BASIC CONCEPTS IN FUNDAMENTLS OF NURSING (Bullets) As defined by the American Nurses Association (2003).

. Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis & treatment of the human response and advocacy in the care of individuals, families, communities and populations. The metaparadigm for nursing consists of 4 elements namely: client/person, health, environment/ situation and nursing. The Code of Ethics for nurses defines the principles by which nurses provide care to their clients. RA 9173 mandated that BON formulate the Code of Ethics, in consultation with PNA and for the approval of PRC, using as reference the Code of Good Governance. Florence Nightingale is considered the Founder of Modern Nursing. St Catherine of Siena is considered the 1 Lady with the Lamp. Mrs. Anastacia Giron Tupas is regarded as the Pioneer of Philippine Nursing and Founder of PNA. (1922) Benners Stages of Expertise is composed of being a novice, advanced beginner, competent nurse, proficient nurse and an expert nurse. The clinical model presents the narrowest interpretation of health which defines health as the absence of disease. Suchmans five (5) stages of illnesses includes: o Symptoms experience o Assumption of the sick role o Medical care contact o Dependent client role o Recovery or rehabilitation The primary level of prevention is concerned with prevention or delay of the actual occurrence of disease. The secondary level of prevention is concerned with restoration and rehabilitation. The nursing process includes assessment, diagnosis, planning. Implementation and evaluation. The nursing process is client centered, not nurse-centered and has similarly with the research and scientific processes. Signs are objective data while, symptoms are considered subjective data. Analysis and interpretation of assessment data is done during the diagnosis phase. Setting priorities is included in the planning phase. Outcome identification refers to the change that occurred in the patient. Documentation identification refers to the change that occurred in the patient. Documentation of nursing activities is part of the implementation phase. Documentation is done throughout the nursing process. It is during the evaluation phase wherein the nurse determines if the goals are met and outcomes are achieved. Quality assurance has 3 components: o Structure o Process o Outcome evaluations. 1

Communication is essential in establishing the helping-healing relationship between the nurse and the client. Important aspects of health education are: o Information(provision of knowledge), o Communication (exchange of information), and o Education (change in knowledge, attitude and skills. Telephone orders should be limited as much as possible to extreme emergency. The nurse must ensure that the order is signed by the physician on her/his next visit within 24 hours. Rehabilitation and discharge planning begins upon admission and eventually becomes the focus for discussion during the working phase. The nurse is responsible for writing a telephone order on the physicians order sheet in the clients permanent records and signs it. Kubler-Ross stages of dying are: o Denial o Anger o Bargaining DABDA o Depression and o Acceptance At 9 years old, a person already views death as an irreversible, universal and natural occurrence. Rigor Mortis is the stiffening of the body 2-4 hours after death. Algor Mortis is the decrease in temperature after death. Livor Mortis is the discoloration of the body after death. Rectal temperature is the most accurate and is 1degree F higher than the oral temperature. Rectal temperature is taken for 2-3 minutes, oral 3-5 minutes, axillary 6-9 minutes and tympanic 2-3 seconds. The point of maximal impulse (PMI) is heard at the left 5th intercostal space mid-clavicular line. The carotid pulse is assessed in cases of shock and cardiac arrest. Stridor can be heard on inspiration while wheezes (like asthma) are heard on expiration. When performing physical assessment on an infant and toddler, perform traumatic procedures last. In interpreting the results for visual acuity, the numerator indicates the distance of the client from the Snellen chart, while the denominator represents the distance from which a normal eye can read the chart. The Weber Test is used to assess the lateralization of sound (compares right and left hearing). The Rinne Test compares air conduction with bone conduction. The Schwabach test compares patients hearing with that of the examiner. The sequence of abdomen assessment is: o Inspection o Auscultation-Percussion o Palpation A score of 8 or less in the Glasgow Coma Scale indicates coma. A score of 3 signifies deep coma. Infection is nosocomial if the client develops the infection 48 hours after admission. If less than 48 hors infection is considered community acquired. 2

Hand washing is the single most effective and least expensive method to prevent nosocomial infection. The ten rights of medication administration are: o Right medication o Dose o Client o Route o Time o Documentation o Assessment o Right to refuse o Education and o Evaluation Electric-coted tablets should NOT be crushed. When mixing two types of insulin in one syringe, the clear insulin is withdrawn first before the cloudy insulin. Only regular insulin can be given per IV. If given in burns (together with glucose), it is to manage hyperkalemia. When giving an intramuscular injection, a nurse should aspirate for 5-10 seconds before administering the medication. DO NOT massage the area after. It is recommended that used needles should NOT be recapped. They are disposed in a punctured-proof container. In case of fire, the priority is rescuing the client/s. o RESCUE o ALARM RACE o CONFINE FIRE o EXTINGUISH A seizure precaution encompasses all nursing interventions to protect the client from traumatic injury, positioning for adequate ventilation and drainage of oral secretions and providing privacy and support following the seizure. Exercises can be classified as: o Isotonic (dynamic) o Isometric (static) or, o Isokinetic (resistive) The handgrips of crutches should be positioned so that the clients body weight is NOT supported by the axillae. Pressure on the axillae increases risk to underlying nerves, which could result in partial paralysis of the arm. In going UP the stairs using crutches, the unaffected leg goes up first. In going DOWN the stairs using crutches, the affected leg goes down first. (UP with good, down with the bad. In bathing the extremities, use long, firm strokes from distal to proximal areas. Inform a patient who is undergoing gastroscopy that sore throat may be experienced for 4 days after the procedure. After undergoing barium swallow, encourage client to increase fluid intake to facilitate elimination of barium In case both barium swallows and barium enema will be done, barium enema is performed first.

For paracentesis, instruct patient to empty the bladder and place the client in semi-fowlers position. After thoracentesis, client should lie on the unaffected side with head elevated for at least 30 minutes. After biopsy, client should lie on the right side with pillow under site for 1-2 hours to prevent bleeding. For bone marrow biopsy, place client in a prone position and put pressure on the side for 5-10 minutes after aspiration. Iliac crest is the preferred site in adults, and the proximal tibia (or iliac crest) in children. A heparinized syringe is used to collect the blood specimen for ABG analysis. Specimen is placed in ice and sent to laboratory immediately. Respiratory acidosis is seen in cases of COPD and asthma because they retain carbon dioxide. Respiratory alkalosis is seen in cases of hyperventilation due to anxiety, increased body temperature and hypoxia. In case this occurs, help client breathe into a paper bag. Metabolic acidosis is seen in cases of prolonged diarrhea. (Remember intestinal content is alkaline). Metabolic alkalosis is seen in cases of prolonged vomiting (remember that stomach is acidic) and Cushings syndrome. Place the client in a fetal or shrimp position for lumbar puncture. Keep client flat on bed for 4 12 hours after. The nurse should watch out for seizures on a client post EEG. Drugs affecting the neurologic system are withheld prior to EEG. If the stool specimen is for ovum analysis, send to the laboratory immediately, do not place in the refrigerator. For cardiac catheterization, client is placed on a supine or trendelenburg position to engorge the veins and facilitate needle insertion. If collecting sterile urine specimen from a Foley catheter, use the aspiration port of the catheters closed drainage tubing. Staging of pressure ulcer development is as follows: o Stage 1 nonblanchable erythema o Stage II shallow crater o Stage III full thickness loss and; o Stage IV damage to muscle and bone. Shearing force is to be blamed for bed sores. Would healing by primary intention is characterized by approximated skin edges or closed and there is a low risk infection. An example of which is a clean surgical incision. Wound healing by secondary intention is left open until in becomes filled with scar tissue and there is a high risk for infection. Examples of which are burn wounds, pressure ulcers and severe lacerations. Chest physiotherapy includes postural drainage, chest percussion and vibration. It is recommended for clients who produce more than 30 ml of sputum per day. DO NOT APPLY suction as the suction catheter is being inserted. Retract catheter by 1 cm before exerting suction. Suctioning should be limited to 4-10 seconds with a 20-30 seconds interval between suctions. The venture mask is most commonly used for patients with COPD because it delivers a more accurate oxygen concentration. 4

Oxygen is a COMBUSTIBLE gas, not flammable. It is dry, odorless, colorless, tasteless gas & is low in higher altitude. Oxygen tanks are green, compressed air tanks are yellow, and nitrous oxide tanks are blue. An obturator should always be in the clients bedside if the client has a tracheostomy. When measuring IV fluids, use the lower meniscus for clear liquids and the upper meniscus for opaque liquids. Isotonic fluids are used most commonly for extracellular volume replacement. Infiltration occurs when IV fluids enter the surrounding space around the venipuncture site and is manifested by swelling, pallor and coolness around the site. Phlebitis is inflammation of the vein and is manifested by pain, edema, erythema and increased temperature over the pain. A large-bore need (e.g. gauge 16) is used for blood transfusion. 0.9% normal saline is the ONLY solution compatible with blood transfusion. NSS is isotonic, like LR and D5W. If a blood transfusion reaction is suspected, blood transfusion is STOPPED immediately, but keep vein open through continuous infusion of 0.9 normal saline. Blood should be transfused within 4 hours after getting from the blood bank as it will become old blood therefore, an increased risk for hyperkalemia and infection. X-ray is the most accurate way to confirm placement of NGT in the stomach (a stomach aspirates pH of 3 or less is also reliable). The succeeding feeding is withheld if 100 ml or more than half of the last feeding is aspirated. In administering total parenteral nutrition, infection control is of utmost importance. Normal urine output is at least 30 ml per hour. Anything lower is reportable. Urine output is best indicator of cardiac output. Male clients have longer urethras, thus needs a longer urinary catheter (40cm.) as compared to females (22 cm). In cases wherein the urinary catheter is accidentally inserted into the vagina, remove the catheter in the vagina and get a new sterile catheter. Cleansing enemas stimulate peristalsis through infusion of a large volume of solution through the rectum. Oil-retention enemas lubricate the colon and rectum and let feces absorb the oil to become softer and therefore easier to pass. Carminative enemas provide relief from gaseous distention o A well-oxygenated stoma is pink and moist. o If a client experiences cramping during colostomy irrigation, clamp the tubing and ask the client to take a deep breath.

SYSTEM
GENERAL CHANGES

CARE OF THE ELDERLY COMMON CHANGES

Lean body mass is reduced. Fat tissue increases. Bone mass decreases. Extracellular fluid remains constant; intracellular fluid decreases. Functional cells in the body decreases. Skin becomes drier, less elastic and more fragile ( manifested by wrinkles, sagging, dryness, easily tears. Increasingly pallor. Presence of brown age spots (lentigo senilis) on exposed body parts. Sweat gland activity decreases. Hair on the scalp, pubic area and axilla becomes gray and thinner. Fingernails & toenails become thickened, brittle and grow slower. Decreased cough reflex. Decreased cough reflex. Decreased removal of mucus, dust and irritants from airways. Decreased vital capacity but increased residual capacity. Increased chest wall rigidity. Fewer alveoli. Increased airway resistance. Increased risk for respiratory infections. Decreased contractile strength of the myocardium decreased CO. BP abnormally elevated. Heart valves become thick & rigid. Blood vessel lumen narrows. Loss of vessel elasticity. Increased peripheral resistance. Decreased baroreceptor sensitivity. Orthostatic hypotension. Decreased peripheral circulation.
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INTEGUMENTARY

RESPIRATORY

CARDIOVASCULAR

GASTROINTESTINAL

Periodontal diseases. Loss of teeth. Swallowing mechanism altered. Decreased in saliva, gastric secretions, and pancreatic enzymes. Decreased esophageal peristalsis and small intestine motility. Decreased muscle mass & strength. Decalcification of bones osteoporosis Increase risk for fractures. Degenerative joint changes. Dehydration of intervertebral disks decreases height. Decreased sense of balance or uncoordinated motor responses. Degeneration of nerve cells. Decrease in neurotransmitters Decrease in rate and conduction of impulses Decreased reflexes. Decreased sense of balance or uncoordinated motor responses. Decreased accommodation to near/far (presbyopia). Loss of visual acuity. Arcus senilis Difficulty adjusting to changes from light to dark. Yellowing of the lens. Altered color perception. Yellowing of the lens. Altered color perception. Thickening of the tympanic membrane. Sclerosis of the middle ear. May have build up of cerumen.

MUSCULOSKELETAL

NEUROLOGICAL

Sensory/PERCEPTUAL
Eyes

Ears

Taste

Smell

Touch

Diminished sense of taste, especially sweet sensations.

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URINARY

Decreased skin receptors. Impaired renal function & reduced filtering ability of the kidneys. Less effective concentration of urine. Urinary urgency & frequency. Tendency for nocturnal frequency and retention of residual urine. Prostate enlargement (benign), diminished sperm count, smaller testes, erections less firm and slow to develop in men. Decreased estrogen production, degeneration of ovaries, atrophy of the vagina, uterus & breasts, decreased vaginal lubrication & elasticity in women. Increased time for sexual arousal. Alteration in hormone production with decreased ability to respond to stress. Decreased thyroid gland secretions. Involution of the thymus gland. Increased insulin resistance. Decreased immune response & lowered resistance to infections. Poor response to immunization.

GENITALS

ENDOCRINE

IMMUNOLOGICAL

COGNITIVE CHANGES IN THE OLDER ADULT

The three (3) common conditions affecting cognition are delirium, dementia and depression.

Delirium

Potentially reversible cognitive impairment. Acute onset, often at twilight or in darkness. Short course. Sometimes accompanies systemic infections. Characterized by fluctuations in cognition, mood, attention, arousal & self-awareness. Generalized impairment of intellectual functioning
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Dementia

that interferes with social and occupational functioning. Chronic onset, generally insidious. Characterized by a gradual, progressive, and irreversible cerebral by dysfunction. Most common form of dementia is Alzheimers disease. Reduces happiness & well-being, contributes to physical & social limitations & increases the risk for suicide. Chronic onset & generally insidious. Late-life depression experienced by 20% of older adults.

Depression

ADDRESSING THE HEALTH CONCERNS OF OLDER ADULTS

Nursing activities should be directed toward improving or maintaining the older adults health needs & concerns, such as the following: 1. Causes of death. 2. Chronic health conditions. 3. Health risk factors. 4. Access to medical care. 5. Participation in the health care system. Teaching Strategies for the Older Adult: Before starting teaching, make sure that the client is ready to learn. Sit facing the client so that he/she can watch your lip movements & facial expressions. Speak slowly and keep a low tone of voice. Present one idea at a time & focus on a single period. Keep environmental distractions to a minimum. Use large-print & a bulleted format for written materials for visual aids. Repeat information if necessary. Uses past experiences & relate new learning to that already learned. Compensate for physical discomfort & sensory decrements. Addressing Physiological Concerns: Establish health maintenance programs to promote wellness and to recommend preventive measures. Preventive measures for illness complications include: o Regular exercise.
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o Weight reduction (if overweight) o Management of hypertension. o Smoking cessation. o Immunizations for certain diseases. Encourage client to undergo different screening tests for certain illnesses. For clients with heart disease and hypertension, teach clients regarding the medication regimen, blood pressure monitoring, nutrition, stress reduction techniques and signs and symptoms to monitor. For clients with cancer or those at risk, educate older adults about early detection, treatment & risk factors. For clients who experienced stroke or those at risk, teach clients/family about risk reduction strategies in caring for an older adult after stroke and during recovery and rehabilitation.

Prepared by: Nurse Tutorial Company Services

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