FUNDAMENTALS OF NURSING
activities, health promotion, the primary
• Think about it…
• ABCDEFGHIJKLMNOPQRSTUVWXYZ
• Is represented as 1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24 25 26
• Then:
• H-A-R-D-W-O-R-K
• 8+1+18+4+23+15+18+11=98%
• K-N-O-W-L-E-D-G-E
• 11+14+15+23+12+5+4+7+5=96 %
• A-T-T-I-T-U-D-E
• 1+20+20+9+20+21+4+5=100 %
• And look how far the love of God will take you
• L-O-V-E-O-F-G-O-D
• 12+15+22+5+15+6+7+15+4=101 %
NURSING
• Is the extent to which an individual or group is
able to realize 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.
Major Nursing Goals
• Promotive – an action or measures designed
to support behavior conducive to health
• Preventive – any actions or measures
designed to protect individuals, families,
groups, communities from harm to their health
• Curative – any actions or measures designed
to correct or remove disease or any illness.
• Rehabilitative – any actions or measures
designed to restore health and promote
recovery from any alteration of health
Roles and Responsibilities of Nurses:
• Caregiver – helping clients promote, restore,
and maintain dignity, health and wellness
• Communicator/Helper – central role of
nurses in identifying needs of the client
• Educator/Teacher – involves nursing
concern
• Counselor – providing emotional, intellectual
and psychological support
• Manager/Coordinator – manages the nursing
care.
• Change agent – assists client to modify
behavior
• Leader – influences other to work together
towards a mutually envisioned goal.
• Clinician – use of technical expertise to
administer nursing care
• Advocate – promotes what is best for the
client, protects the client rights
• Researcher – participates in scientific
investigation; uses research findings in
practice
• Collaborator – initiates nursing action within
the health team
NURSING THEORIES
Florence Nightingale
• mother of modern nursing
• developed and described the first theory of
nursing
• environmental theory
Virginia Henderson
• defined nursing to assist the individual , sick or
well, in the performance of those activities
contributing to health or its recovery that he
would [perform unaided if he ad the necessary
strength, will or knowledge.
• introduced the nature nursing model
• identified fourteen (14) components of basic
nursing
Faye Glenn Abdellah
• defined nursing as service to individuals,
families and society.
• introduced patient-centered approaches to
nursing model
• identified twenty one (21) nursing problems
Dorothy Johnson
• nursing’s primary goal is foster equilibrium
within the individual, which allows for the
practice with individuals at any point in the
health-illness continuum.
• conceptualized the behavioral system model
• identified seven (7) behavioral subsystem
Hildegard Peplau
• defined nursing as a healing art of human
relationship between an individual who is sick,
or in need of health services, and a nurse to
recognize and respond to the need for help.
• viewed nursing as an interpersonal process
• conceptualized four (4) sequential phases of
interpersonal relationship
• characteristics of Interpersonal Relationship
Goal oriented
Understanding, emphatic
Concreteness
Honest, open communication
Acceptance, nonjudgmental attitude
Lydia Hall
• nursing is participation in care, core and cure
aspects of patient care
• key concepts of three interlocking circles
Dorothea Orem
• nursing is needed when the self care demands
are greater than the self care abilities
• defines three steps in nursing process
• key concepts of self care deficit theory of
nursing
• identified three (3) classifications of nursing
systems
Wholly compensatory – dependent on others
Partly compensatory – both nurse and patient
perform care
Supportive-Educative – can perform but with
assistance
Imogene King
• nursing is a process of action, reaction, and
interaction whereby nurse and client share
information about their perception in the
nursing situation
• postulated the Goal Attainment Theory
Martha Rogers
• nursing is an art and science that is humanistic
and humanitarian
• conceptualized the science of unitary human
beings and principles of homeodynamics
Jean Watson
• conceptualized the human caring model
• emphasized that nursing is the application of
the art and human science through
transpersonal caring transactions through self
knowledge, self control, self care and self
healing
Ida Jean Orlando
• conceptualized the dynamic nurse – patient
relationship model
• advocated the three (3) elements composing
nursing situation; client behavior, nurse
reaction and nurse action.
Joyce Travelbee
• postulated interpersonal aspect of nursing
model
• viewed that interpersonal process is a human
to human relationship formed during illness
and “experience of suffering”
NURSING PROCESS
Nursing Process
• the cornerstone of the nursing profession.
• it is synonymous to problem solving approach
• it is originated from the theory of Lydia hall,
Dorothy Johnson and Ida Jean Orlando
• It is problem-oriented, goal-oriented,
organized, systematic, humanistic care /
interpersonal, dynamic, cyclical and universal
Assessment
• collecting, validating, organizing and recording
data
• to establish data base
• identify appropriate nursing interventions
• write a nursing care plan
Implementation
• skills performed competently
• perform in appropriate environment
• clients safety protected
• putting nursing care plan to action
• carry out planned nursing interventions to help
attain goals and achieve optimal level of health
• to determine the order in which nursing
interventions are carried out

• collection of data • relevant documentations should be done

• methods of collection data Evaluation

• making information is accurate • assessing the client’s response to nursing

interventions
• clustering facts into groups of information
• appraise the extent to which goals and
Diagnosing outcome criteria of nursing care have been
achieved
• clinical art of identifying problems
• identify the client’s needs and to prepare • analyze the reasons for the outcomes
diagnostic statements
• use PES format MEDICATION
• organize cluster or group data Pharmacokinetic Process
• compare data against standards • Absorption
• analyze data after comparing with standards. • Distribution
• determine the client’s health problems, health
risks and strength • Metabolism
Planning
• Excretion
Types of Doctor’s Order
• formulating and documenting client focused
goals • Standing Order
• provide individualized care • Single Order
• promote client participation • STAT order
• allow involvement of support people • PRN order
• establishing priorities
Therapeutic Actions of Drugs
• short term goal and long term goal
• SMART well stated outcome criteria • Palliative
• Curative A patient is to receive NPH 50 u s.c. daily. Stock
is 100 u/ml in 10 vial. How many milliliter should
• Supportive be administered?
Answer is: _______
• Substitutive
Example 5:
• Chemotherapeutic The physician order reads “Administer 0.02 gram
• Restorative furosemide (Lasix) IM.” Stock is 20 mg /ml
ampule. How many milliliters will you administer?
Answer is: ________
7 Rights of Medications
• Pediatric Dose:
• Right Client A. Clark’s Rule
• Right Medication weight in lbs X usual adult dose = Safe
• Right Dosage CD
150 lbs

Example 6:
• Adult Dose: Baby Tina weighs 30 lbs and the adult dose 25
mg. What is the safest dose for Baby Tina?
Oral Medication (Solid) Answer is: _______

Desired dose = safe adult dose B. Freid’s Rule

Stock dose
Example 1: Age in months X usual adult dose = Safe
An hypertensive agent, minoxidil (Loniten) 5 mg CD
p.o. is ordered. Stock is 2.5 mg/tab. How many 150 months
tablets should be administered?
Example 7:
Answer is: _______
Baby Joey is now 11 months old, the adult dose
Example 2: is 50 mg. What is the safest child’s dose
An hypertensive agent, Captopril (Capoten) ½ according to Freid’s rule?
grain p.o. is ordered. Stock is 60 mg/tab. How
tablet will you give to your patient? Answer is: ________
Answer is: _______
C. Young’s Rule

• Parenteral / Oral Medication (Liquid) Age in years X usual adult dose = Safe child’s
dose
Desired dose X Quantity of Dilution = safe AD Age in years + 12
Stock dose
Example 8:
Example 3:
The expectorant guiafenesin (Robitussin) 300 mg Baby Jay is 5 years old last December 16,
p.o. has been ordered. The bottle is lab 100 mg/ 2007, the adult dose is 75 mg. What is
5ml. How many milliliters should be given? the safe child’s dose?
Answer is: ________
Answer is: ________
Example 4: 4. Right Route

a. Oral
• Advantages
• marasmus
• Disadvantages
Protein
• Drug Forms
• growth and repair of tissues
b. Sublingual • maintain fluid and acid base balances
• Advantages • meat, fish, dairy products, eggs, nuts,
• Disadvantages legumes, cereals

c. Buccal
• kwashiorkor
Vitamin D
• Right Time • calcium and phosphorous absorption, bone
• Right Advise / Attitude / Approach mineralization

• Right Documentation / Recording
PRINCIPLES IN ADMINISTERING
MEDICATIONS
• Observe the rights in giving medications.
• Practice asepsis.
• Nurses who administer medications are
responsible for their action.
• Be knowledgeable about the medications that
you administer.
• Keep narcotic in locked place.
• Use only medications that are clearly labeled
containers.
• Do not leave the medications at the bed side.
• If the patient vomits after taking the
medication, report.
• Preoperative medications are discontinued
during the postoperative, unless ordered.
• When a medication is omitted for any reason,
record with the reason.
• When a medication error is made, report it
immediately.
NUTRITION
Carbohydrates
• provides energy; protein sparing
• cereal, fruits, vegetables, milk
• dairy products, eggs, yolks and fatty fish
• rickets (in children), osteomalacia (in adults)
Vitamin K
• blood clotting
• green vegetables
• hemorrhages
Calcium
• bone and tooth formation, muscle function and
nerve transmission
• milk products, dark green leafy vegetable,
salmon, orange juice, tofu
• stunted growth in children, osteoporosis in
adult
• 99% is in the bone
• major component of renal calculi
Magnesium
• bone and tooth formation
• whole grain, nuts, legumes, dark green leafy
vegetables
• growth failure in children
Potassium
• major intracellular cation
• fluid balance, nerve and muscle function
• meat, milk, vegetables, legumes, bananas
Iron • 37 C (98.6 F) - normal temperature
0

• components of hemoglobin • Hypothalamus – thermoregulation center

• red meat, organ meat, egg yolk • Pyrexia – temperature of 38-40 C 0

• anemia • Hyperpyrexia – very high temperature as 41 C 0

Fluoride
• Rectal – most accurate
• formation of bones and teeth • Rectal 2-3 minutes
• fluoridated water and toothpastes • Oral 3-5 minutes
• higher frequency of tooth decay • Axillary 6-9 minutes
Types of Fever
Vitamin B1
• Thiamine • Intermittent fever – fever – no –
fever – no
• muscle nerve function
• whole grains, pork, cereals, legumes, seeds • Remittent fever – fluctuates but
and nuts remains above normal
• Beriberi, poor coordination
• Relapsing fever – elevated for few
Vitamin B3 days then normal temp. for 1-2 days
• Niacin
• coenzyme for energy metabolism • Constant fever – fluctuates
minimally and consistently high
• whole grains, meats, fish, nuts and eggs
Factors Affecting Heat Loss
Vitamin B9
• Folic acid • Radiation – transfer of heat from the
surface of the object without contact between two
• aids in metabolism of genetic material (DNA, objects.
RNA)
• green leafy vegetables, nuts, legumes, grain • Conduction – transfer of heat from one
products surface to another.
• poor growth, birth defects
• Convection – transfer of heat by air
PHYSICAL ASSESSMENT currents

Methods
• Evaporation – insensible heat loss
• Inspection
• Palpation Conversion Centigrade to Fahrenheit
F = (Temperature in C) X 1.8 + 32
• Percussion
• Auscultation • Example:

Temperature
• Convert 41 C to F: Answer is ________
• Convert 38 C to F: Answer is ________ • Volume

• Convert 36.5 C to F: Answer is _______ Pulse Deficit

• Convert 39.4 C to F: Answer is _______
Conversion Fahrenheit to Centigrade
C = (Temperature in F ) – 32 / 1.8
Example:
• Convert 105.8 F to C: Answer is _______
• Convert 100.4 F to C: Answer is _______
Respiration
• Ventilation
• Inspiration and Expiration
• Respiratory Center – pons and medulla
oblongata
• 12 – 20 breaths per minute - normal

• Convert 97.7 F to C: Answer is ________ • 500 ml – normal tidal volume

• Convert 102.9 F to C: Answer is _______ • Carbon dioxide – major chemical stimuli

Pulse 60-100 bpm for respirations
• Age • Hering Breuer reflex – prevents the lungs
• Sex / Gender from over expanding
Assessing Respirations
• Exercise
• Fever • Rate – tachypnea, bradypnea, eupnea
• Medications • Depth /Volume – Hyperventilation,
• Hemorrhage Hypoventilation
• Stress • Rhythm – Cheyne-Stokes, Kussmaul,
• Position Biots
Pulse sites • Quality / Effort / Character - dyspnea,
orthopnea, apnea
• Temporal Chest movements

• Carotid
• Intercostals retractions - ribs
• Apical
• Substernal retractions –
• Brachial breastbone

• Radial • Suprasternal retractions – above

the clavicle
• Femoral Blood Pressure
• Popliteal
• Systolic pressure (100-130 mmHg)
• Posterior Tibial
• Diastolic pressure (60-90mmHg)
• Dorsalis Pedis
Assessment of the Pulse • Pulse pressure

• Mean Arterial pressure

• Rate
• Korottkoff’s sound
• Rhythm
Determinants of Blood Pressure
• Pumping action of the heart
(cardiac output)
• Peripheral Vascular Resistance
• Blood Volume
• Blood Viscosity
• Elasticity or Compliance of Blood
Vessels
Factors Affecting Blood Pressure
• Age
• Exercise
• Stress
• Race
• Obesity
• Gender / Sex
• Medications
• Diurnal Variations
• Disease Process
Assessing Blood Pressure ( common error)
HEAD
• Skull, scalp, hair
EYES and VISION
• PERRLA, Anisocoria, 3-7 mm, snellen
chart, 20/20, 20/200, myopia, hyperopia,
presbyopia, astigmatism, tonometry, perimetry,
ophthamoscopy, genioscopy, Cranial Nerves 2,
3, 4, 6, comjunctiva, ishihara chart, peripheral
fields
EARS and HEARING
• 3 divided parts, otoscope, tunning fork, up
and back, down and back, weber test, rinne test,
conductive hearing loss, schwabach test, cranial
nerve 8, watch tick test
NOSE and PARANASAL SINUSES
• Facial sinuses, nasal speculum, penlight,
cranial nerve 1
MOUTH and PHARYNX
• Firth teeth (central lower incisors) appear
5 to 8 months, 20 temporary teeth at 2 years old,
losing them at 6-7 years old, replaced by 32
permanent teeth with appearance of wisdom
tooth (3rd molar), buccal mucosa, 3 pairs of
salivary glands, tonsils, uvula, cranial nerves 9,
10, 12
NECK
• Occipital, Postauricural, preauricular,
submandibular, submental, anterior cervical,
posterior cervical, deep cervical, supraclavicular,
trachea, thyroid gland, bruits, thyroid storm,
jugular veins, sternocleidomastoid and trapezius,
cranial nerve 11
THORAX and LUNGS
• Barrel chest, Pigeon chest, Funnel chest,
vesicular, bronchovesicular, bronchial, crackles,
gurgles, friction rub, wheezes, resonant, dullness,
hyper-resonance
CARDIOVASCULAR
• Systole, Diastole, Aortic, Pulmonic, Erb’s
point. Tricuspid, Mitral, S1, S2, Murmurs
ABDOMEN
• Sequence IAPP, bowel sounds,
borborygmi, light palpation, deep palpation,
costovertebral angle tenderness, 4 quadrants, 9
regions, dullness
MUSCULOSKELETAL
• Assessed for muscle strength,
contractures, muscle tone, muscle strength,
fasciculation, tremors, signs of inflammation,
abnormal spinal curvature, flatness, active range
of motion limitation, joints for swelling and
tenderness,
SKIN
• The first line of defense
• Composed of the superficial epidermis
and the true skin dermis
• Pallor
• Cyanosis
• Jaundice
• Erythema
NERVOUS SYSTEM
• Mental status, level of consciousness,
reflexes, DTR, superficial cutaneous reflexes,
pathologic reflexes, motor functions, sensory
function, stereognosis, graphesthesia, cerebellar
function, cranial nerves
FEMALE and MALE GENITALS
• History of menstruation, LMP, external
genitalia, internal genitalia, history of voiding
changes, pubic hair, penis, scrotum, inguinal
areas, rectum
BASIC CONSIDERATIONS FOR BASIC
NURSING PROCEDURES
HAND WASHING
• Single most effective and least expensive
method to prevent nosocomial infection
• Part of every beginning and end of
nursing procedures
• Use warm running water
• Apply soap and rub palms, wrists, and
back of hand firmly with circular motion,
interlace fingers and thumbs and rub with lather
and friction mechanically loosen dirt.
• Rinse hands and wrist with hands held
lower that forearm
• Dry with paper towel or blower, wiping
from fingertips toward the forearm, turn off faucet
with clean paper towel
COUGHING
• Single most effective measure to control
respiratory secretions upward
• Splint incision, if any, with pillow
• Patient to take a deep breath, hold for 3
seconds, and cough deeply 2 to 3 times
• Perform 2 to 3 hours postoperatively
• Contraindicated for eye surgery
DEEP BREATHING
• Expands alveoli and mobilizes secretions
• Place patient in fowler’s or sitting
• Place client’s hands (palm) along the
lower rib cage to feel diaphragm movement
• Inhale fully through the nose, hold for 2 to
3 seconds
• Exhale slowly through the mouth
PURSED LIP BREATHING
• Allows a gradual decline in intrapulmonic
pressure hence preventing lung collapse
• Takes a deep breath, hold it for a moment
then exhale slowly through a pursed lip
• Builds pressure backwards keeping the
airways open through out exhalation
• More air escapes during exhalation and
helps prevent air trapping
CHEST PHYSIOTHERAPY
• Help clear excessive bronchial secretions
from airways by shaking mucus from the walls of
the airways and draining them from the lungs
• Produce mechanical wave of energy that
is transmitted through chest wall (Percussion)
• With the use of hand placed on client’s
chest with rapid and vigorous vibration as client
exhale
• Use of gravity to assist in the movement
of secretion (postural drainage)
NASOGASTRIC TUBE FEEDING
• Provide enteral nutrition for clients who
cannot swallow, with esophageal obstruction,
unconscious, and cannot consume oral feeding.
• Measure the distance from the tip of the
nose to earlobe through the bottom of the xiphoid
process
• Use water soluble jelly as lubricant
• Advance tube forward, head bent forward
closes the epiglottis and trachea
• High fowler’s, if contraindicated place right
side lying position with head slightly elevated to
prevent aspiration.
• Flush with 30-60 ml of water after feeding
• If NGT is to removed, instruct client to
exhale and remove tube with smooth, continuous
pull
• Inject 10 ml of air and auscultate for
gurgling sound in the epigastrium.
• Aspirate for residual stomach content (ph
1-3 of yellow to green)
• Immerse tip of the NGT into water and
observe for bubbling.
• X-ray confirms
FECAL IMPACTION REMOVAL
• Prepare all materials (gown, gloves,
bedpan, water soluble lubricant) in anticipation of
strong odor and large quantity of stool.
• Rule out contraindications related to vagal
stimulation (innervating GIT, decreases PR and
lead to dysryhtmia for weak and cardiac
patients).
• Side lying position, insert index finger with
a gentle hooking position, careful as perforation
may occur
• Note for any signs of fatigue, pallor,
diaphoresis, and changes in pulse rate.
• Prepare for quick evacuation as hardened
stool blocking the lumen is removed.
OXYGEN THERAPY
•
•
To reverse hypoxemia
To improve tissue oxygenation
• Decrease work of breathing in dyspneic
clients
• Decreases myocardial workload
NURSING IMPLICATION
• Oxygen is colorless, odorless, tasteless
gas so leakage cannot be detected
• Oxygen is a dry gas, it can irritate mucous
membrane of the airways
• Oxygen supports combustion, it can
cause fire
OXYGEN THERAPY
• Position the client in semi-fowler’s position
• Insert flowmeter, with humidifier (oxygen
dries up)
• Regulate the prescribed flow rate (LPM)
• Assess vital signs, oxygen saturation,
color, breathing pattern and orientation
Oxygen Toxicity:
• Retrolental fibroplasia – retinal damage
leading to irreversible blindness due to exposure
to 100% oxygen in adult and to high oxygen flow
rate (40% or more) in neonate, especially
premature (retinopathy of prematurity)
BLOOD GROUPS
Transfusion Reaction
– Allergic Reaction
 Flushing, urticaria, wheezing, rashes
– Pyrogenic / Febrile Reaction
 Fever and chills
 Headache and body malaise
– Hemolytic Reaction
 Facial flushing, chills, low back pain,
hypotension, hematuria leading to anaphylactic
shock
CLEANSING ENEMA • Most rapid route of absorption of
medication

Non-Retention Enema
Solutions used are as follows:
• Tap water (500-1000 milliliters)
• Soap suds (20 ml of soap in 500 - 1000
ml of water)
• Route can be use for clients with
compromised gastrointestinal function or
peripheral circulation
• Large doses of medication can be
administered
Purposes:

• Normal Saline Solution (9 ml of NaCl to • Fluid and electrolytes imbalance

1000 ml of water) • Provide food
• Hypertonic solution / fleet enema (90-120
• Vehicle for medication
ml)
Position: • For blood transfusion
Adult: left lateral position
Infant/Children: dorsal recumbent Equipments:
• IV Fluid, IV set, Micropore, tourniquet,
• Sizes of rectal tube: cotton balls, alcohol, splint
Adult - Fr 22-32 Complications of I.V. Therapy
Children - Fr 14-18
Infant - Fr 12 • Infiltration

• Height of Solution: 18 inches above the • Thrombophlebitis

rectum
• Nerve damage
• Temperature of Solution: 115 – 125 F on
• Circulatory Overload
preparation
• Time of retention: 5 -10 minutes for better • Air Embolism
cleansing effect • Speed shock
Retention Enema • Drug Overload
Solutions used are as follows:
• Carminative Enema IV Fluid Formula

• Oil (90-120 ml of mineral, olive or cotton Volume X Drop Factor

seed oil Time 60

• Height of Solution: 12 inches above the

rectum Example:
• Temperature of Solution: 105 – 110 F on
The doctor ordered for 2 liters of D5LR to run
for 18 hrs with drop factor of 20. How many drops
preparation per minute?
• Time of retention: 1 -3 hours until Answer is :________
therapeutic effect is obtained
The doctor ordered for 1L of PNSS to run
I.V. Therapy
for 10 hrs with drop factor of 15. How many drops
per minute?
Intravenous
Answer is :________
• Direct IV, IV Push, IV infusion

The doctor ordered for 500ml of 0.45
NaCl to run for 6hrs with drop factor of 10. How
many drops
per minute?
Answer is :________
The doctor ordered for 100ml of D5 water
to run for 1hr with drop factor of 60mcgtts. How
many drops per minute?
Answer is :________
SUCTIONING
• Use appropriate catheter size:
F 5-8 for infants; F 8-10 for children; F 12-
18 for adult
• Position client fowlers (for those with
intact gag reflex); side lying (for unconscious) to
prevent aspiration
• Adjust pressure:
• Wall unit - 50-75 mmHg in infants, in
children 95-100 mmHg, in adults 100-120 mmHg
• Portable unit – 2-5 mmHg in infants, in
children 5-10 mmHg, in adults 10-15 mmHg
• Pre-oxygenate client
• Lubricate Catheter
• Exert suction by closing the open port,
withdrawing catheter in rotating motion within 5-
10 seconds only
• Hyper-oxygenate for a full minute
between subsequent suctioning. Encourage
deep breathing
Urinary Catheterization – is the introduction
of catheter through the urethra into the
urinary bladder.
Purposes
• To relieve discomfort due to bladder
distention.
• To assess the amount of residual urine if
the bladder empties incompletely.
• To obtain urine specimen.
• To empty the bladder completely prior to
surgery.
• To Facilitate accurate measurement of
urinary output.
• To provide intermittent or continuous
bladder drainage.
• To prevent urine from contacting an
incision after perineal surgery.
• To manage incontinence when other
measure have failed.
Position
• Male : Supine, legs abducted and
extended
• Female : Dorsal Recumbent position
Location of urinary meatus
• Male : at the tip of the glands penis
• Female : between the clitoris and vaginal
orifice
Size of Catheter
• Male: Fr 16-18
• Female : Fr 12-14
Length of catheter insertion
• Male : 6-9 inches
• Female : 3-4 inches
Assessment
• Determine the most appropriate method
of catheterization.
• Use a straight catheter if only a spot urine
specimen is needed.
• Use indwelling/retention catheter if the
bladder must remain empty/continuous urine
measurement collection is needed.
• Determine when the client last voided or
was last catheterized.
• Percuss the bladder to check for fullness
or distention.
POSITIONING
Side lying position
• client lies on the side with weight on the
hip and shoulder, with pillows support legs,
arms, head and back.
• choice position for clients with pressure
sore on bony prominence
• contraindicated post hip replacement and
other orthopedic surgery
• tonsillectomy to promote drainage of
secretions
• seizure to prevent backward falling of the
tongue
• pyloric stenosis (right) after meals to
facilitate entry of stomach contents into the
intestines
• lumbar puncture (lateral – during the
procedure) to facilitate the entry of the needle
between L3-L4
• hemorroidectomy to prevent pain
• liver biopsy (right) post procedure to
prevent bleeding
Sims position
• client lies on the side with weight
distributed toward the anterior ileum,
humerus, and clavicle with pillows support
on flexed arms and legs.
• choice position for clients with pressure
sore on bony prominence
• contraindicated with spine or orthopedic
condition
Fowler’s position
• sitting position raises client’s bed head to
90 degrees
• clients with DOB, eating and improvement
of cardiac output
• contraindicated with post spine surgery
• placenta previa (sitting) to minimize
bleeding
• pulmonary edema to facilitate breathing
• thoracentesis (during the procedure) to
facilitate removal of fluid in the chest wall
• congestive heart failure to improve
oxygenation
• autonomic dysreflexia to prevent
hypertensive stoke
Semi-fowler’s position
• semi-sitting with head elevation of 30-45
degrees
• clients with DOB, eating and improvement
of cardiac output
• contraindicated with post spine surgery
• abdominal aneurysm surgery to prevent
pressure on the graft
• appendicitis (if ruptured) to prevent the
upward spread of infection
• bronchoscopy (post procedure) to prevent
aspiration
• cataract (post op) to prevent edema on
the operative sit
• cerebral aneurysm to prevent pressure in
the aneurysm site
• supratentorial craniotomy to facilitate
venous drainage from the head
• CVA to reduce ICP
• hypophysectomy to prevent increased
ICP
• laryngectomy to maintain patent airway
and minimize edema
• lobectomy to promote breathing
• paracentesis to facilitate removal of fluid
in the abdominal cavity
• thyroidectomy to prevent hyperflexion and
hyperextension of the neck, to prevent tension on
the suture line
• myelogram (if water based dye –
Amipague) to prevent upward dispersion of the
dye
• hiatal hernia (after meals) to prevent
reflux of the stomach contents
Dorsal recumbent
• Lung and Lymph Node biopsy
• client lies supine with legs flexed and
rotated outward
• Pulmonary Function Studies
• for vaginal examination
Knee chest position
• Arterial Blood Gas Studies
• lies prone with buttocks elevated and
knees drawn to the chest
• rectal procedures and examination
• Thoracentesis

• contraindicated for arthritis and other joint

• Holter Monitoring
deformity
• prolapsed cord to prevent pressure on the
cord • Magnetic Resonance Imaging

• proctosigmoidoscopy to facilitate
visualization
Trendelenburg • Computed Tomography
• lies supine with head 30-40 degrees lower
than the feet • Upper Gastrointestinal Series / Barium
• for postural drainage and promotion of Swallow
venous return
• contraindicated may result in increase • Lower Gastrointestinal Series / Barium
intracranial and intraocular pressure and may Enema
result hypotension.
• shock to promote venous return to the • Endoscopy
heart
• TPN during tube insertion to prevent air • Proctosigmoidoscopy
embolism
DIAGNOSTIC EXAMINATIONS
AND • Colonoscopy
PROCEDURES

• Mantoux Test • Liver Biopsy

• Chest X-ray • Paracentesis

• Bronchography • Gastric Analysis

• Bronchoscopy • Bone Marrow Aspiration

• Lung Scan • Intravenous Pyelography

• Sputum Examination • Angiography

• Lumbar Puncture

• Electroencephalogram

• Electrocardiography

• Endoscopic Retrograde
Cholagiopancreotography (ERCP)

• Close Thoracostomy Tube

• Sengstaken Blakemore Tube