) Leave in place 3 min

Leave in place 5-10 min. Measures 0.5 C lower than oral temp. Leave in place 2-3 min. Measures 0.5 C higher than oral

When unsafe or inaccurate by mouth (unconscious, 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+

Assessing Radial Pulse

Left ventricle contracts causing a wave of bld to surge through

arteries called a pulse. Felt by palpating artery lightly against underlying bone or muscle. Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis Assess: rate, rhythm, strength can assess by using palpation & auscultation. Pulse Pressure- 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. Atrial fibrillation.

Procedure for Assessing Pulses

Peripheral place 2nd, 3rd & 4th fingers lightly on skin where an

artery passes over an underlying bone. Do not use your thumb (feel pulsations of your own radial artery). Count 30 seconds X 2, if irregular count radial for 1 min. and then apically for full minute.
Apical beat of the heart at its apex or PMI (point of maximum

impulse) 5th intercostal space, midclavicular line, just below lt. 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

Assess: rate, rhythm, strength & tension

Rate N 60-100, 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, the volume of bld pushed against the wall of an artery during the ventricular contraction weak or thready (lacks fullness) Full, bounding (volume higher than normal)
Imperceptible (cannot be felt or heard)

0----------------- 1+ -----------------2+--------------- 3+ ----------------4+ Absent Weak NORMAL Full Bounding

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

Assess (cont.)
Tension or elasticity, the compressibility of

the arterial wall, is pulse obliterated by slight pressure (low tension or soft)
Stethoscope
Diaphragm high pitched sounds, bowel, lung & heart

sounds tight seal Bell low pitched sounds, heart & vascular sounds, apply bell lightly (hint think of Bell with the L for Low)

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

Common Pulse Points

Central Pulses
Carotid Femoral

Peripheral Pulses
Radial Brachial (children

under 1) Posterior Tibial, Dorsalis Pedis

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

Respirations
Assess by observing rate, 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, so pt is

unaware you are counting respiratons

Assessing Respiration
Rate # of breathing cycles/minute (inhale/exhale-1cycle) N 12-20 breaths/min adult - Eupnea normal rate & depth breathing Abnormal increase tachypnea Abnormal decrease bradypnea Absence of breathing apnea Amt. 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, gradual increase & decrease in rate & depth of resp. with period of apnea at the end of each cycle.

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

Blood Pressure
Force exerted by the bld against vessel walls. Pressure of bld within the

arteries of the body lt. ventricle contracts bld is forced out into the aorta to the lg arteries, smaller arteries & capillaries Systolic- force exerted against the arterial wall as lt. ventricle contracts & pumps bld into the aorta max. pressure exerted on vessel wall. Diastolic arterial pressure during ventricular relaxation, when the heart is filling, 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 - medications

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 - >160, >90 Hypotensive <90 Non invasive method of B/P measurement

Sphygmomanometer, 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. o Mercury mercury in glass tube - more reliable read at eye level. o Electronic cuff with built in pressure transducer reads systolic & diastolic B/P

B/P (cont.)
Cuff inflatable rubber bladder, tube connects to the manometer,

another to the bulb, important to have correct cuff size (judge by circumference of the arm not age)
Support arm at heart level, palm turned upward - 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. P&P p. 240.
Do not take B/P in Arm with cast Arm with arteriovenous (AV) fistula Arm on the side of a mastectomy i.e. rt mastectomy, rt arm

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

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
3.5-8 Liters average

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

B/P Variation Factors

Age Diurnal Rhythms Stress Ethnicity Weight

Gender
Body Position Exercise Medications [anti-HTN, cardiac, opiod analgesics,

contraceptives]

Physical Assessment
Inspection Palpation Percussion Auscultation

Skin Pallor Cyanosis Jaundice Erythema

Circumscribed, flat, non palpable change in skin color Macule-freckles, petichiae Patch-vitiligo

Palpable elevated solid mass Papule- elevated nevus Plaque-psoriasis Nodule- 2 cm deeper than papule Tumor- larger 1-2 cm Wheal- localized skin edeme (hive)

 Eroison- scratch mark chicken pox Ulcer-pressure sores Fissure- athlete foor Crust- impetigo

Scale- dandruff
Scar Keloisd-hypertrophied scar

Excoriation-scratch mark
Lichenification-rough thickened (dermatitis)

Eyes and Vision

PERRLA

Anisocoria
N pupil size 3-7 mm in diameter Snellens Chart- 20/20

Myopia Hyperopia Presbyopia Astigmatism

Tonometry PerimetryOpthalmoscopy Gonioscopy

Ears and Hearing

Outer- auricle pinna,

external canal and tympanic membrane Middle- 3 ossicles (incus malleus stapes, Eustachian tube) Inner- Cochlea, vestibule and semicircular canal

 Tuning fork

Weber- lateralization test that compares right and

left ear Rinne- compares air conduction with bone conduction Schwabach-compares client hearing with examiner

Nose and paranasal sinuses

Nasal speculum

Penlight

Mouth and pharynx

Central lower incisor 5-8 mos

20 temporary teeth
32 permanent teeth Parotid- stensens duct Submandibular- wharton duct Sublingual

Thorax and Lungs

Barrel Chest- when

the AP diameter is wider than the transverse diameter Pigeon Chestpermanent deformity with narrow transverse diamter, protruding sternum Funnel Cheststernum is depressed with narrowing Kyphosis

Normal breath sound

Bronchial Sounds- consist of a full inspiratory and

expiratory phase with the inspiratory phase usually being louder. 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. They are normally heard over the hilar region in most resting animals and should be quieter than the tracheal breath sounds. Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are heard over the periphery of the lung field. 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.

Abnormal Breath Sounds

Crackles

Wheezes
Rhonchi Friction Rub

Dull- Pneumonia Hyper-resonance- emphysema Tactile Fremitus

Cardiovascular system
Systole

Diastole
Tricuspid Valve Mitral Pulmonic Valve Aortic Valve

Abdomen
Empty bladder, supine

position, use warm hands and stethoscope, 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

Musculoskeletal
Muscle size- atrophy

Contractures- shortening of tendons

Muscle tone Muscle strength Fasculation- abnormal contraction Tremor-involuntary trembling of a limb or body

part, intentional and resting

Joint movement

Inflammatory Response

Abnormal Spinal Curvature

Nervous System

 Confusion Disorientation Lethargy Obtundation Stupor

Coma

DysarthriaDysphonia- abnormal Aphasia Agnosia

Reflexes

Crisis
Maturational or Developmental Situational Crisis Coping mechanisms

Primary appraisal Secondary appraisal Pre crisis Impact Crisis Resolution Post Crisis