FUNDAMENTALS OF NURSING

Man
Forms the
Nursing

foundation

Vital Reparative Process

By Florence Nightingale
Man is passive in influencing
the nurse or the environment

of

Four Components or Attributes of

Man
Capacity to think on an
Abstract Level
Establish a family
Establish a territory
Ability to use verbal symbols
as language

Man is a whole. Man is complete

By Virginia Henderson
Man
has
fourteen
(14)
fundamental needs
Human Needs
Needs are physiologic and
psychologic
Both these needs must be
met in order to maintain wellbeing.

Concept:
Animals form a family by
instinct
Via hormonal scents

Key Concept:
Basic Human Needs are
equivalent
to
COMMON
NEEDS

Nursing Concepts of Man

Biopsychosocial Spiritual Being
By Sister Calista Roy
Man
interacts
with
the
environment

Characteristics of Human Needs

Universal
Interrelated
One need is related to another
need
May be stimulated by internal
or external factors
May be deferred (but not
indefinitely)

Open System
By Martha Rogers
Man
interacts
with
the
environment
Exchanges matter with energy
Exchanges
energy
with
environment

Maslows Hierarchy of Needs

Unified Whole
By Martha Rogers
Man is composed of certain
parts
Total of those parts is more
than the sum of all parts
This is because man has
attributes

Why do we study this?

In order to prioritize nursing
actions
1. Physiologic needs
Food,
maintenance
homeostasis
2. Safety and security
3. Love and belongingness
4. Self-Esteem

of

 Feeling good about ones self

Two factors affecting Selfesteem
o Yourself
Sense
of
adequacy
Accomplishment
o Others
Appreciation
Recognition
Admiration
Belongingness
5. Self-Actualization
Able to fulfill needs and
ambitions
Maximizing ones full potential
6. Aesthetics
Beauty

Open to new ideas

o Not adopts new ideas
o Not one track mind
Highly creative and flexible
Does not need fame
Problem-centered rather than
self-centered
Concept:
Self-Actualization
is
very
difficult to attain
It is impossible to attain
New needs come after getting
one need
Illness
Highly subjective feeling of
being sick or ill
Two types of Illness:
Acute Illness
Sudden in onset (most of the
time, but not always)
Less than six (6) months

Two Additional Needs by Maslow

Need to know
Need to understand
Richard Kalish
Man needs stimulation
Needs to explore
o Sex
o Activity
o Novelty
Stimulator
Desire to come
up
with
something
of
your own

Chronic Illness
Gradual in onset (most of the
time, but not always)
Types of Chronic Illness
o Exacerbation
Period
characterized by
active signs and
symptoms of the
illness
o Remission
Periods where
no signs and
symptoms
are
present

Characteristics of Self-Actualized
Persons
Judges people correctly
Superior perception
Decisive
o Capable of making
decisions
Clear notion as to what is right
and wrong

Disease
Objective pathologic process
Concepts:
2

 Illness without disease is

possible
Disease without illness is
possible
Illness may or may not be
related to a disease
One can have a disease
without necessarily feeling ill

Walter Cannon
Ability
to
maintain
homeostasis
A dynamic equilibrium
A state of balance of the
internal environment while
external
environment
is
changing

Deviance
Any behavior that goes
against social norms
Shortens life span
Results to disrupted family
and community
Concept:
Deviant behavior can
considered a disease

Florence Nightingale
Health is using ones power to
the fullest
Being well
Can
be
maintained
by
manipulating the environment
Virginia Henderson
Viewed in terms of ability to
perform the fourteen (14)
fundamental
needs
or
components of nursing care
UNAIDED

be

Rationale:
Because it also shortens the
life span like a disease

Martha Rogers
Positive health symbolizes
wellness
Health is a value term defined
by a certain culture

Example:
Alcoholism
o A disease rather than a
social problem
Wellness
Feeling of being well

Sister Calista Roy

A state and process of being
and
becoming
an
INTEGRATED PERSON

Definitions of Health
World Health Organization
Health is the complete
physical,
mental,
social
(totality) well-being and not
merely the
absence
of
disease or infirmity
A high-level wellness!

Dorothea Orem
Characterized by soundness
and
wholeness
of
DEVELOPED
HUMAN
STRUCTURES
and
FUNCTIONS

Claude Barnard
Ability to maintain internal
milieu

Imogene King
A dynamic state in the life
cycle (contrasted with illness)

 Illness is interference in the

life cycle

o Perceived seriousness
o Perceived threat
Likelihood of Action influenced
by:
o Perceived benefit out of
the action
o Perceived barriers

Betty Neuman
Wellness is that all parts and
subparts are in harmony with
each other and the whole
system
Dorothy Johnson
Elusive
dynamic
state
influenced
by
biologic,
psychologic and social factors

Smiths Four Levels of Health

1. Clinical Model
Man
is
viewed
as
a
Physiologic Being
If there are no signs and
symptoms of a disease, then
you are healthy
Against WHO definition of
health
This is the NARROWEST
concept of health
2. Role Performance Model
As long as you are able to
perform SOCIETAL functions
and ROLES you are healthy
3. Adaptive Model
Health is viewed in terms of
capacity to ADAPT.
Therefore, goal of treatment is
to restore capacity to adapt.
Failure to adapt is disease
4. Eudaemonistic Model
This is the BROADEST
concept of health
Because health is viewed in
terms of Actualization

Models of Health and Illness

Health-Illness Continuum
Dunns High Level Wellness and
Grid Model
X-axis is HEALTH
Y-axis is environment
Quadrant 1
High-level
wellness
in
favorable environment
Quadrant 2
Protected poor health in
favorable environment
Quadrant 3
Poor health in unfavorable
environment
Quadrant 4
Emergent high-level wellness
in unfavorable environment
Health Belief Model
By Rosentock
Based on a motivational
theory
It assumed that good health is
an objective common to all
people
Consider
perceptions
(influences
individuals
motivation toward results)
o Perceived susceptibility

Leavell and Clarks Agent, Host,

Environment Model
Also known as the Ecologic
Model
Expands to the MULTICAUSATION of a DISEASE
Definitions of a disease as to
its cause is expanded to a
4

multi-causation of a disease
(i.e. cancer is a multi-factorial
disease)
Triad is composed of the
agent, host and susceptible
host
Based on the interplay of
three components of the
model

Effects of Adrenalins
Increases Cardiac Rate
Response
to
increased
metabolic rate and oxygen
demand
Increases Respiratory Rate
Response
to
increased
metabolic rate and oxygen
demand
Bronchodilation
Vasoconstriction
Increased
Peripheral
Resistance
Increased Cardiac Workload
Increased Blood Pressure
Decreased Renal Perfusion
Decreased Renal Output
Pale, Cool, Clammy Skin

Concept of Health and Illness

Stress
By Hans Selye
Is a non-specific response of
the body to any demand
placed upon it.
General Adaptation Syndrome
(GAS)
Local Adaptation Syndrome
(LAS)

Adrenal Gland is composed of:

1. Adrenal Medulla
Releases adrenalins
2. Adrenal Cortex
Releases the following:
Mineralocorticoids
o Aldosterone
Glucocorticoids
Cortisol
o A
potent
vasoconstrictor

General Adaptation Syndrome

Involves two (2) body systems:
Nervous System
Endocrine System
Nervous System involves:
Sympathetic Nervous System
Parasympathetic
Nervous
system
Endocrine System involves:
Adrenal Glands

Mineralocorticoids
Increased Aldosterone levels
Increases sodium retention
and water retention
Increases circulating blood
volume
Increases cardiac workload
(due to vasoconstriction)

The Adrenal Gland is composed

of:
Adrenal Medulla
Adrenal Cortex
Adrenal
Medulla
Adrenalins or Fight
Hormones:
Epinephrine
Norepinephrine

releases
or Flight

Glucocorticoids
Increased
(transient)

hyperglycemia

Increased glycogenolysis
Increased neogenesis
Increases blood sugar
Increases osmotic pressure
Increases
fluid
retention
(glucose is a colloid which
attracts water and adheres to
it)
Increases cardiac workload

Stress
resulted
from
interaction of man with his
environment and fellowman
Therefore, Lazarus describes
the SOCIAL ASPECT OF
STRESS
Also
an
adopted
PHYSIOLOGIC RESPONSE

Key Concept!
The most comprehensive
concept of stress is the stress
concept of LAZARUS as it
combines Physiologic and
Social aspects of stress.

Concept:
Complications of Stress:
Cerebrovascular Attack
Increased
Diabetic
Ketoacidosis (if patient is
diabetic)
Hypertension
leading
to
cardiac arrest

Statements about Stress

Stress is NOT a nervous
energy
Man, whenever he encounters
stress, tends to adopt
Are you going around all
stress? ANSWER IS NO!!!
because stress is not always
to be avoided and stress is
not always undesirable
Stress may lead to another
stress
A single stress does not lead
to a disease

Local Adaptation Syndrome

Also known as non-specific
inflammatory response
Bradykinin
o Activates inflammatory
response
o Activates histamine
Histamine
o Activates the following:
Prostaglandin
Serotonin

Concepts:
Adaptation
to
stress
comprises of adjustments
made in order to cope with a
stressor

Concept:
Bradykinin,
Histamine,
Prostaglandin, and Serotonin
all increase swelling
Key Concept!
Hans Selye
o Author of Physiologic
Response to Stress

Man is holistic in his

adaptation to stress
It involves the totality of man:
o Physiologic
o Psychologic
o Social

Lazarus
Stress is a transaction

Illness Behavior and Stages of

Illness

Factors Affecting Compliance

Client motivation
Degree of required change in
lifestyle
Perceived severity of health
problem
Difficulty of understanding
instructions
Belief about the effectiveness
of the therapy
Nature of the therapy itself
o Adverse effects
o Cost
Cultural influences
Degree of satisfaction with the
relationship with health care
providers

Illness Behavior
Pertains to any activity
undertaken by a person who
feels ill in order to
Define his state of health
Discover a suitable remedy
IGUN Eleven stages of Illness
and Health-seeking Behaviors
1. Symptom Experience
Client realizes there is a
problem
Client responds emotionally
2. Self-medication / Self-treatment (if
not effective)
3. Communication to others
4. Assessment of symptoms
Purpose is to verify the
veracity of the complaint
5. Sick-Role Assumption
6. Concern Stage
7. Efficacy of treatment
Assess sources of treatment
Assess potential effectiveness
of treatment
8. Selection of Treatment Stage
Availability
Cost of Treatment
9. Treatment Proper
10. Assessment of Effectiveness of
Treatment
May go back to stage 7
(Efficacy of Treatment) if
treatment is not effective
May go to next stage if
treatment is effective
11. Recovery and Rehabilitation

Suggested Nursing Actions in

case of Non-compliance
Assess the reasons
Correct the misconception
Demonstrate a caring attitude
Encourage
and
provide
positive reinforcement
o Focusing
on
the
positive rather than on
the negative
o Focus on things patient
can still do and not on
what the patient can no
longer do
Establish
a
therapeutic
relationship of freedom and
mutual responsibility
o Make patient realize he
is also responsible for
his recovery
o He is a partner with the
health care team
o He
is
an
active
participant

Compliance
Adherence to professionals
advice

Guidelines
Compliance
7

to

Enhance

 Be sure patient understand

procedure
by
giving
information
Make sure patient is capable
of performing activity
o Set realistic goals
Ensure that he is a WILLING
participant
o Look for buying signals
Looking
at
wound
Looking
at
materials
needed

Martha Rogers
Nursing is a HUMANISTIC
SCIENCE
dedicated
to
compassionate concern for
the promotion of health,
prevention of illness and
rehabilitation of the sick
Sister Calista Roy
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

Definitions of Nursing:
American Nurses Association
Nursing is the diagnosis and
treatment
of
human
responses to illness (to actual
and potential health problems)

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!

Canadian Nurses Association

The same definition plus
includes the supervision of
functions and services in
collaboration with others to
promote health

Imogene King
Nursing
is
a
helping
profession that assists a
person
(same
with
Henderson)
towards
a
DIGNIFIED DEATH

Florence Nightingale
Nursing is the act of utilizing
the ENVIRONMENT for the
following purposes:
o Recovery
o Reparative process

Betty Neuman
Nursing is a profession that is
concerned
with
INTRAPERSONAL,
INTERPERSONAL,
and
EXTRAPERSONAL
VARIABLES
affecting
a
persons
response
to
stressors

Virginia Henderson
The unique function of the
nurse is to assist individuals,
sick or well, with the activities
towards health that he would
do unaided, if with strength
and knowledge. If that is not
possible,
towards
a
PEACEFUL DEATH

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

2. Dorothy Johnson
Behavioral Systems Model
Seven Subsystems
o Attachment
and
Affiliative
o Dependency
o Ingestive
o Eliminative
o Sexual Achievement
o Aggressive

Example:
o In a COPD patient who
remains a smoker, the
nurse who encourages
the patient not to
smoke, serves as an
external
regulatory
force

3. Virginia Henderson
Fourteen (14) Fundamental
Needs
focusing
on
PHYSIOLOGIC
SOCIAL
RECREATION
4. Faye Abdella
Problem Solving Approach to
Twenty-One (21) Nursing
Problems
Focus
is
on
PROPER
IDENTIFICATION
of
the
problem
Particularly about the proper
nursing diagnosis

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

5. Marjorie Gordon
Proposed
the
Human
Functional Health Patterns
used
as
a
systematic
framework for data collection
Focus is on Eleven (11)
Health Patterns
Advantage to the nurse:
o It enables the nurse to
determine the clients
response as functional
or dysfunctional
Eleven Functional Health
Patterns
o Health perception
o Nutritional / Metabolic
o Elimination

Hildegard Peplau
Nursing
is
the
INTERPERSONAL process of
THERAPEUTIC
INTERACTION between the
nurse and the patient.
NURSING THEORIES
Concept:
First
Nursing
School
Florence Nightingale

1. Florence Nightingale
Environmental Nursing Theory

o Activity and Exercise

Pattern
o Cognitive
Perceptual
Pattern
o Role
Relationship
Pattern
o Sexuality
/
Reproductive
o Coping-StressTolerance
o Value Belief Patterns

3. Conservation of Personal
Integrity
o Example:
maintain
patients privacy
4. Conservation of Social
Integrity
o Example: maintenance
of
patients
relationships
9. Betty Neuman
Health Care Systems Model
The concern of nursing is to
PREVENT
STRESS
INVASION

6. Imogene King
Goal Attainment Theory
Patient
has
three
(3)
interacting systems:
o Individuals / Personal
systems
o Group
systems
/
Interpersonal systems
fraternity
o Social systems

10. Dorothea Orem

Self-care and Self-care Deficit
Theory
Three (3) Nursing Systems
based on Art of Care of
Patient Needs
1. Partial Compensatory
o Patient performs some
of nursing care needs
2. Wholly Compensatory or
Total Compensatory
o For paralyzed patients,
for ICU patients
3. Supportive-Educative
o For up and about
patient

7. Madeleine Lehninger
Transcultural Nursing Theory /
Model
Nursing is a HUMANISTIC
and SCIENTIFIC mode of
helping through CULTURESPECIFIC PROCESS
8. Myra Levine
Four
(4)
Conservation
Principles of Nursing
1. Conservation of Energy
o Example: complete bed
rest without bathroom
privileges
2. Conservation of Structural
Integrity
o Example: turn patient
from side to side every
two hours to avoid bed
sores

11. Hildegard Peplau

Interpersonal Model
Four (4) Phases of NursePatient Interaction
1. Orientation
o Nurse and patient test
the role each one
assumes
o Prepares patient for
termination
o Patient identifies areas
of difficulty
10

 2. Identification Phase
o Patient identifies with
the personnel who can
satisfy his needs
3. Exploitation Phase
o Nurse maximizes all
the resources to benefit
the patient
4. Resolution Phase or
Termination Phase
o Occurs when patients
needs have been met

Man
is
a
BIOPSYCHOSOCIAL BEING
Four (4) modes of Adaptation
o Physiologic Mode
Compatible with
Hans Selye
o Self Consent
o Role Function
o Interdependence
14. Lydia Hall
CARE, CORE, CURE
Care
o Comfort
measures
given by the nurse to a
patient
o Nurturance aspect of
Nursing
Core
o Therapeutic use of self
Cure
o Activities in relation to
doctors orders
o Dependent orders

Concepts:
Various
settings
for
application of:
o Pre-Interaction Phase
In
psychiatric
setting,
this
consists
of
gathering data
o Pre-Entry Phase
In
community
health nursing,
this consists of a
courtesy call
12. Martha Rogers
Science of Unitary Human
Beings
Man is composed of energy
fields, which are in constant
interaction
with
the
environment

15. Jean Watson

Human Caring Model
Nursing
involves
the
application of ART and
HUMAN SCIENCE through
TRANSPERSONAL
TRANSACTIONS in order to
help the person achieve mind,
body and soul harmony

Concept:
The most reliable method of
identification is the Energy
Field. This is better than the
fingerprints as a persons
energy field is absolutely
unique!

16. Rosemarie Rizzo Parse

Theory of Human Becoming
Emphasis is a FREE CHOICE
(with personal meaning)
Actions of patients may either
be:
o Revealing
or
concealing
o Enabling or limiting

13. Sister Calista Roy

Adaptation Model

11

 Therefore,
there
is
a
consequence
o This
pertains
to
behavior and action

20. Margaret Newman

Health
as
Expanding
Consciousness
Humans are Unitary Human
Beings
The nurse is a NOT A GOALSETTER or an OUTCOME
PREDICTOR, rather is a
PARTNER OF THE PATIENT

17. Josephine Patterson and

Loretta Zderad
Humanistic Nursing Practice
Theory
Nursing is an EXISTENTIAL
EXPERIENCE between the
nurse
and
the
patient
(nagkataon-nagkatagpo!)
Nursing is a LIVE DIALOGUE
between the patient who
wants to be nursed and the
nurse who has the skill to
nurse

21. Joyce Travelbee

Interpersonal Process Theory
Nurse needs to go beyond
nursing roles to establish
therapeutic relationship
TRANSPERSONAL
COMMUNICATION as the
means
to
establish
therapeutic relationship
This implies that the nurse
should not be rigid in the
nursing role

18. Helen Tomlin, Evelyn Tomlyn

and Mary Ann Swain
Modeling and Remodeling
Theory
Focus is on the PERSON
Emphasis
is
on
the
UNCONDITIONAL
ACCEPTANCE
of
the
PATIENT

22. Ida Jean Orlando

Dynamic
Nurse-Patient
Relationship Model
There is movement, the
relationship is not static
If the patients condition
improved,
then
the
intervention is effective and
the patient moves on to new
problems

19. Ann Boykin and Savina

Schoenhofer
Grand Theory of Nursing as
Caring Theory
Nursing is NOT BASED on a
DEFICIT but rather it is an
EGALITARIAN
MODE
of
helping
This theory is against the
theory of OREM
Nursing is an obligation
towards humanity, whether
there is a need or NOT!

23. Nola Pender

Health Promotion Model
Motivation to participate in
health care activities is
influenced by COGNITIVE
and
PERCEPTUAL
FACTORS, which are:
o Importance of health to
the person
o Perceived control of
health

12

o
o
o
o

Self-efficiency
Perceived health status
Definition of health
Perceived barriers to
action

o Patients
illness
is
controlled
o Patient may still be in
the hospital
6. Unstable Phase
o Patient is on a critical
period
o Signs and symptoms
are present
o Patient is NOT in the
hospital
o Patient is NOT under
control
o Patient is OUT of the
hospital
7. Downward Phase
o Patient
is
in
a
deteriorating phase
8. Death

24. Poppy Buchanan, Barker and

Phil Barker
Tidal
Model
(Psychiatric
Nursing)
Helping patients recall their
own personal stories of
DISTRESS is the FIRST
STEP in helping them regain
control of their lives again!
25. Corbin and Strauss
Trajectory Model
The patient moves in a
TRAJECTION of Eight (8)
Phases
Nurse needs to follow the
patient along the eight phases
of trajection:
1. Pre-Trajectory Phase
o Patient shows no signs
and
symptoms
of
illness
o No sickness

26. Bonnie Weaver and Duldt

Battey
Humanistic
Nursing
Communication Theory
Emphasis
is
on
the
interpersonal
relationship
between the nurse, the
patient,
the
peers
and
colleagues
27. McGill Model of Nursing
Emphasis is to encourage and
engage the patient and the
family to actively participate in
learning about health

2. Trajectory Onset Phase

o Patient now has signs
and
symptoms
of
illness
3. Crisis Phase
o Patient is unstable
o Patient is in a lifethreatening situation
o Patient is critical
4. Acute Phase
o Patient is in a state of
active illness
5. Stable Phase

28. Kathryn Barnard

Parent-Child Interaction Model
(Pediatric Nursing)
In order to produce a healthy
person, the babys need
should be ADDRESSED AT
ONCE!
Application: Bonding

13

29. Alfred Adler

The
personality
of
an
individual is affected by the
BIRTH ORDER

o Environmental
Sanitation
o Recreation
Housing

30. Gladys Husted and James

Husted
Symphonological
Bioethical
Theory
Symphono- means harmony
and agreement
Governed
by
ethical
standards, which influence
nursing actions.

2. Secondary Prevention
Emphasis placed on:
o Early
detection
/
diagnosis
o Prompt treatment
o Health maintenance of
persons already having
health problems
o Prevention
of
complications
When given:
o During illness
Examples:
o Screening survey
o Encouraging
regular
check-ups
o Complying with regular
check-ups
o Teaching Breast-selfexamination
o Teaching
Testicularself-examination

LEVELS OF PREVENTION:
1. Primary Prevention
Emphasis on:
o Generalized
health
promotion and specific
protection
o Recipients
are
GENERALLY
HEALTHY PEOPLE
When given:
o Before onset of illness
or before onset of
disease
Examples:
o Generalized
health
education
Prevention
of
accidents
Standards
of
nutrition
o Immunizations
Specific
preventions
o Risk Assessment for
specific disease
o Family
Planning
Services and Marriage
Counseling

and

Concept:
o Most effective method
of
teaching
is
DEMONSTRATION
Additional
Examples
of
Secondary Prevention
o Assessment of growth
and development
o General
nursing
assessment and care
at
the
hospital,
community and the
home
3. Tertiary Prevention
Emphasis placed on:
14

o Support of the client to

achieve the following:
Successful readaptation
Optimal
reconstitution
Regain
highlevel wellness
Therefore, the purpose is
more of REHABILITATION
When given:
o Begins after the illness
or when a defect or
disability is fixed or
irreversible
Examples:
o Referring a client to
support groups
o Teaching a diabetic
client how to inject
insulin

o Helping
develop
skills

the
new

patient
coping

Concept:
Do not give advice!
o This is meant to
facilitate
decisionmaking on the part of
the client
o This is observed so
that the client would not
develop
DEPENDENCY
3. Client Advocate
Protects rights of patients
Activity:
o Speaking on behalf of
the patient
4. Change Agent
Brings change or adjustments
Nurse only influences a
patient
Nurse does not change the
patient

ROLES OF A NURSE
1. Caregiver / Care Provider
To convey understanding and
support
Activities:
o Support and comfort
measures (mothering
aspect of nursing /
nurturance aspect of
nursing)

5. Teacher
Teaching
Imparting of knowledge
6. Leader
Application of interpersonal
influence to bring out desired
behavior (leadership)

2. Counselor
Involves
helping
patient
identify and avoid stressful
and psychological problems
Focuses on:
o Helping client establish
capacity for successful
interpersonal relations

7. Manager
Decision-making
Planning
Giving directions
Monitoring operations
Facilitating staff development

15

 Therefore, this is done on the

supervisory
level
of
organization

Addresses
affective
cognitive learning
3. Answering Questions
Cognitive

8. Researcher
After graduation, nurse cannot
yet be a researcher
He can only be a researcher
after he receives his Master of
Arts in Nursing (M.A.N)
degree
TEACHING
AND
STRATEGIES

and

4. Demonstration
Motor
5. Discovery
Cognitive and Affective

LEARNING

Concept:
Learning is more effective if
the learner discovers the
content for himself. (That is,
through experience!)

Basic Guidelines
Develop
a
well-defined
objective
Assess clients readiness to
learn
Start with what the client is
concerned about
Assess and start with what the
client already knows; proceed
from the known to the
unknown
Start
with
the
simple
proceeding to the complex
Schedule a review of the
content

6. Group Discussion
Affective and Cognitive
Sharing feelings during group
dynamics
7. Practice
Motor
8.Printed and Audiovisual Material
9. Role-playing
For pediatric and psychiatric
nursing settings

Concept:
Areas of Learning Domain
o Knowledge cognitive
o Skills motor
o Attitude emotional

10. Modeling
What you say is what you do
11. Computer Assisted Learning
Programs
Online review

TEACHING STRATEGIES

THE NURSING PROCESS

1. Explanation and Description

Address cognitive aspect of
learning

Concept:
The Nursing Process was
introduced by LYDIA HALL!

2. One-to-one Discussion

16

Definition:
The Nursing Process is a
systematic, organized, rational
method of planning and
providing
individualized,
humanistic nursing care

BENEFITS DERIVED FROM THE

NURSING PROCESS
Concepts:
Both the nurse and the patient
benefit from the nursing
process
Patient obtains greater benefit
Remember:
Nursing process is CLIENTCENTERED or PATIENTCENTERED
and
NOT
NURSE-CENTERED

Purposes of the Nursing Process:

To identify health status
o Actual health problems
o Potential
health
problems
To establish plans
To deliver specific nursing
care

Benefits from Nursing Process:

Improves quality of care
Ensures
continuity
and
appropriate level of care
Facilitates client participation
through planning with patient
Enables nurse to maximize
resources
Feedback allows nurse to
evaluate care
Serves as a framework for
accountability
through
documentation
Promotes a positive working
atmosphere
through
collaboration
Helps the nurse define roles
to
those
outside
the
profession
For job satisfaction
Facilitates professional growth
Avoidance of legal action
Meeting
standards
of
accredited hospitals

Characteristics
of
Nursing
Process (MEMORIZE THIS!!!)
1. Goal-oriented
and
clientcentered
2. Cyclical
(no
absolute
beginning and end), dynamic
(moving) rather than static
3. Plan of care organized
according to client problems
rather than nursing goals
4. Basis of prioritizing nursing
activities
would
be
the
problems and not the goals
5. Follows a logical sequence
6. Universally applicable (to any
type of patient)
7. Interpersonal
and
collaborative
Work with patients and
relatives
Work with colleagues and
other members of the
health team
8. Adaptation of problem-solving
techniques and principles
9. Problem-oriented,
flexible,
open to new information
10. Allows creativity of nurse and
patient

PARTS OR COMPONENTS OF THE

NURSING PROCESS

17

 When performed:
o Integrated throughout
the nursing process
Purpose
of
On-going
Assessment:
o To identify problems
overlooked earlier
o To determine the status
of a health problem (i.e.
hydration status every
fifteen minutes)

ASSESSMENT PHASE OF THE

NURSING PROCESS
Nursing
Activities
Assessment Phase
Data collection
Data Organization
Data Validation
Data Recording

in

the

IMPORTANT CONCEPT!
No conclusion is developed in
the assessment phase

3. Emergency Assessment
When done:
o During
acute
physiologic
and
psychologic crisis
Where done:
o Emergency Room
o Comfort Room
o Anywhere!!!
o On site!!!
Purpose
of
Emergency
Assessment
o To
identify
lifethreatening condition
Framework or Principle in
Emergency Assessment
o A Airway
o B Breathing
o C Circulation
o Utilize either Maslows
Hierarchy of Needs or
ABC principle

Purposes of the Assessment

Phase
To create a data base of the
clients response to health and
illness
To determine the nursing care
needs of the patient
Four (4) types of Assessment:
1. Initial Assessment
When performed:
o At specified time after
admission
Where done:
o Done at the ward
Where Admitted:
o At the ward
Purpose of Initial Assessment:
o To create a data base
for
problem
identification
o For
reference
and
future comparison

4. Time-Lapsed Assessment
When done:
o Several months after
initial assessment
Purpose
of
Time-Lapsed
Assessment
o To compare current
status of patient with
base line data (initial
assessment)

2. Focus Assessment or On-going

Assessment

18

 The person who brought the

patient to the hospital

ASSESSMENT PROCESS
Concepts:
Data
is
information

equivalent

3. Environment of the Patient

Example:
o Patient with diabetes
mellitus
exhibits
acetone breath
Assess
for
diabetic
ketoacidosis

to

What is the initial output of the

Assessment Phase?
Data or Recorded Data
Never validated data!!!
Types of Data:

Methods of Data Collection

Observing
Interviewing
Examining

1. Subjective or Covert Data

Felt by the patient
During the recording of data,
this should be stated using the
patients own words
These are the symptoms felt
by the patient

1. Observing
It should be deliberate
Exert effort
Two (2) aspects of observation
process:
Noticing the stimuli
Do an interpretation of the
stimuli

2. Objective or Overt Data

Capable of being observed by
use of senses sight, touch,
smell, taste, hearing
These are the signs which are
observable

2. Interviewing
Two (2) types of Interview:

Sources of Data:

Directive Type of Interview

Structured
Uses closed-ended questions
calling for specific data
When used:
o When you need to elicit
specific data
o When there is little time
available

1. Primary Source
Patient himself except when:
o He is unconscious
o Patient is a baby
o Patient is insane
2. Secondary Source
Patients record
Health care members
Related literature or journals
Significant
others
(they
become primary source when
patient is unconscious
Family or relatives

Concept:
Characteristics of Closed-ended
questions:
Yes or No questions

19

 Asks when or asks for the

time when event happened
Asks how many
Point with finger when asking
to provide clarity
Therefore, they call for highly
specific answers

you already know or what

information is available
An interview is a planned
conversation with a purpose
An interview is a two-way
process
When is it done?
o When
patient
available
o When
patient
comfortable

Non-Directive Type or RapportBuilding Interview

Uses
more
open-ended
questions
Advantage is that it allows the
patient
to
volunteer
information

Stages of the Interview

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

2. Closed-Ended Questions
Questions answerable by
yes or no
Leading Questions
Phrasing of question suggests
what answer the interviewer is
expecting

2. Body of the Interview

Occurs when patient responds
to questioning

3. Neutral Questions
Phrasing allows patient to
answer with least pressure
Usually NOT addressed to
patient personally (i.e. what is
your opinion about)
Raised as a general topic

3. Closing Stage
How to close the interview:
o Summarizing
Technique
Validation of Data
Act of double-checking the
data
Purposes of Data Validation
o To ensure the:
Correctness
Completeness

Planning the Interview Setting

the
what

is

Recommended distance from

the patient is three (3) to four
(4) feet.

Types of Interview Questions:

1. Open-Ended Questions
Questions not answerable by
yes or no
Questions
that
elicit
information or explanation

Concepts:
Before
determine

is

interview,
information

20

Accuracy
of the data

Problem present at the time

the statement was made

Guidelines in Validating Data

Compare
subjective
and
objective data
Be familiar with word usage
(particularly if the patient is a
child)
Reassess / double-check data
which are extremely abnormal
Be sure that your data
contains CUES and not
INFERENCES
Be sure that your data is
FREE OF BIASES
Avoid jumping to conclusions

2. High-Risk Nursing Diagnosis

A diagnosis that a patient is
more
vulnerable
or
susceptible compared with
others in the same situation
3. Possible Nursing Diagnosis
There is an evidence of a
health problem but the causes
are NOT fully understood
4. Wellness Nursing Diagnosis
A positive statement
Indicates a healthy response
Examples:
o Potential for increased
compliance related to
increased
level
of
knowledge
o Potential for enhanced
body image related to
regular exercise
o Potential for effective
coping
related
to
adequate
support
systems

Data Recording
Concepts:
Data Recording COMPLETES
the Assessment Phase
Initial
Output
of
the
Assessment Phase is DATA
Final
Output
of
the
Assessment
Phase
is
RECORDED DATA
DIAGNOSING PHASE
NURSING PROCESS

OF

THE

Domains of Nursing Diagnosis

Key Concept!
It
only
includes
health
problems that a nurse is
capable and licensed to treat

Activities during the Diagnosing

Phase:
This
involves
sorting,
clustering,
analyzing
and
interpreting data

Parts of a Nursing Diagnosis

1. Problem Statement
Example:
o Fluid Volume Deficit
2. Presumed Etiology
Example:
o related to frequent
loss
of
bowel
movement

Concept:
The final output in the
Diagnosing Phase is a
NURSING DIAGNOSIS!!!
Different
Types
of
Nursing
Diagnoses:
1. Actual Nursing Diagnosis

21

3. Defining Characteristics
Example:
o as manifested by
decreased skin turgor

o At specified time upon

or after admission of
the patient
2. On-going Planning
Who are involved:
o Done by all nurses who
worked with the patient
o The patient himself
o The family
o But
primarily,
the
NURSE
Purposes
of
On-going
Planning
o To determine if the
clients health status
has changed
o To
decide
which
problems to focus on
during the shift
o To set priorities for
client care during the
shift
o To
coordinate
the
patient
care
and
activities so that more
than one problem can
be addressed at the
same time

Advantages of Using Standardized

Diagnostic Terminology
Provides
professional
accountability and autonomy
by defining and describing the
independent areas of practice
Provides effective vehicle of
communication
Provides
an
organizing
principle
for
meaningful
research
Facilitates
continuity
and
individualized care
PLANNING
PHASE
NURSING PROCESS

OF

THE

Concept:
Planning means:
Determining ahead of time
Forecasting a course of action
Key Concept!!!
For your plans to be effective,
involve the patient and the
family

3. Discharge Planning
Purpose
of
Discharge
Planning
o To ensure continuity of
care

IMPORTANT CONCEPT!!!
Final output of the Planning
Phase is a NURSING CARE
PLAN or a WRITTEN CARE
PLAN

Characteristics or the Planning

Process
S Specific
M Measurable
A Attainable
R Realistic
T Time bound

Types of Planning
1. Initial Planning
Done by the nurse
When done:

Activities during Planning Process

22

 Set priorities
Set goals
Identify alternatives of nursing
care
Select nursing measures
Write
nursing
orders
(supervisors do this)
Write the nursing care plan

Requirements for Implementation

Adequate knowledge
Technical Skills
Communication skills
Therapeutic use of self
Right
attitude
as
a
requirement
Nursing Activities during the
Implementation Phase
Reassess the patient
o Rationale
To determine if
the procedure is
still needed
Determine the need for
nursing assistance
Implement
the
nursing
strategies
Communicate the procedure
performed by documenting
the procedure
Understand orders
o Clarify / verify doctors
orders
Encourage
patient
to
participate actively

Purposes of Goal-setting
To set direction
To provide a time span
To have a criteria for
evaluation
To enable the nurse and the
patient to determine whether
the
problem
has
been
resolved or not
To help motivate the client and
the patient by providing a
sense of accomplishment
Key Concept!!!
For your goal to be useful
during evaluation, it should be
stated
in
BEHAVIORAL
TERMS
IMPLEMENTING PHASE OF THE
NURSING PROCESS

Guidelines for Implementation of

the Nursing Strategies

Implementation
Putting the care plan into
action

Key Concept!!!
It should be based on
scientific
knowledge,
research,
professional
standards of practice (care)
o Rationale:
This is done to
ensure
safe
nursing care
It should be adapted to the
individual patient
It should always be safe. Do
not compromise

Purpose of Implementation
To carry out planned activities
To help the client
Concept!!!
The implementation phase
ends upon recording of the
care given and the response
of the patient to that
procedure

23

 It should be holistic
It should be accompanied by
support, comfort and teaching

EVALUATION PHASE
NURSING PROCESS

OF

o Allows the nurse to

decide and make onthe-spot modification/s
in an intervention

THE
2. Intermittent Evaluation
When done:
o At a specified time
Purpose:
o It shows the extent of
progress of the patient
Importance:
o Enables the nurse to
correct deficiencies and
modify the nursing care
plan

Purpose of the Evaluation Phase

To determine clients progress
To
determine
the
effectiveness of the care plan
To determine as to what
extent the nursing goals have
been met
Importance of doing an Evaluation
It determines if the care plan
will be:
o Continued
o Modified
o Discontinued

3.Terminal Evaluation
When done:
o At
or
immediately
before discharge
Importance:
States the status of a health
problem at the time of
discharge
It determines whether the
goals are:
o Met
o Partially met
o Unmet

Activities during the Evaluation

Phase
Identify
the
OUTCOME
CRITERIA to be used as
measurement
Gather information (data)
relevant to the outcome
criteria
Compare outcome (data) with
the criteria
Assess the reasons for the
outcome
Revise the nursing care plan
as needed

DOCUMENTATION
It is a written, formal
document
A record of clients progress

Types of Evaluation
1. On-going Evaluation
When done:
o During or immediately
after the intervention
Importance:

Purposes of Documentation
Planning Care
Communication
For
legal
documentation
purposes
For research
24

 For education
Reimbursements
For
statistics,
reporting,
epidemiology
Accreditation, licensing

assembled into an orderly or

scientific manner
Classification of information is
based on SOURCE
Each person or department
maintains a different section
on chart

Guidelines on Documentation
Timing
o Document patient care
as soon as possible
Observe confidentiality
Observe permanence
o Use non-erasable ink
o Do not use sign pen
Signature
o Sign full name and
append R.N.
Accuracy
o Ensure that data is
correct
o Avoid biases
o Avoid ambiguous terms
Appropriateness
o Write only appropriate
information
Completeness
Use standard terminology
Brevity
o Make it concise yet
meaningful
Legal Awareness
o Cross out erroneous
entry
o Write Error
o Countersign

Components of a Source Oriented

Clinical Record
Admission Sheet
Face Sheet
Medical History and Physical
Examination Sheet
Diagnostic Findings Sheet
TPR Graphic Sheet
Doctors Treatment and Order
Sheet
Therapeutic Sheet
Problem Oriented Clinical Record
Same as Problem Oriented
Medical Record
Entry of data is based on
CLIENTS PROBLEM
Example:
o Problem
No.
1:
constipation
Increase
fluid
intake: doctor
Diatabs:
pharmacist
NPO:
Includes observations about
the patient
Example:
o Radiologists notes are
with doctors notes
under one problem

TYPES OF RECORDS
Source Oriented Clinical Record
Accumulation
of
chronological,
variative
notations that are difficult to
follow because they are not

Problem List
Contains
problems
information
problem)
25

only
ACTIVE
(and
relevant
about
the

 No potential problems (these

are contained only in the
progress notes)

Is the Kardex a part of the

patients record?
No, it is not!!!
It is just a bulletin board

Four (4) Basic Components of

Problem Oriented Clinical Record

Purpose of the Kardex

To make valuable information
readily available
Allergies are written in red ink
It is a reminder
It is not a record

1. Baseline Data
All information gathered from
a patient when he first entered
the agency
2. Problem List

Concept:
A Nursing Care Plan is not a
record

3. Initial list of orders or Care

Plans

COMMUNICATION
IN NURSING

4. Progress Notes
Includes:
o Nurses narrative notes
(SOAPIE)
o Flow sheets
o Discharge Notes and
Referral Summaries

Communication
Exchange
of
ideas,
information, feelings, data
between two communicators
Concept:
Communication is the basic
component
of
Human
Relationships

Formats:
SOAPIE for revisions
COMMON
METHODS
OF
COMMUNICATION
AMONG
NURSES

Elements of Communication
1. Message
Data
2. Sender
Encoder
3. Receiver
Decoder
4. Feedback
5. Context
Setting
Overall environment where
the
communication
takes
place

1. Referring
To endorse patients special
concern to a higher authority
or a specialized department or
personnel
2. Confer
Verifying information
3. Reporting
Giving information
concerned person

to

TECHNIQUES

Modes of Communication
1. Verbal

KARDEX
26

Oral
Spoken
Written communication
Texted communication
Cable communication
Telex communication
Facsimile communication

o One person believes

that the space and all
the things in that space
belongs to him
o Do not enter abruptly;
this may result in
breach of privacy
Roles and relationships

2. Non-verbal communication
Facial expression
Grimacing
Posture
Gait
Adornment
Make-up
Gestures

Therapeutic Communication in
Nursing
Using Silence
o Supplement with nonverbal communication
Provide General Leads
o Examples:
go on
tell me more
Open-ended questions
Use Touch
o But assess the culture
of the patient
o If the patient is a child,
touch the patient on the
top of the head
o If the patient is an
elderly,
touch
the
patient on the hand
o If the patient is of the
same age level, touch
the patient on the
shoulder
Offering yourself
o For autistic child
Stay nearby or
stay beside the
patient
Presenting Reality
o Example:
You are in the
hospital
Reflecting
o Example:

Factors Affecting Communication

Ability of the communicator
Perceptions
Proxemics
o Distances
between
communicators
Intimate
Distance
Actual
physical
contact to
1.5 feet
Personal
Distance
1.5 feet to
4 feet
3 feet to 4
feet
for
interview
Social Distance
4 feet to
12 feet
Public Distance
12
feet
and
beyond
Territoriality
27

What do you
think will make
you happy
o Never
agree
nor
disagree
o Reflect it back or throw
it back

REM sleep is NOT AS

RESTFUL
as
NON-REM
sleep
However, REM sleep is
NEEDED
Dreaming is a psychological
outlet of pent up emotions

Non-therapeutic Communication
Stumbling blocks to effective
communication
Stereotyping
Generalizing
Agreeing and Disagreeing
No confrontation
No argument
Being defensive
Moralizing
or
Passing
Judgment
Giving Common Advise
Examples:
If I were you
You should have done it

Nursing Alert!
Deprivation of REM sleep
results to:
o Irritability
o Restlessness
o Poor concentration

2. Non-Rapid Eye Movement Sleep

(Non-REM Sleep)
Deep restful sleep
Benefit is that it restores the
body
physically
and
psychologically (especially for
post-operative patients)
Concept!
Deprivation of Non-REM sleep
causes:
o Physical exhaustion
o Decreased resistance
against infection

PROMOTING REST AND SLEEP

Circadian Rhythm
A biological rhythm
A biological clock
Regulated from outside the
persons body

Wellness Teachings to Enhance or

Promote Sleep
Establish a regular routine
Have adequate exercise at
daytime
o Avoid
stimulating
activity by bedtime
Avoid all types of stimulants
o Caffeine-containing
foods
Coffee
Cocoa
Chocolate
Tea
Cola

Types of Sleep
1. Rapid Eye Movement Sleep
(REM sleep)
Increased brain metabolism
and activity
Also called PARADOXICAL
SLEEP
Characterized by:
o Vivid dreams
o Easily recalled upon
awakening
Concepts!
28

o Nicotine
o Alcohol
Prolongs
the
REM stage of
sleep
It excites the
patient like an
anesthetic
Not a stimulant
Avoid shabu
Use the bed mainly for sleep
If unable to sleep, get up and
pursue satisfying activity
Drink something warm or hot
(except stimulants)
o Milk
contains
Ltryptophan
o L-tryptophan
is
an
amino acid with a
natural sedative effect
that induces one to
sleep
Do something HOT!
o Twice-a-week
masturbation is ideal
o Facilitates release of
tension of the day
Side-to-side turning every two
hours with back tapping
Support bedtime rituals
Remove all music in order to
sleep

Proteins
Fats
Concepts:
Glucose is a ready source of
energy
for
metabolic
processes
Carbohydrates
When eaten are metabolized
to glucose for energy
Excess carbohydrates are
converted to glycogen and
stored in the liver
Other excess carbohydrates
go to the fat cells
Key Concept!
During
starvation,
stored
glycogen is converted to
glucose via a process called
glycogenolysis
If glycogen is used up, fat
resources are converted to
glucose via a process called
gluconeogenesis
Nursing Alert!
Fat conversion to glucose
produces waste products
called KETONE BODIES
These give rise to metabolic
acidosis as in Diabetic
Ketoacidosis

PROMOTING NUTRITION
Proteins
Macromolecules composed of
o Carbon
o Hydrogen
o Oxygen
o Nitrogen

Additional concepts!
During
starvation
protein
reserves are converted to
glucose via process called
gluconeogenesis

Basic Body Needs:

Carbohydrates

Gluconeogenesis
Production of glucose out of
non-carbohydrate products

29

 Plant protein is considered as

incomplete protein

Lipoproteins
Substances composed of fats
and proteins

2. Non-essential Proteins
Proteins that can be produced
by the body

Types of Lipoproteins
1. High Density Lipoproteins
(HDL)
High-grade lipoprotein
Good grade lipoprotein
Good cholesterol
Function of HDLs
o Transports the bad
cholesterol
from
systemic circulation to
the liver for metabolism
and
eventual
elimination

Functions of Protein
Main element of our cells.
o Building blocks of the
cells are proteins
Resistance against infection
o Formation
of
Immunoglobulins
(globular proteins)
Maintenance
of
normal
intravascular fluid volume
o Works with glucose
and sodium
o Albumin
Main protein of
blood
Acts as a colloid
Attracts
water
around it

2. Low Density Lipoproteins (LDL)

Low-grade lipoprotein
Bad cholesterol
Function of LDLs
They clog the blood vessels
3. Very Low Density Lipoproteins
(VLDL)
Very bad cholesterol

Concepts!!!
If
protein
levels
are
decreased,
sodium
and
glucose will not be enough to
hold plasma inside blood
vessel resulting into edema

Functions of Fats
Insulation
Heat Conservation
Source of Energy

In
liver
cirrhosis,
hypoalbuminemia results to
edema

Proteins
Two (2) types in terms of needs of
the body:
1. Essential Proteins
Proteins that cannot be
produced by the body itself
To be sourced out from food
eaten
Animal protein is complete
protein

VITAMINS
Two (2) types of Vitamins
Fat Soluble Vitamins
Water Soluble Vitamins
Fat Soluble Vitamins
1. Vitamin A

30

 Essential for normal vision

For transmission of light
stimulus via the optic nerve

MICRONUTRIENTS
Ferrous sulfate (FeSO4)
Forms:
o Tablet
o Liquid
o Injectable
Oral (tablet and liquid forms)
o Take on an empty
stomach
o If there is GI distress
(i.e. diarrhea), take with
food
o If GI distress subsides,
take on an empty
stomach
Toxic effects:
o Constipation
(first
option)
Oral Liquid Iron
o Use dropper and apply
at the back of the
tongue or use a straw

2. Vitamin D
Source is food
Precursor is in the skin
Sunlight is needed for Vitamin
D to be converted to its active
form
Function:
o Influences
calcium
metabolism
o To metabolize calcium
Concept!
Without Vitamin D, there
would be decreased calcium
levels
Increased levels of Vitamin D
leads to increased calcium
levels
Vitamin E
Anti-oxidant
Promotes cell membrane
integrity (like Vitamin C)
Vitamin for the heart and skin
Sources are meats and in
vegetables
Deficiency results to Vitamin E
deficiency hemolytic anemia

o Rationale:
To avoid staining
the teeth
Health Teaching!!!
o To
enhance
iron
absorption,
advice
taking orange juice
o Vitamin C in orange
juice enhances iron
absorption
o Do not take milk
o Milk inhibits absorption
of iron
o Too
much
fiber
prevents absorption of
iron
o Thus, do not take oats
when taking iron.
Injectable Iron
o Route is deep I.M.

Vitamin K
Synthesis of clotting factors
Synthesis of prothrombin
Concept!
Decreased levels of Vitamin K
leads
to
prothrombin
deficiency
Deficiency in prothrombin
leads to bleeding
31

o Use Z-track technique

o Gauge of Needle is at
least 18
o Length of Needle is
1.5 to 2.0
o Site of administration is
the
GLUTEAL
MUSCLE ONLY!!!
o Rationale:
To avoid staining
the skin
Concept:
o Use an airlock
o Place 0.5 ml of air in
syringe
so
that
medication would not
leak
into
the
subcutaneous tissues
Nursing Alert!
o Apply firm pressure for
at least five (5) minutes
after injection
Do NOT massage

Raw fruits and

vegetables
Fried Foods
Whole
grains
and cereals

3. Pureed Diet
Osteorized diet
4. Full Liquid Diet
Foods that melt or liquefy at
body temperature
5. Clear Liquid Diet
Given to surgical patients
Limited to:
o Water
o Coffee
o Tea
o Cola
o Clear stained broth
o Gelatin
o Hard candies
Nursing Alert!
o Dairy products are
avoided

SPECIAL DIETS
1. Light Diet
Given
for
post-operative
patients
Plainly cooked
No spices
Large amounts of FAT omitted
Avoid bran and high fiber

6. High Fiber Diet

For patients
constipation

at

risk

for

7. Candidiasis Diet
Free of the following:
o Fruits
o Sugar
o Yeast
o Fermented foods

2. Soft Diet
For people with difficulty with
swallowing and chewing
Generally low residue diet
Nursing Alert!
o Avoid the following:
Nuts
Seeds (tomato,
guava, berry)

8. Low Residue Diet

Reduced fiber
To decrease GI irritation
For patients with bowel
inflammatory diseases:
o Chrons disease

32

o Ulcerative colitis

ENTERAL FEEDING
1. NASOGASTRIC TUBE FEEDING
(NGT)
Purpose of NGT insertion
o For gastric gavage and
lavage
o For administration of
food and medication
o To keep the stomach
empty
o To prevent aspiration
from regurgitation of
gastric contents
o For
gastric
decompression
How to Insert NGT
o Depth of Insertion
Measure length
from the tip of
the nose to the
ears to the tip of
the
xiphoid
process
Insertion:
o Position the patient in
semi-Fowlers
or
Fowlers position
o While
inserting
to
NASOPHARYNX
Position
the
head
in
a
hyperextended
manner
o When glottis, epiglottis
are approached
Flex the head
o Rationale:
To prevent entry
of the tube into
the trachea
Nursing Alert!
o Watch for signs and
symptoms
of

Acid-Ash Diet
To alkalinize urine
To soothe an irritated bladder
and urethra
Give citrus fruits
Give vegetables
Exceptions are:
o Prune Juice
o Cranberry Juice
o Both produce ACIDIC
URINE
Ash-Acid Diet
Given to acidify urine
To minimize or help control
Urinary Tract Infections
Give the following:
o Protein
o Meat
o Poultry
ASSESSMENT OF NUTRITIONAL
STATUS
Anthropometric Measurements
Skin Fold Test
Derived from reserved fat of
the body
Mid-upper arm Circumference
Measurement
Obtains the muscle mass of
the body
This reflects the protein
reserves of the body
Laboratory
diagnostic
procedure for albumin
SUPPORTING
NUTRITION
OF
PATIENT:
ENTERAL
AND
PARENTERAL FEEDING
33

RESPIRATORY
DIFFICULTY
o If there are signs,
WITHDRAW TUBE
o While inserting tube,
observe for coughing or
difficulty of breathing
After
inserting,
ascertain
proper placement on the
stomach
Concept!
o Most accurate method
to test for proper
placement of the NGT
is via X-RAY
Other ways to test proper
placement:
o 1. Let patient hum
If positive for
humming, tube
is
in
the
esophagus and
stomach
If negative for
humming, tube
is in the trachea
Nursing Alert!
o Small-bore tube allows
patient to hum
o Therefore, this method
is NOT RELIABLE
o 2. Determine the pH of
the aspirate
Use litmus paper
Change of color
from BLUE to
RED indicates
that the aspirate
is acidic and,
therefore, from
stomach
contents
Change of color
from RED to
BLUE indicates

that the aspirate

is basic and,
therefore, from
lung contents
IMPORTANT CONCEPTS!!!
o To insure safety of the
patient prior to feeding,
CHECK
THE
FOLLOWING:
Placement of the
tube
For
patient
safety
To
prevent
LUNG
aspiration
of food
Patency of the
tube
To
insure
successful
introduction or
administration
of food
o 3. By auscultating the
epigastric region while
insufflating 50 ml of air
Hear
gurgling
sound
TUBE FEEDING
Never try to submerge the
free end of the NGT to water
o This
is
potentially
dangerous
o If in trachea and
submerging of free end
to water coincides with
inspiration, it will suck
the water and lead to
pulmonary aspiration
Position during feeding:
o Fowlers Position

34

 Measure
gastric
residual
volume
o Subtract this from total
feeding to introduce
o If aspirate is greater
than 50 ml for adult or
10 ml for infant, then
WITHHOLD FEEDING
for 2 3 hours.
o Rationale:
Patient is not yet
ready for next
feeding.
o If same occurs after 2
3
hours,
NOTIFY
DOCTOR.
There
is
a
problem
with
gastric emptying
Watch out for COUGHING
o Leakage to trachea
If with DIFFICULTY OF
BREATHING
o Stop the procedure
Flush with water after feeding
to avoid clogging of the tube
After the procedure
o Do not place the
patient on bed before
30
minutes
have
lapsed
o Rationale:
To
prevent
aspiration
and
regurgitation
Average volume of feeding:
o 300 ml to 400 ml

o External jugular vein of

the neck
Important Concept!!!
o Tube must reach two
(2) centimeters before
or above the RIGHT
ATRIUM
Nursing Responsibilities:
o Watch out for signs and
symptoms of embolism
Care of Insertion Site
o Application of sterile
dressing
with
antibacterial ointment as
ordered by doctor (prn)
GASTROSTOMY TUBE FEEDING
(Enteral)
No auscultation needed
Assess for the patency of the
tube
Use water to do this
PROMOTING OXYGENATION
DEEP BREATHING
Two (2) types of Deep Breathing:
1. APICAL DEEP BREATHING
Done to expand the upper
portion of the lungs
Let the patient place palms on
the upper chest
Concentrate on that area
Take a slow deep breath at a
count of 1,2,3
Release it slowly through the
nose or a pursed lip at a count
of 4,5,6,7
Therefore, expiration is longer
than inspiration
Rationale:
o To prevent respiratory
alkalosis
Taught to patients who will
undergo:

TOTAL PARENTERAL NUTRITION

Introduced directly to the
bloodstream
Tube is inserted via the:
o Subclavian vein
o Internal jugular vein of
the neck
35

o Upper
abdominal
surgery
o Cholecystectomy
Incision site on
diaphragm
Patient does not
want to breathe
Predisposed to
hypostatic
pneumonia

NURSING ALERT!!!
o Coughing
is
contraindicated in the
following patients:
With increased
intracranial
pressure (ICP)
With increased
intraoptical
pressure (IOP)
With
cardiac
arrhythmias (but
are allowed to
do
deep
breathing)

2. BASAL DEEP BREATHING

Same procedure
Area of concentration is the
lower ribcage
When to teach patient:
o Before surgery
o Before pain is present
Rationale:
o If pain is already
present, it would be
difficult for patient to
follow
When done:
o Done q2 hours together
with turning

Concepts!!!
Deep Breathing and Coughing
o Purpose is to stimulate
surfactant production
Yawning and sneezing also
stimulate
surfactant
production
OXYGEN
INHALATION
ADMINISTRATION

AND

Practical Application Concept!

When administering oxygen,
be sure to open the valve of
the oxygen tank first.
Be certain that the valve on
the regulator is closed so that
the flow meter would not
break!

COUGHING EXERCISES
Purpose
o To expand the lungs
o To
facilitate
expectoration
of
secretions
How often done:
o At least every two (2)
hours
Procedure
o Teach the patient to
inhale and exhale
o Tell the patient to inhale
and exhale a second
time
o Tell the patient to inhale
and cough out

Concept!
Humidifier
moistens
the
oxygen administered
Purpose
o To avoid drying and
irritation of the mucosal
lining
o Also traps particulates
from the tank

36

Iron oxide may

be present in the
tank (iron plus
oxygen
produces
iron
oxide or rust)

2. High Flow Administration

Uses a venturi mask
NEBULIZATION
With sodium chloride and
salbutamol
A physiologic solution
Water liquefies secretions
Sodium chloride stimulates
coughing
Salbutamol is a bronchodilator
Purpose:
o For expectoration of
secretions

Concept!
Fire Precaution
o Place NO SMOKING
sign at the door or at
the head part of the
patient
Tank and oxygen do not
explode
They
merely
support
combustion

Nursing Pre-therapy Assessment

Prior to Nebulization
Have
baseline
data
of
patients breath sounds
Assess
again
after
nebulization
to
assess
effectiveness of the procedure

Other Concepts!
Do
not
use
volatile
substances
Acetone and alcohol can react
with oxygen and lead to
toxicity of patient
Do not use oil based or
grease on any part of the
oxygen set
Do not allow the patient to use
an electric razor as sparks
may trigger combustion

SPIROMETRY
Purpose is to expand the
lungs
Done when inhaling
Instruction to the patient:
o Inhale
from
the
spirometer and NOT
blow to the spirometer
Procedure:
o Inhale exhale
o Inhale exhale fully
o Place
mouthpiece
between teeth
o Hold breath for four (4)
seconds
o Then inhale, fully rising
the ball
Upon inhalation, the ball rises

Nursing Alert!
Retrolental Fibroplasia occurs
if there is excess oxygen
administration
in
infants.
Excess oxygen leads to
destruction of the retina and
blindness
Modes of Administration
1. Low Flow Administration
Utilizes nasal cannula or nasal
prongs or nasal catheters
Given to COPD patients

CHEST PHYSIOTHERAPY
This is a dependent procedure
37

 There
are
no
absolute
contraindications
to
this
procedure
Contraindicated
for
the
following patients with:
o Pacemakers
o Lung abscess
o Hemoptysis
o Dangerous Arrhythmias
o Active PTB (which
goes to the other lobe)
o Lung CA (malignancy
goes to other lung)
Three components of
Physiotherapy
Vibration
Percussion
Postural Drainage

Assess breath sounds to

know which lung fields have
secretions
Then assess again after
procedure
to
check
effectiveness
of
the
procedure.
Concepts!!!
Vibration and percussion are
done to mechanically dislodge
secretions
Nebulization is done to liquefy
secretions
Suctioning is done to clear
secretions
Postural Drainage is done to
drain secretions using gravity

Chest

Postural Drainage
When done:
o Before meals
o Two (2) hours after
meals
Before doing the procedure,
the following baseline data are
needed:
o Breath sounds
o Vital signs
o Continuous
ECG
monitoring
During the procedure:
o Ensure the comfort of
the patient
o Provide a kidney basin
and tissue paper
Nursing Alert!
o Watch out for signs of
symptoms which may
require stopping of the
procedure:
Sudden dyspnea
Cyanosis
Extreme
diaphoresis

Vibration
Palms of your hand are
placed on chest or back of
patient
giving
quivering
motions
Palms remain in contact with
the chest or back
Percussion
Use cupped hands
Hands alternate in rising and
coming into contact with chest
or back of patient
Postural Drainage
Drain secretions by gravity
Change positions
IMPORTANT CONCEPT!!!
o Rule
out
contraindications
before
performing
chest physiotherapy
Pre-therapy
Assessment
Vibration and Percussion

for

38

Sudden
alteration
of
blood pressure,
respiratory rate,
pulse rate
Appearance of
arrhythmias
Hemoptysis
General
intolerance
of
the procedure

SUCTIONING
Purpose is
secretions

to

seek

out

Concepts!!!
Question:
o If you have only one (1)
suction catheter, which
will you suction first,
the nose or the mouth?
Answer:
o If the patient is an
infant or a newborn:
Start on the
mouth
then
proceed to the
nose
Rationale:
o If you start on the nose,
you will trigger the
sneezing reflex and this
would
result
into
aspiration
Answer:
o If the patient is an
adult,
suction
the
mouth
first,
then
proceed to the nose
Rationale:
o This
is
done
for
aesthetic reasons

Important Concept!
If any of the above occurs,
STOP THE PROCEDURE
and inform the physician
Concepts!
After the procedure assess
the following:
o Breath sounds
o Vital signs
o Quantity and quality of
sputum
o Overall response of the
patient
to
the
procedure
Give oral hygiene
o Rationale:
To
eliminate
phlegm from the
mouth
Important Concept!!!
Patients with cystic fibrosis
benefit much from postural
drainage
TYPES OF SUCTIONING
Type of
Position of
Suctioning
the Patient
while
Suctioning

Depth

Oropharyngeal

39

Duration

Interval
with
each
Pass of
Suction

Total
Time

Suctioning
If
patient
conscious

is Fowlers (high 10 15
or moderate);
centimeters
Head turned to
one
side
(towards
the
nurse)

Not more 20 30
than 10 seconds
15
seconds

Not
more
than 5
minutes

If the patient is Place on one 10 15

unconscious
side (facing the centimeters
nurse);
Tilt neck to
move
head
slightly forward
towards
the
basin to avoid
aspiration
during
suctioning
Nasopharyngeal
Suctioning

Not more 20 30
than 10 seconds
15
seconds

Not
more
than 5
minutes

If the patient is Neck should be

conscious
hyperextended;
Fowlers
position

From tip of
the nose to
tip of the
earlobe

Not more 20 30
than 10 seconds
15
seconds

Not
more
than 5
minutes

If the patient is Flat on bed

unconscious
with
head
turned to the
nurse
Lateral position
may
be
assumed

From tip of
the nose to
the tip of
the earlobe

Not more 20 30
than 10 seconds
15
seconds

Not
more
than 5
minutes

TYPES OF SUCTIONING
Type of
Position of
Suctioning
the Patient
while
Suctioning
Orotracheal
Suctioning

Depth

Duration

40

Interval
with each
Pass of
Suction

Total Time

If patient is Low
to Measure
Not more 20 30 Not more
conscious
semifrom mouth than
10 seconds
than
5
fowlers
to
mid- seconds
minutes
position
sternum
If the patient Flat
on Measure
Not more 20 30 Not more
is
bed;
from mouth than
10 seconds
than
5
unconscious
Suction
to
mid- seconds
minutes
trachea
sternum
through the
mouth
Nasotracheal
Suctioning
If the patient Low
to From tip of Not more 20 30 Not more
is conscious
semithe nose to than
10 seconds
than
5
fowlers
earlobe to seconds
minutes
position
dominating
side
of
neck to the
thyroid
cartilage
If the patient Flat
on From tip of
is
bed;
the nose to
unconscious
Suction
earlobe to
trachea
dominating
through the side
of
nose
neck to the
thyroid
cartilage

41

Not more 20 30 Not more

than 10 seconds
than
5
15
minutes
seconds

TYPES OF SUCTIONING
Type of
Position of
Suctioning
the Patient
while
Suctioning

Depth

Interval
Total
with
Time
each
Pass of
Suction
Endotracheal
Semi-Fowlers 12.5
5 10 2 3 Not
Tube Suctioning if
not centimeters seconds minutes more
contraindicated or 6 inches;
than 5
Insert
as
minutes
far as it
goes until
you meet
resistance
or
until
patient
coughs

42

Duration

Tracheostomy
Semi-Fowlers Insert
as 5 10 2 3
Tube Suctioning if
not far as it seconds minutes
contraindicated gets until
you meet
resistance
or until the
patient
coughs

Important Concepts!!!
For Endotracheal Suctioning
o NO TUBE IS USED
HERE
o This is suctioning of the
trachea through the
mouth or through the
nose
Two (2) types of Endotracheal
Suctioning
o Orotracheal Suctioning
Oral approach
o Nasotracheal
Suctioning
Nasal approach

Not
more
than 5
minutes

For
Endotracheal
and
Tracheostomy (Naso and Oral
and Tube)
o Before
suctioning,
HYPEROXYGENATE
the patient
o During
intervals,
HYPEROXYGENATE
the patient
For ET, Tracheostomy, ET
Tube
o Nursing Alert!
During insertion,
if you encounter
resistance,
withdraw
the
catheter about
one centimeter

General Conditions for Suctioning

43

o
o
o

(1 cm) before
applying suction
Rationale:
To avoid trauma
on the mucous
membrane
Do
suctioning
intermittently
Suctioning should not
be continuous
Rotate the catheter
(between the thumb
and the index finger) as
you withdraw
Apply
suction
only
when you are ready to
withdraw (i.e. keep
finger
away
from
suction port if you are
still not ready)

o Instill 2.5 ml to 5.0 ml

Normal Saline Solution
for adults to liquefy the
mucous plug
o Instill 2.0 ml Normal
Saline Solution for
children to liquefy the
mucous plug
Instill 0.5 ml to 1.0 ml Normal
Saline Solution for infants to
liquefy the mucous plug
VITAL SIGNS
TEMPERATURE
Oral
Axillary
Rectal
Oral Method
Most convenient
Most accessible
Nursing Alert!
o Applicability
is
for
children aged six (6)
years and above
o Not
applicable
for
children below six (6)
years old
Contraindicated in patients
with:
o Oral surgery
o Mouth breathers
o History of convulsive
seizures
o Unconscious
o Incoherent
o Irrational
o Mentally disrupted
o Insane
Procedure
o Nothing Per Orem for
about
thirty
(30)
minutes before taking
temperature

How to Hyperoxygenate the

Patient
Give two (2) to three (3) blows
by ambubag
Increase
flow
rate
and
concentration of oxygen
Nursing Alert!
o If the patient has thick,
tenacious secretions,
DO NOT USE AN
AMBUBAG
o Use
an
OXYGEN
INSUFFLATION
SUCTION CATHETER
instead!!!
o This is a two-lumen
catheter (one lumen
brings oxygen to the
patient, the other lumen
brings out secretions
from the patient)
In the event of encrustations,
PERFORM
TRACHEAL
LAVAGE

44

o No food intake
o No drinks
o No smoking
o No chewing gum
o No whistling
o No gargling
Rationale:
o Any of the above would
alter the result
Placement:
o Under
the
tongue,
beside the frenulum
(right or left)
Total Time:
o Two (2) to three (3)
minutes

Rectal Method
Most reliable (except for
tympanic thermometer)
Most accurate (except for
tympanic thermometer)
Concept!
o If tympanic method is
used using a tympanic
thermometer, the rectal
method is only second
most
reliable
and
second most accurate
Disadvantage:
o Placement
on
a
different site yields a
different reading
o Therefore, ensure that
the bulb of the rectal
thermometer rests on
the mucous membrane
Contraindications:
o Hemorrhoids
o Rectal Surgery
o Certain
Cardiac
ailments
due
to
stimulation of the vagus
nerve;
valsalva
maneuver leads to
arrhythmias
Position of Patient when
taking the reading:
o Sims left position
o Sims right position
o For Newborn, lift up
ankles to keep buttocks
up
o In Toddlers, set on
prone
position
on
adults lap
Duration:
o Two (2) minutes

Axillary Method
Least realiable
Safest method
Nursing Alert!
o During application, be
sure that axilla is dry
o Dry using a patting
motion
Nursing Alert!
o Do NOT RUB!!!
Rationale:
o This increases heat
due to friction
o Rubbing
increases
blood supply to the
area
o Therefore, there will be
increase in temperature
reading
o Rubbing provides a
false-positive elevation
of temperature reading
Duration:
o In adults nine (9)
minutes
o In children five (5)
minutes

Conversion
Fahrenheit
45

of

Centigrade

to

 Centigrade = (5/9)F 32
Centigrade = (F/1.8) 32
Conversion of Fahrenheit
Centigrade
Fahrenheit = (9/5)C + 32
Fahrenheit = (1.8)C + 32

to

Concepts!!!
Peak
body
temperature
occurs at 12NN to 3PM or
4PM
Lowest body temperature
occurs in the early morning
hours of the day

FEVER
Normally, the hypothalamus is
able
to
adjust
body
temperatures between 37C
to 40C
But due to the presence of
pyrogenic materials like the
following:
o Pathogenic
microorganisms
o Toxins
o Foreign substances
o Any substance capable
of increasing body
temperature
Creates a deficiency of -3C,
making a person enter the
FIRST STAGE OF FEVER

First Stage of Fever

Typical signs and symptoms
indicate
the
bodys
compliance mechanism to
increase and conserve heat:
o Chills
o Shivering
o Gooseflesh
Contraction
of
arectores

46

pilorum or pilo
arecti muscles
o Vasoconstriction
Decreases blood
supply to the
skin
Pallid Skin
o Cyanotic nail beds
Key Concept!!!
o Patient complains of
feeling cold
o Sweating
will
stop
because
body
will
minimizes heat loss
Also called:
o Onset Stage
o Chill Stage
o Cold Stage
This stage is characterized by
low febrile temperatures
Nursing Management
o Key Concept
Aim
is
to
minimize
heat
loss
o Key Concept
Do NOT apply
TEPID SPONGE
BATH because
this would make
patient progress
to SHOCK
Provide additional clothing as
necessary
Provide additional blankets as
necessary
Provide something warm to
drink
These measures would result
to a gradual increase in body
temperature
Question:
o When will you start
application of TSB?

 Answer:
o If there is a 1C to 2C
increase
in
body
temperature

Patient complains of:

o Loss of appetite
o Myalgia
or
muscle
pains due to increased
catabolism
Nursing Management
o Tepid Sponge Bath
o Cooling Bed Bath

Second Stage of Fever

Also called:
o Coarse Stage of Fever
o Peak Stage of Fever
Key Concept!
o Patient does not feel
hot or cold
o Skin is warm to touch
o Skin is flushed
o Fever
blisters
are
present
Herpetic lesions
o Absence of shivering
o Possible dehydration
Important Concept!!!
o For every increase of
temperature, there is a
corresponding increase
in pulse rate
Rationale:
o Increase
in
temperature results in
an increase in pulse
rate due to increased
metabolic rate
o Increased
metabolic
rate increases oxygen
demand
o 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
Increased oxygen demand
also leads to an increase in
respiratory rate

Tepid Sponge Bath

Temperature of water is
32C
o This temperature is
maintained
throughout
the
procedure
How to apply:
o Done by patting
Rationale:
o To avoid friction,
which
increases
temperature
Important Concept!
o Do
NOT
use
ALCOHOL
when
applying TSB
Rationale:
o Alcohol dries the
skin and leads to
irritation
Key Concept!
o TSB should not be
done hurriedly
Rationale:
o When
done
hurriedly, TSB will
stimulate shivering
o Shivering
would
lead to increased
muscle activity
o Increased muscle
activity would lead
to
increased
temperature

47

Cooling Bed Bath

Water temperature will
start at 32C
Procedure will go on with
gradual decrease in water
temperature until it is
maintained at 18C
Therefore, to achieve this
drop in temperature, utilize
ice
Same
procedure
of
application as in Tepid
Sponge Bath
Types of Fever
1. Intermittent Fever
A fever that is alternated at
regular intervals by periods
of normal and subnormal
temperature

If pulse is regular, count or

monitor pulse for thirty (30)
seconds and multiply by
two (2). This is legal!
If pulse is irregular, count
or monitor the pulse for
one (1) FULL minute
Assessment of the Pulse Deficit
This is the most accurate
method
Involves two nurses using one
watch
Starts at the same time
Ends at the same time
Comparison of results ensues
Count is done for one (1) full
minute

2. Remittent Fever
Fever alternated by wide
range of fluctuations in
temperature, all of them
are ABOVE NORMAL.
Duration is within a 24hour period

Scale in Pulse Assessment

0 - Absent or cannot be felt
1+ - Weak or thready
2+ - Normal
3+ - Grounding

3. Relapsing Fever
Short periods of febrile
episodes alternated by one
(1) to two (2) days of
normal temperature

Systolic
Produced
by
ventricular
contraction
Pressure on blood vessels
during
depolarization
or
ventricular contraction

BLOOD PRESURE

4. Constant Fever
Minimal fluctuations of
temperature, all of which
are ABOVE NORMAL

Diastolic
Pressure that remains in the
walls of the blood vessels
during
relaxation
or
repolarization or resting

5. Staircase or Spiking Fever

Common in patients with
TYPHOID FEVER

Broadly two (2) types:

Direct
o By insertion
catheter

PULSE ASSESSMENT
Concepts!
48

of

 Indirect Method
o Auscultatory method
o Palpatory method
o Flush Method

o 160 / no muffling / 110

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

Auscultatory Method
Uses Korotkoff sound
o A popping sound
o NOT the heart beat
o It is a phenomenon
an
unknown
phenomenon!
Determining Amount of Inflation
Using auscultatory method
o Ask patient what is his
last BP reading and
then add 30 40
mmHg
from
last
systolic reading.
o Deflate gradually rate
is approximately 2 3
mmHg per second
Alternative
auscultatory
method
o Auscultate for the last
sound as you go up.
Then add 30 40
mmHg
o Then deflate

Repeat using:
Auscultatory method
Palpatory method
How to do the Palpatory Method
Inflate
o Determine up to what
point to inflate
o Palpate pulse
o If pulse is absent, add
30 40 mmHg
Deflate
o First palpable pulse is
true systolic pressure
For
diastolic
pressure,
proceed
using
the
auscultatory method

Tripartite Blood Pressure

Done if patient is an adult.
Example:
140 mmHg systolic first
loudest sound
100 mmHg 1st diastolic
muffling
70 mmHg 2nd diastolic last
sound
o Therefore, the tripartite
blood pressure is 140 /
100 / 70
If there is no muffling, an
example would be:

Flush Method
Represents the mean blood
pressure
Represents the average of the
systolic
and
diastolic
pressures

49

 When done:
o When you have a BP
apparatus without a
stethoscope
o Used
for
pediatric
patients
How done:
o Inflate up to the point
where
extremity
becomes pale
o Deflate slowly and look
for
a
REBOUND
FLUSH

when
extremity becomes red
again
This is the true reading!!
Note that there is only ONE
reading!!!

Stage 1
Involves the epidermis
Manifestation
o Non-blanchable
erythema of INTACT
SKIN
o This
is
the
first
heralding
sign
of
decubitus ulceration
Stage 2
Partial Thickness Skin Loss
Involves epidermis and dermis
Manifestation
o Blister formation
o Shallow craters
o Shallow abrasion and
ulceration

SKIN INTEGRITY
Decubitus ulcers are caused
by:
o Unrelieved, sustained
pressure
o Localized ischemia
o Shearing force
o Pressure plus friction
Predisposing Factors:
o Unconsciousness
o Incontinence
o Loss of Sensation
o Hypoproteinemia
Decreased lean
muscle mass
Increase in fluid
shifting leads to
edema
Dependent
position is the
skin attached to
or facing the bed
o Emaciation
Stages
of
Formation

Decubitus

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
Stage 4
Formations
and
manifestations of Stage 3
plus
o Involvement of bones,
supporting structures
(tendons),
joint
capsules
o Massive damage
Tools to Assess Risk of Ulceration
Nortons Pressure Area Risk
Assessment Form
Shannons Scoring System

Ulcer

50

 Branden Scale of Predicting

Ulceration
Waterlow Risk Assessment
Cards
o Most important tool
o Most common tool
o Most often used tool

3+
4+
5+

3 cm induration
4 cm induration
5 cm induration

PAIN MANAGEMENT
Pain
A noxious stimulation of actual
or threatened / potential tissue
damage

EDEMA
Caused by shifting of fluid into
the interstitial tissues

Categories of Pain according to

Origin
Cutaneous
o Skin
Deep Somatic
o Tendons, ligaments
o Bones
o Blood Vessels
Visceral Pain
o Organs of the body

Management of Edema
1. Elevation of the edematous part
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

Categories of Pain based on

Cause
Acute
o Due to trauma or
surgery
o Persists for less than
six (6) months
Chronic Malignant Pain
o Related to cancer
o On and off
o Persists for more than
six (6) months
Chronic Non-malignant Pain
o Persists for more than
six (6) months

Concept!
If edema is due to prolonged
standing,
DO
THE
ELEVATION
2. Wear elastic stockings
3. Use warm compress alternated
with cold compress
Rationale:
Vasoconstriction
and
vasodilation
causes
recirculation of fluid
Concept!
This is contraindicated if there
is inflammation

Categories of Pain according to

Where It Is Experienced
Radiating Pain
o Felt on the source and
is extending to nearby
tissues
Referred Pain

Assessment of Edema
Induration
1+
1 cm induration
2+
2 cm induration

51

o Felt on other parts

detached
from
the
source
o Example:
o Pain on a lacerated
liver may be felt on the
right shoulder and not
on the right upper
quadrant
Intractable Pain
o Highly resistant to painrelief methods
Phantom Pain
o Pain that is felt on a
MISSING BODY PART
or a PART THAT IS
PARALYZED
by
SPINAL
CORD
INJURY.

o Pain signals are carried

to the spinal cord by
the small diameter
nerve fibers
Large diameter nerve fibers
also
pass
through
the
substancia gelatinosa
o Large diameter nerve
fibers close the gate
prevents
the
transmission
of
impulses through the
spinal cord
o Therefore,
when
LARGE
DIAMETER
NERVE FIBERS ARE
STIMULATED,
THE
GATE IS CLOSED
Pain management operates
on the principle of how to
stimulate the Large Diameter
Nerve Fibers to close the
gate.

Pain Threshold
Amount of pain stimulation
that is required in order to feel
pain

Pain Management Strategies

Pain Tolerance
Maximum amount of pain and
duration that a person is
willing to endure

Pharmacologic Methods
Narcotics
NSAIDs
Adjuvants or Co-analgesics

Gate Control Theory

Concept!
This is the most widely used
theory in pain management

Non-Pharmacologic Methods
Physical Interventions
Cognitive
/
Behavioral
Interventions

Concepts!
At the dorsal horn of the
spinal cord is a gate.
This gate is called the
SUBSTANCIA GELATINOSA
A series of nerves pass
through this gate
Small diameter nerve fibers
pass through the substancia
gelatinosa

Non-Pharmacologic
Physical
Interventions
1. Cutaneous Stimulation
Massage
o Effleurage
o Soft massage
o Gentle stroking
Petrissage
o Hard massage

52

o Large
and
quick
pinches
o Also done by striking
Application of Counter-Irritant
o Bengay
o Menthol
o Omega Pain Killer
o Flax Seeds
o Poultices
Heat and Cold Application
o Nursing Alert!
o Rebound Phenomenon
When you apply
heat
(usually
done
for
20
minutes),
vasodilation
is
produced
If heat is applied
for more than 20
minutes, there is
vasoconstriction
This
is
an
inherent defense
mechanism from
burning
of
tissues
Cold Application
o Maximum
vasoconstriction
is
reached when skin
reaches 15C
o If there is further drom
in temperature, there is
vasodilation
(skin
becomes reddish)
o This is the inherent
defense
mechanism
from being frozen
Accupressure
o Pressure on certain
points of the body
o Stimulates release of
endorphins, which have

natural
analgesic
effects
o This started in Ancient
China
Accupuncture
o Insertion
of
long
slender needles on
certain
chemical
pathways
o Origin is also Ancient
china
Contralateral Stimulation
o Example: Injury on left
side and massage is
done on the right side
o Useful when patient
cannot be accessed:
For patients in a
cast
For patients with
burns
For patients with
phantom pain
2. Immobilization
Application of splints
3.Transcutaneous Electrical Nerve
Stimulation
Composed of electrodes
Operated by battery
Electrodes are applied on
painful site or over the spinal
cord
4.Administration of a Placebo
Relieves pain because of its
intent and not because of
physical
or
chemical
properties
Cognitive or Behavioral NonPharmacologic Interventions
Purpose:
o To alter pain perception

53

o To alter pain behavior

o To provide client with a
greater sense of control
over the pain

URINARY ELIMINATION
Oliguria
Renal output of less than 500
ml per day

Specific Interventions
1.Distraction
Purpose is to divert attention
from pain
Slow Rhythmic Breathing
o Stare at a certain
object
o Take
deep
breath
slowly
o Release
or
exhale
slowly
o Concentrate
on
breathing
o Picture
a
peaceful
scene
o Establish a rhythmic
pattern
2.Massage
Breathing

and

Slow

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
o Never had a dry period
Secondary Enuresis
o Acquired enuresis
o At age 7, bladder
control is present for at
least one year
o Then, enuresis comes
back
o Urinating could NOT be
controlled again

Rhythmic

3.Rhythmic Singing and Tapping

Key Concept!
o Faster beat music is
more preferable
4.Guided Imagery
Imagine that you are walking
along a peaceful shore
Eyes
are
closed
and
suggestions are given

Incontinence
Involuntary passage of urine

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

Types of Incontinence
1.Functional Incontinence
Involuntary passage
Unpredictable time

54

2.Reflex Incontinence
Occurs
at
somewhat
predictable
times
when
specific bladder volume is
reached
No awareness of bladder
filling
No urge to void
It may be related to neurologic
impairment

o Advise patient to stand

with legs slightly apart
o Concentrate
on
perineum
o Draw perineum upward
slowly
Alternative way:
o When urinating, try to
stop in the middle of
flow or try to stop
diarrhea from flowing
o Advantage of Kegels
Exercises
o Increases muscle tone
of the pelvis
o Increases
muscle
control

3.Stress Incontinence
Loss of urine is less than 50
ml occurring with increased
intra-abdominal pressure
o Occurs when laughing
o Occurs when sneezing
o Occurs when smiling
Total Incontinence
Continuous flow of urine
No bladder distention
No bladder spasm
No awareness of bladder
filling

2.Clean
Intermittent
Self
Catheterization
Applicable
for
Reflex
Incontinence
How done:
o Use a mirror for:
Obese
male
patients
Female patients
Concept!
o Possible
Board
Question:
Is your Clean
Intermittent Self
Catheterization
procedure
a
sterile
procedure?
o Answer:
No, it is just a
clean procedure.
Therefore, you
can just wash
the catheter for
the next use.

Urge Incontinence
Urine flows as soon as a
strong sense of feeling to void
occurs
Strong bladder spasm
Management of Incontinence
1.Kegels Exercises
Also called:
o Pubococcygeal Muscle
Exercises
o Pelvic Floor Muscle
Exercises
Applicable for:
o Functional
Incontinence
o Stress Incontinence
How done:

3.Credes Maneuver
55

 Application of a steady but

gentle pressure on the suprapubic region to force urine out
of the bladder
Nursing Alert!
o Do not use if there is
OBSTRUCTION
(i.e.
renal obstruction in the
form of renal stones)
o This is done only for
patients who are no
longer expected to
regain control (Reflex
incontinence
and
retention)

o Let
patient
wash
genitals
o Dry the genitals
o Get to bed
Place patient in semi-Fowlers
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

4.Prompted Voiding or Scheduled

Toileting
For Reflex Incontinence

Coude Catheter
o Elbowed catheter for
Benign
Prostatic
Hypertrophy patients
Robinson Catheter
o Straight catheter
Multi-Lumen
Retention
Catheter
o 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 selfsealing rubber

5.Application of Adult Catheter and

External Condom Catheter
For
elderly
with
Total
Incontinence
6.Catheterization
MIDSTREAM
CLEAN
CATCH
URINE SPECIMEN
How is this done?
If patient is a Male
o Clean the penis
o Do this from the
meatus down to the
shaft
o Let the patient urinate
o Discard the first or the
initial urine
o Collect midstream urine
o Purpose is to attain
sterile specimen for
urine
culture
and
sensitivity testing
If patient is a Female

Concepts!!!
See to it that penis is
perpendicular to body to
straighten up the urethra to
bladder
While inserting the catheter,
ask the patient to breathe
through the mouth

56

 Cleanse the penis before

insertion
Grasp penis firmly to avoid
stimulating erections
Where to tape catheter
o Tape it upward on the
abdomen
Rationale:
o To
avoid
scrotal
excoriation
o Tape on the inner thigh
(with penis sideways
either on left or right
and follow the normal
contour of the penis
Length of Catheter
o 40 centimeters
Depth of Insertion
o While inserting, the
point at which urine
starts to flow, insert
further by five (5)
centimeters and then
inflate the balloon
KOZIER
o Insert up to a the Ypoint,
retract
after
inflating (this method is
more prone to infection
For females
o Insert at female Urethra
Length of Catheter
o 22 centimeters
Depth of Insertion
o Point at which urine
starts to flow, insert
further by five (5)
centimeter
before
inflating balloon

Regular exercise
High fiber diet
Avoid ignoring the urge to
defecate
Do not abuse laxatives
Concepts!
For Flatulence
o Avoid
carbonated
drinks
o Do not use straw
o Avoid chewing gum
o Avoid
gas-forming
foods:
Camote
Cabbage
Cauliflower
Onions
For Constipation:
Increase fluid intake
Prune juice
Papaya
Increase fiber in the diet
Use METAMUCIL (natural
fiber) instead of laxatives
Special Laboratory Procedures
1.Guiac Test
To determine the presence of
occult blood
Concepts!!!
o Have a meat-less diet
three (3) days before
examination
o Withhold
oral
iron
supplements
o Injectible
iron
is
allowed
o Avoid any food that
discolors the stool.

GIT FECAL ELIMINATION

Wellness Teachings
Fluid intake of at least 2,000
ml per day

2.GI SERIES

57

Upper GI Series Barium Swallow

Nursing Considerations:
o Elimination of contrast
medium
How:
o Increase fluid intake
o Increase fiber in the
diet
Rationale:
o To offset the risk of
constipation
o Inform patient that the
color of the stool will be
WHITE

o Also contraindicated in
possible appendicitis or
appendicitis patients
Rationale:
o Can lead to rupture of
the appendix
2. Carminative Enema
Used to expel out flatus
Burned sugar
Now commercially available
3. Oil Retention Enema
Purpose:
o To lubricate the colon
and to soften the feces
o Retention time is one
(1) to three (3) hours

Lower GI Series Barium Enema

Done
at
the
radiology
department
Nursing Concern:
o Elimination of Barium
How:
o Cleansing enema may
be needed after barium
enema

4. Retention Flow Enema

Also called Harish Flush
Enema
Solution
is
continually
administered until what comes
out of the body is clear.

Different Types of Enema

Positions in Enema
Cleansing Enema
High Cleansing Enema
o Clean as much of the
colon as possible
o On introduction, Sims
Left position facilitates
flow of enema to
sigmoid colon
o Then, assume Dorsal
Recumbent position to
facilitate flow of enema
to transverse colon
o Then, Right Side-Lying
position to facilitate
flow of enema to the
descending colon
Low Cleansing Enema

1. Cleansing Enema
Soap suds enema
Alkaline solution
Nursing Alert!
o Contraindicated
in
patients
with
liver
cirrhosis
and
with
increased ammonia in
the blood
Rationale:
o Alkaline
solution
facilitates transfer of
ammonia from the GI
tract to the bloodstream
Therefore, use lemon juice or
dilute vinegar instead!!!
Nursing Alert!

58

o For cleaning of rectum

and colon only

During stimulation or Period of

Excitement
Males
o Erection of the penis
Females
o Redness near the ear
o Nipples, breasts move
up
o Fourchette retracts
o Clitoris becomes visible
o Increased
vaginal
secretion
o If female is unaroused,
there is backpain as
penis hits the cervix
If the female is wellstimulated, the cervix rises

SEXUALITY
Human Sexual Response
Excitement / Physical Stimulation
Erotic stimuli causes sexual
stimulation
Lasts for a few minutes to
several hours
Types of Stimulation
Physical Stimulation
Oral stimulation
o Fellatio
Oral stimulation
of the penis
using the mouth
o Cunningulus
Oral stimulation
of the vagina
o Anningulus
Oral stimulation
of the anus
In homosexual
male,
typhoid
fever may be
obtained
from
anningulus
Male
and
Female oral sex
is
called
SOIXANTE
NEUF

Plateau Stage
Lasts thirty (30) seconds to
three (3) minutes
In males:
o Scrotum rises upward
o Shaft
of
penis
increases in length and
width
In females:
o Cervix rises
In both sexes:
o There is increased
muscle tone
o Myotonia
Orgasmic Phase or Orgasmic
Stage
Climax of sexual tension
Peak of sexual experience
Lasts three (3) to ten (10)
seconds

Physiological Sexual Stimulation

Stimulation by:
o Smell
o Sight
o Hearing
o Fantasy
o Spoken words
o Mental imagery

Resolution Stage
Key Concepts!
o Females have longer
resolution phase
59

o Males have shorter

resolution phase

Concepts!
Hair on the skin should not be
shaved if it does not interfere
with the procedure
If hair needs to be removed,
the best method would be
through the use of:
o Clippers
o Depilatory cream
Shaving is NOT ADVISED.
This is the last choice
Where is shaving done?
o Not at the Operating
Room!

PERIOPERATIVE NURSING
Stages of Perioperative Nursing
Pre-operative Phase
Intra-operative Phase
Post-operative Phase
Pre-operative Phase
Begins upon decision of
patient
to
undergo
the
operation
Ends when patient is placed
on the operating table

TYPES OF WOUNDS

Intra-operative Phase
Begins when patient is placed
on the operating table
Ends when client is admitted
to the Post-Anesthesia Care
Unit or PACU

1. Clean Wound
Uninfected
No inflammation
Respiratory, Alimentary and
Urinary tracts are not entered
2. Clean Contaminated Wound
A surgical wound
No evidence of infection
Respiratory, GI, Urinary tracts
are entered

Post-operative Phase
Begins upon admission to the
PACU
Ends upon the discharge of
the patient
Skin Preparation
Purpose:
o To
reduce
postoperative infection by:
Removing
soil
and
transient
microbes
Reducing
microbial count
to
subpathological
level in a short
period of time
with
minimal
skin irritation.

3. Contaminated Wound
Involves large spillage of
content from the GI, Urinary
and Respiratory tracts
Positive for inflammation
Positive for infection
Dirty Infected Wound
Old wounds
Necrotic, gangrenous wound
Modes
of
Dressing
1. Dry to Dry
60

Applying

Gauze

 A wide mesh of cotton applied

to the surface of the wound
A second layer is applied over
it
2. Wet to Dry
Inner layer is saturated with
NSS or anti-microbial agent
On top is a moist absorbent
material
3. Wet to Damp
A variation of wet to dry
It is removed before it is
completely dried
4. Wet to Wet
Inner layer is saturated with
NSS or anti-microbial solution
Second layer is a wide mesh
It is kept moist with a wetting
agent

61