Assessment - First Step in the Nursing Process

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It is systematic and continuous collection, validation and communication of client data as compared to wh It includes the client‘s perceived needs, health problems, related experiences, health practices, values and

Purpose
To establish a data base (all the information about the client):
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nursing health history physical assessment the physician‘s history & physical examination results of laboratory & diagnostic tests material from other health personnel

FOUR Types of Assessment

1. Initial assessment – assessment performed within a specified time on admission o Ex: nursing admission assessment 2. Problem-focused assessment – use to determine status of a specific problem identified in an earlier asse o Ex: problem on urination-assess on fluid intake & urine output hourly 3. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client t o Ex: assessment of a client‘s airway, breathing status & circulation after a cardiac arrest. 4. Time-lapsed assessment – reassessment of client‘s functional health pattern done several months after in baseline data previously obtained.

Activities
1. 2. 3. 4. 5. Collection of data Validation of data Organization of data Analyzing of data Recording/documentation of data

Assessment

Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of

Collection of data
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gathering of information about the client includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client‘s health s includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing metho includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatm

Types of Data

1. Subjective data o also referred to as Symptom/Covert data o Information from the client‘s point of view or are described by the person experiencing it. o Information supplied by family members, significant others; other health professionals are conside o Example: pain, dizziness, ringing of ears/Tinnitus 2. Objective data o also referred to as Sign/Overt data o Those that can be detected observed or measured/tested using accepted standard or norm. o Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin Methods of Data Collection

1. Interview o A planned, purposeful conversation/communication with the client to get information, identify pro counseling. o it is used while taking the nursing history of a client 2. Observation o Use to gather data by using the 5 senses and instruments. 3. Examination o Systematic data collection to detect health problems using unit of measurements, physical examin o should be conducted systematically: 1. Cephalocaudal approach – head-to-toe assessment 2. Body System approach – examine all the body system 3. Review of System approach – examine only particular area affected Source of data

1. Primary source – data directly gathered from the client using interview and physical examination. 2. Secondary source – data gathered from client‘s family members, significant others, client‘s medical reco literature/journals. o In the Assessment Phase, obtain a Nursing Health History - a structured interview designed to co client. Components of a Nursing Health History:

o o o o o o o o o o

Biographic data – name, address, age, sex, martial status, occupation, religion. Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization. History of present Illness – includes: usual health status, chronological story, family history, disab Past Health History – includes all previous immunizations, experiences with illness. Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, Review of systems – review of all health problems by body systems Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation Social data – include family relationships, ethnic and educational background, economic status, ho Psychological data – information about the client‘s emotional state. Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family

Validation of Data

The act of ―double-checking‖ or verifying data to confirm that it is accurate and complete.

Purposes of data validation 1. 2. 3. 4. 5. Cues

ensure that data collection is complete ensure that objective and subjective data agree obtain additional data that may have been overlooked avoid jumping to conclusion differentiate cues and inferences

Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, he

Inferences
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The nurse interpretation or conclusion based on the cues. Example: o Red swollen wound = infected wound o Dry skin = dehydrated

Organization of Data
Uses a written or computerized format that organizes assessment data systematically. 1. Maslow‘s basic needs 2. Body System Model 3. Gordon‘s Functional Health Patterns:

Standard/norm are generally accepted measu o Ex: Normal vital signs. An interview has 3 major stages: 1. normal Communicate/Record/Document Data    nurse records all data collected about the client‘s health status data are recorded in a factual manner not as interpreted by the nurse Record subjective data in client‘s word. restating in other words what client says might change its origina Assessment. Role-relationship pattern 9. Sexuality-reproductive pattern 10. Coping-stress tolerance pattern 11. Reviewing the client‘s record before beginning an assessment prevents the nurse from repeating question information that needs clarification. Client records contain information collected by many members of the healthcare team. standard Weight and Height.Objective & Subjective Data Review of clinical record 1. normal laboratory/diagnostic values.Gordon’s Functional Health Patterns 1. and prov 2. Interview 1. Value-belief pattern Analyze data  Compare data against standard and identify significant cues. this is often achiev . Cognitive-perceptual pattern 7. Nutritional-metabolic pattern 3. identify problems of concerns. Sleep-rest pattern 6. Health perception-health management pattern. Self-perception-concept pattern 8. such as demograp consultations 2. Activity-exercise pattern 5. The goals of an interview are to develop a rapport with the client and to collect data 3. The purpose of an interview is to gather and provide information. Opening: purpose is to establish rapport by creating goodwill and trust. Elimination pattern 4. 2.

Subjective data o May be called ―covert data‖ o Not measurable or observable o Obtained from client (primary source). or recent current event. e. eyes. local sports team. or health professionals (secondary sourc o For example. Closed questions used in directive interview  Re____ short factual answers. e. ears. Closing: either the client or the nurse may terminate the interview. ―How have you b  Specify the broad area to be discussed and invite longer answers  Useful at the start of an interview or to change the subject 3.g.handshake). Body: during this phase. a blood pressure reading of 190/110 mmHg.g. ―I have a headache‖ o Objective data o May be called ―overt data‖ o Can be detected by someone other than the client o Includes measurable and observable client behavior o For example. nose. Types of questions 1. Open-ended questions used in nondirective interview  Encourage clients to express and clarify their thoughts and feelings. a 2. A body system format for physical assessment is found below: o General assessement o Integumentary system o Head. th this time. significant others. the client states. inspection. the client responds to open and closed-ended questions asked by 3. 2. ―You don‘t have any questions about your medications. ―Do you have pain?‖  Answers usually reveal limited amounts of information  Useful with clients who are highly stressed and/or have difficulty communicating 2. it is important fro the n developed thus far during the interview process. Collection of information about the effect of the client‘s illness on daily functioning and ability to cope w 2. throat o Breast and axillae o Thorax and lungs . Physical assessment 1. 4. e. and small talk about the weather. Systematic collection of information about the body systems through the use of observation. Leading questions  Direct the client‘s answer. do  Suggests what answer is expected  Can result in client giving inaccurate data to please the nurse  Can limit client choice of topic for discussion Nursing History 1.g.

Reviewing professional journals and textbooks can help provide additional data to support or help analyz ssist Patient from the Bed to Chair or Wheelchair I. . Freud. support p 2. Helpful framework for organizing data 2. Kohlberg and Piaget may also be helpful for guiding Consultation 1. A suggested format for psychosocial assessment is found below: o Vocation/education/financial o Home and Family o Social. Purpose 1. To strengthen the patient gradually. spiritual and cultural o Sexual o Activities of daily living o Health Habits o Psychological 3. A professional nurse engages in continued education to maintain knowledge of current information relate 2. leisure. Havighurst. Consultation with individuals who can contribute to the client‘s database is helpful in achieving the most 3. Supplemental information from secondary sources (any source other then the client) can help verify infor and convey information about the client‘s status prior to admission Review of literature 1. The developmental of Erickson.o o o o o o o Cardiovascular system Nervous system Abdomen and gastrointestinal system Anus and rectum Genitourinary system Reproductive system Musculoskeletal system Psychosocial assessment 1. The nurse collects data from multiple sources: primary (client) and secondary (family members.

To put him back to bed. Take pulse after. To prevent bedsore 3.2. To stimulate the circulation and give general relief. Adjust the pillows and wrap blanket over patient‘s lap. (In wheelchair to take her around for a change) II. (Or let your arm around his waist. Draw up bedding. Place the foot stool under the patient‘s feet. assist him to stand. I. Help him 9. Place the chair conveniently at night angles to the bed—back of chair parallel to the foot of the bed and fa 3. step down and knees and lower body to seat him to the chair. Observe frequently for changes in color and pulse rate. If using wheelchair. dizziness or sign of fatigue. sheet or draw sheet III. put one arm under the head and shoulders and the other the legs hanging over the side of the bed.. Equipment . supporting her head and shoulders with one arm and her knees with the 12. help to turn and stand on stool and back to bed. 2. II. 7. 2. 8. Back Care After bathing and drying the back. 6. See that the chair or wheelchair is in good condition. line it with a blanket or sheet and arrange pillow lock the wheels. i. it should be massaged or rubbed thoroughly. To give comfort to the patient. To provide a change in position. Anchor chair with foot or have someone hold it on. Purpose 1. Assist the patient to a sitting position on bed. Turn patient around with his back to the chair and seat him gently). Stand directly in front of the patient and with a hand under each axilla. pulse and respiratory rate. Put on patient‘s robe and slippers. Place pillow on the seat of the chair. Equipment     Chair or wheelchair Patient‘s robe and slippers Pillows Blanket. Watch the patient for a minute to defect any change in his color. Take the patient‘s pulse 5. 10. Support patient w Pivot to a sitting position in bed. If in a wheelchair adjust the foot rests.e. assist to stand. Procedure 1. 11. 4.

) 5. and thumble grasping the skin and subcutaneous tissues which move with the hand of the operator. This movement is a circular from of kneading with pressure against the underlying part of tissue which cannot be grasped. 4. 3. Apply to back rubbing lotion or talcum powder to reduce friction. Begun from neck and shoulders then proceed over the entire back. Strokes should be slow. 2. If the supine position is used and the patient is a woman. Fix and make patient comfortable. Massage with both hands working with a strong stroke. over small surface (on the neck) the thumb and fingers are used. Give particular attention to pressure areas in rubbing (Alcohol 25%) to 50% is generally used for its refreshing effect. Movements Used 1. Turn patient on his back and put on camisa or gown. Whole blood stored for transfusion. Raise the camisa and gown. Kneading—performed with the ulnar side palm resting on the surface and the fingers. Effleurage (stroking—is a long sweeping movement with palm of hand conforming to the contour of the surface treated. 3. Powder again the area at the completion of the rubbing process which should consume from 3-5 minutes. 2. Procedure 1. Blood Transfusion Therapy Blood transfusion therapy involves transfusing whole blood or blood components (specific portion or fraction o consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant. rhythmical and gentle with pressure constant and in the direction of venous stream. 7. In rubbing the back use firm long strokes and kneading motions. nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII). In upward than in downward motions. Friction—is performed with the whole palmar surface of the hand or fingers and thumbs over limited areas. 6.   Alcohol 25% Talcum powder Bath towel III. but rubbing lotion may be used. pillow under the abdomen removes pressure from the breasts and favor relaxation. The amount of pressure to exert depends upon the patient‘s condition. Help the patient to turn on his abdomen or on his side with his back toward the nurse and his body near the edge of the bed so that he is as near the operator as possible. Blood components include: .

indicated for patients who have experience previous febrile no hemolytic 3. and freeze-dry 10. and neutrophils ) 5. 6. Advantages of blood component therapy 1. Platelets. Factor VIII concentrate. fibrinogen. Avoids the risk of sensitizing the patients to other blood components. Granulocytes ( basophils. including factors V and VIII (the labile factors). X. Leukocyte-poor packed RBCs. Increases availability of needed blood products to larger population. a plasma derivative rich in factor VIII. 8. containing all coagulation factors. either HLA (human leukocyte antigen) matched or unmatched. Factor IX concentrate. containing all stable coagulation factors but reduced levels of factors V and VIII. Cryoprecipitate. Single donor plasma. factor XIII. fractionating. a plasma protein. Principles of blood transfusion therapy . Albumin. and freeze-d 11. IX. and some factor XI. and fibronectin. Provides optimal therapeutic benefit while reducing risk of volume overload. a concentrated form of factor IX prepared by pooling. and 20% of plasma originally present in one un carrying capacity of blood with minimal expansion of blood. 3. 7. Packed RBCs (100% of erythrocyte. th anticoagulation. eosinophils. 4. fractionating. containing prothrombin and factors VII. Fresh frozen plasma.1. Prothrombin complex. a concentrated form of factor IX prepared by pooling. 9. 2. 2. 100% of leukocytes.

3.. Factor IX concentrate o Indicated for treatment of hemophilia B. heat-treated product decreases the risk of hepatitis and H 10. Verify doctor‘s order. Objectives 1.g. To ensure compatibility Obtain and record baseline vital signs Practice strict Asepsis At least 2 licensed nurse check the label of the blood transfusion o Check the following: . providing proper refrigeration of remaining blood until needed. 7.000/mm3: however.g. if patient cannot tolerate volume over a maximum of 4 ho into smaller volumes. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia 3. disseminated intravascular co 8. 2. Platelets o Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). 4. Plasma o Because plasma carries a risk of hepatitis equal to that of whole blood. severely granulocytopenic patients (less than expected to experienced prolonged suppressed granulocyte production. trauma. Cryoprecipitate o Indicated for treatment of hemophilia A. Granulocytes o May be beneficial in selected population of infected. One unit of 1%. 5. Inform the client and explain the purpose of the procedure. Check for cross matching and typing. To increase circulating blood volume after surgery. and hypertension. poor incremental increases occur with alloimmunization from previous tra destruction. clotting factors. Factor VIII concentrate o Indicated for treatment of hemophilia A. Von Willebrand‘s disease. if only volume expansion i solutions (e. 2. hemactocrit 3%. Each unit of platelets s 10. Albumin o Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circ large protein molecule is a major contributor to plasma oncotic pressure. 4. carries a high risk of hepatitis because it requires pooling 9. Whole blood transfusion o Generally indicated only for patients who need both increased oxygen-carrying capacity and resto obtain the specific blood components needed. platelets. albumin) Nursing Interventions 1. To provide selected cellular components as replacements therapy (e. 6. Fresh frozen plasma should be administered as rapi unstable after thawing. Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors. or hemorrhage 2. 3.1. Packed RBCs o Should be transfused over 2 to 3 hours. Ringer‘s lactate) are preferred. 5.

Use needle gauge 18 to 19. packed RBC). Warm blood at room temperature before transfusion to prevent chills. Two Nurses check the client‘s identification. To prevent adverse effects o Do not incorporate medication into the blood transfusion o Do not use blood transfusion lines for IV push of medication. 10. malarial smear) . platelets or plasma protei transfusion o Assessments:  Sudden chills and fever  Flushing  Headache  Anxiety 3. during or after BT.*this is to ensure that the blood is free fr transfusion. Administer BT for 4 hours (whole blood. 9. Adverse reaction usually occ 11. For plasma. 12.9% NaCl before. Allergic Reaction – it is caused by sensitivity to plasma protein of donor antibody.Serial number Blood component Blood type Rh factor Expiration date Screening test (VDRL. This allows easy flow of blood. 6. hives  Pruritus  Laryngeal edema. Do not mix medications with blood transfusion. Start infusion slowly at 10 gtts/min. 8. Remain at bedside for 15 to 30 minutes. transfuse q 15. Altered vital signs indicate adverse reaction. Notify physician. Septic Reaction – it is caused by the transfusion of blood or components contaminated with bacteria. Non-Hemolytic – it is caused by hypersensitivity to donor white cells. HBsAg. Never administer IV fluids with dextrose. Identify client properly. difficulty of breathing 2. Febrile. Use BT set with special micron mesh filter. Dextrose cau 14. 13. Observe for potential complications. which reacts with rec o Assessments:  Flushing  Rush. 7. platelets. Circulatory Overload – it is caused by administration of blood volume at a rate greater than the circulato o Assessment:  Rise in venous pressure . Administer 0. Monitor vital signs. o Assessment:  Rapid onset of chills  Vomiting  Marked Hypotension  High fever 4. cryoprecipitate. To prevent administration of blood clots and particles.       Complications of Blood Transfusion 1.

Febrile non-hemolytic reaction is marked by: o Temperature rise during or shortly after transfusion o Chills o headache o flushing . Signs and symptoms of hemolytic transfusion reaction include: o Fever o Chills o low back pain o flank pain o headache o nausea o flushing o tachycardia o tachypnea o hypotension o hemoglobinuria (cola-colored urine) 3. Clinical manifestations of transfusions complications vary depending on the precipitating factor. 2. Clinical signs and laboratory findings in delayed hemolytic reaction include: o fever o mild jaundice o gradual fall of hemoglobin o positive Coombs‘ test 4. o Assessment:  Low back pain (first sign). This is due to inflammatory response of the kidneys to incompa  Chills  Feeling of fullness  Tachycardia  Flushing  Tachypnea  Hypotension  Bleeding  Vascular collapse  Acute renal failure      Assessment findings 1. Hemolytic reaction. It is caused by infusion of incompatible blood products.Dyspnea Crackles or rales Distended neck vein Cough Elevated BP 5.

scaling) o edema o hair loss o hemolytic anemia 10. Hyperthermia 7. Signs and symptoms of circulatory overload include: o Dyspnea o cough o rales o jugular vein distention 8. Characteristics of GVH disease include: o skin changes (e. Reactions associated with massive transfusion produce varying manifestations o Possible Nursing Diagnosis 1. Impaired Skin Integrity 12. High Risk for Infection 9. Impaired Gas Exchange 6. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously. High Risk for Injury 10.anxiety 5. Hypothermia 8. Fluid Volume Excess 5. Fluid Volume Deficit 4. erythema. Ineffective breathing pattern 2. Allergic reactions may produce: o hives o generalized pruritus o wheezing or anaphylaxis (rarely) 7. Pain 11. Altered Tissue Perfusion Planning and Implementation 1. Decreased Cardiac Output 3. d 9. o Rapid onset of high fever and chills o vomiting o diarrhea o marked hypotension 6. Help prevent transfusion reaction by: . Signs and symptoms of septic reaction include.g. ulcerations.

3. vasopressor. Intervene as appropriate to address symptoms of the specific reaction: o Treatment for hemolytic reaction is directed at correcting hypotension. particularly duri within 15 minutes after the start of transfusion). transfusion can sometimes continue but at a slower rate. culture. On detecting any signs or symptoms of reaction: o Stop the transfusion immediately. fluids.9% saline to provide access for po o Send the blood bag and tubing to the blood bank for repeat typing and culture. or abnormal color before administratio o Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely.e. 2. DIC. Start IV line (0. before transfusion.Meticulously verifying patient identification beginning with type and cross match sample collectio identification prior to transfusion. treat septicemia with antibiotics. 3. o Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate fi aggregates during transfusion. o Draw another blood sample for plasma hemoglobin. o Nursing Interventions when complications occurs in Blood transfusion 1. The nurse remains with the client. o Transfusing blood within 4 hours. o Disconnect the transfusion set-but keep the IV line open with 0. o Preventing hypothermia by warming blood unit to 37 C before transfusion. observing signs and symptoms and monitoring vital signs as often as e Notify the physician immediately. 4. and retyping. and renal failure asso o Febrile. and transfusion record are saved and returned to the laboratory fo Evaluation . 5. leukocy subsequent transfusions. increased hydration. and notify the physician. 7. steroids and epinephrine as indicat manifestation. irradiation alters ability of donor lymphocytes to engraft and divide. o Collect a urine sample as soon as possible for hemoglobin determination.. attached label. and steroid Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RB Blood container. steroids and vasopressors o Intervene for allergic reaction by administering antihistamines. STOP THE TRANSFUSION. immediate treatment includes positioning the patient upright with feet de prescribed. 6. nonhemolytic transfusion reactions are treated symptomatically with antipyretics. clothing. If blood transfusion reaction occurs. o In septic reaction. The nurse prepares to administer emergency drugs such as antihistamines. tubing. and changing blood tubing every 4 hours to minimize the risk o o Preventing infectious disease transmission through careful donor screening or performing pretest a o Preventing GVH disease by ensuring irradiation of blood products containing viable WBC‘s (i. 2. o Inspecting the blood product for any gas bubbles.9% Na Cl) Place the client in fowler‘s position if with SOB and administer O2 therapy.) o For circulatory overload. 8.

The patient demonstrates adequate cardiac output. 2. 4. 5.5 L) Manufacture of some vitamins Formation of feces Expulsion of feces from the body The Small and Large Intestines Process of Peristalsis     Peristalsis is under control of nervous system Contractions occur every 3 to 12 minutes Mass peristalsis sweeps occur 1 to 4 times each 24-hour period One-third to one-half of food waste is excreted in stool within 24 hours Peristalic Movements in the Intestine – Colonic peristalsis is slow. few waves per da Factors that influence Bowel Elimination 1. 3. with no lesions or pruritus. The patient maintains good fluid balance.1. . 8. 7.1-1. Age Diet Position Pregnancy . The patient maintains normal breathing pattern. The patient remains free of infection. The patient reports minimal or no discomfort. 3. Bowel Elimination The Large Intestine   Primary organ of bowel elimination Extends from the ileocecal valve to the anus Functions     Completion of absorption of H2O. 2. intest. The patient remains normothermic. 6. The patient maintains good skin integrity. 4. The patient maintains or returns to normal electrolyte and blood chemistry values. Nutrients (chyme from sm. Mass peristalsis is strong.

or tumor Palpation—note any muscular resistance. red. adult—defecation patterns vary in quantity. and flatus Describe bowel sounds as audible. Psychological 8. a mass. hyperactive. enlargement of organs. scars. adolescent. masses Physical Assessment of the Anus and Rectum  Inspection and palpation .5. any masses. Activity 7. anticoagulants pink. cauliflower Effect of Medications on Stool     Aspirin. chocolate. cabbage. tenderness. lean meat. coffee Gas-producing foods—onions. bran. hypoactive. & pasta Foods with laxative effect—fruits and vegetables. or black stool Iron salts—black stool Antacids white discoloration or speckling in stool Antibiotics—green-gray color Physical Assessment of the Abdomen       Inspection—observe contour. Surgery/Anesthesia Developmental Considerations     Infants—characteristics of stool and frequency depend on formula or breast feedings Toddler physiologic maturity is first priority for bowel training (1 ½ – 2 yrs) Child. Medications 11. Pain 10. alcohol. frequency. or distension Auscultation—listen for bowel sounds in all quadrants Note frequency and character. audible clicks. Fluid Intake 6. eggs. or inaudible Percussion—expect resonant sou Areas of increased dullness may be caused by fluid. beans. Personal Habits 9. and rhythmicity Older adult—constipation is often a chronic problem Foods Affecting Bowel Elimination    Constipating foods cheese.

parasites. distended veins. and transport according to agency policy Patient Guidelines for Stool Collection      Void first so urine is not in stool sample Defecate into the container rather than toilet bowl Do not place toilet tissue in bedpan or specimen container Notify nurse when specimen is available get to lab quickly (30 min) if anything viable in sample ie.   Examine anal area for cracks. fecal mass Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining Inspect perineal area for skin irritation secondary to diarrhea Stool Collection      Medical aseptic technique is imperative Wear disposable gloves Wash hands before and after glove use Do not contaminate outside of container with stool Obtain stool and package. label. etc Types of Direct Visualization Studies . nodules. masses or polyps. C-diff.

and exercise is explained Patient should seek medical evaluation if changes in stool color or consistency persist Promoting Regular Bowel Habits        Timing -attend to urges promptly Positioning – have pt. gravity aids in BM Privacy – close door & pull curtain Nutrition Exercise – abdominal muscles & thighs Abdominal settings Thigh strengthening Individuals at High Risk for Constipation . fluid.    Esophagogastroduodenoscopy (EGD) Colonoscopy Sigmoidoscopy Wireless capsule endoscopy Indirect Visualization Studies    Upper gastrointestinal (UGI) Small bowel series Barium enema Scheduling Diagnostic Tests    1 — fecal occult blood test 2 — barium studies (should precede UGI) make sure ALL barium is removed* 3 — endoscopic examinations Noninvasive procedures take precedence over invasive procedures Patient Outcomes for Normal Bowel Elimination    Patient has a soft-formed bowel movement every 1-3 days without discomfort The relationship between bowel elimination and diet. sit up.

. medication) If there is impaction.oil Return-flow – bag of solution taken in (100-300 ml fluid) for pt with gas Retention Enemas . suggest the intake of fermented dairy products Fecal seepage may indicate impaction Preventing Food Poisoning         Never buy food with damaged packaging Never use raw eggs in any form Do not eat ground meat uncooked Never cut meat on a wooden surface Do not eat seafood that is raw or has unpleasant odor Clean all vegetables and fruits before eating Refrigerate leftovers within 2 hours of eating them Give only pasteurized fruit juices to small children Methods of Emptying the Colon of Feces     Enemas Rectal suppositories Rectal catheters Digital removal of stool Types of Enemas    Cleansing – high volume Retention .g. obtain physician order for rectal examination Give special care to the region around the anus After diarrhea stops.    Patients Patients Patients Patients on bed rest taking constipating medications with reduced fluids or bulk in their diet who are depressed with central nervous system disease or local lesions that cause pain *Valsalva maneuver (straining & holding breath) ↑intrathoracic / intracranial pressure – possible brain injur Nursing Measures for the Patient With Diarrhea       Answer call lights immediately Remove the cause of diarrhea whenever possible (e.

empty appliance frequently Inspect the patient's stoma regularly Note the size. which should stabilize within 6 to 8 weeks Keep the skin around the stoma site clean and dry Measure the patient's fluid intake & output Explain each aspect of care to the patient and self-care role Encourage patient to care for and look at ostomy Normal-Appearing Stoma Patient Teaching for Colostomies  Community resources are available for assistance . formed stool at regular intervals without laxatives When achieved. discontinue use of suppository if one was used Types of Colostomies – each has different stool consistency      Sigmoid colostomy Descending colostomy Transverse colostomy Ascending colostomy Ileostomy Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy Location of an Ileostomy Colostomy Care        Keep patient as free of odors as possible.     Oil-retention—lubricate the stool and intestinal mucosa easing defecation Carminative—help expel flatus from rectum Medicated—provide medications absorbed through rectal mucosa Anthelmintic—destroy intestinal parasites Nutritive—administer fluids and nutrition rectally Bowel Training Programs     Manipulate factors within the patient's control Food and fluid intake. time for defecation Eliminate a soft. exercise.

Color – varies from light to dark brown foods & medications may affect color Odor – aromatic. 5. Constipation – abnormal frequency of defecation and abnormal hardening of stools 2. 3.      Initially encourage patients to avoid foods high in fiber Avoid foods that cause diarrhea or flatus Drink two quarts of water daily Teach about medications Teach about odor control (intake of dark green vegetables helps control odor) Resume normal activity including work and sexual relations Comfort Measures     Encourage recommended diet and exercise Use medications only as needed Apply ointments or astringent (witch hazel) Use suppositories that contain anesthetics Characteristics of Normal Stool 1. Incontinence – involuntary elimination of feces 5. phosphates) Common Bowel Elimination Problems 1. Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red b Care of the Dead I. 4. semi-solid. soft. 2. inorganic matter (calcium. Diarrhea – increased frequency of bowel movements (more than 3 times a day) as well as liquid co urgency. sloughed dead bacteria and epithelial cells. To prepare the body for the morgue. f pigments). Flatulence – expulsion of gas from the rectum 6. Impaction – accumulated mass of dry feces that cannot be expelled 3. discomfort and possibly incontinence 4. affected by ingested food and person’s bacterial flora Consistency – formed. Purpose 1. moist Frequency – varies with diet (about 100 to 400 g/day) Constituents – small amount of undigested roughage. .

3.r.n. Mortuary pack: should. a basin of lysol solution 2% Soap in dish. 3. 11. Procedure 1. The patient has pronounced dead by the doctor. 13. non-absorbent cotton. Remove all appliances. Equipments Tray with:       Basin of warm water. pair of scissors.r. See that dentures are placed in the mouth if patient has any 3. Attach the other tag at the center 14. 4. Put on the shroud. 6. Bathe the body using the Lysol solution to rinse. etc. Pad wrists with cotton and the tie the 2 wrists together with bandage. Full hands over the chest. 9. place the body in dorsal position with only a small pillow 2. Bed screen III.n. To prevent discoloration or deformity of the body. Venoclysis sets. Mouth—bring the jaws together by placing a rolled towel under the chin. Leave one sheet to cover the body. Points to Remember 1. Remove extra bed linen and camisa. forceps. Vagina (if female). Wrap body with a sheet well. If there is any discharge from 10. To protect the body from post mortom discharge. Attach on 12. 2. jewelry and other valuables or belongings must be kept and cared for properly. 7. drainage tubings. comb or brush Bath towel and wash cloth Surgical dressings p. bandages.2. 5. The body should be identified properly. pins. Close the eves and mouth when open. Cover the prepared body with a sheet and notify the head nurse or call for the messenger to take the body Caring . II. 8. diaper sheet 2 death tags. Respect the dead body. Avoid unnecessary exposure and irrelevant conversations. Eyes—bring upper lid down to the lower and apply gentle pressure over it for a while. Clothing‘s. Pack anus with cotton. Place the diaper. catheters. Pad the ankles and tie them together. IV. Change surgical dressings p.

Example: ICU had a dominant value of technological caring (i. monitors. treatments). family focused. and practi Cultures exhibit both diversity and universality Diversity . and things matter Nursing Theories of Caring Culture Care Diversity and Universality Theory (Leininger)        Based on transcultural nursing model Transcultural nursing: a learned branch of nursing that focuses on the comparative study & analysis of beliefs. the meaning of caring was further influen valued caring in terms of its relatedness to client. and values Goal of Transcultural Nursing: to provide care that is congruent with cultural values. beliefs. hospital) as cultures.. econom technological) Caring. The theory suggests that caring organizational structure. the Human Mode of Being (Roach) . folk health or well-being system Theory of Bureaucratic Caring (Ray)    Ray‘s theory focuses on caring in organizations (e.commonalities of care Fundamental Theory Aspects .e. while administrator valued caring as system related. and practicing care in different ways Universality .culture.perceiving. ventilators. comforting.e.Definition   Central to all helping professions. Means that people. Furthermore. knowing. compassionate). relationships. cultural care.g. Onco (i. world view. care. legal. Spiritual –ethical caring influences each of the aspects of the bureaucratic system (political. and enables persons to create meaning in their lives..

and language. active expression of love. sorrows. concern. Caring is a moral enhancement. energy. Presentin respect. attitude. and family. Commitment  Convergence between one‘s desires and obligations and the deliberate choice to act in accordance with th Comportment  Appropriate bearing. and preservation of human dignity. ethics. Theory of Caring (Swanson) . that is in harmony with a caring presence. or benevolent desire. proposes that all persons are caring. Awareness of personal responsibility. Conscience  Morals. client. experience. judgment. pain. and is the intentional and embodied recognit Theory of Human Care (Watson)  Human caring in nursing is not just an emotion. dress.  Caring is the human mode of being. and accomplishments. and develop their caring abilities Develop the Six C‘s of Caring in Nursing: Six C’s of Caring in Nursing Compassion  Awareness of one‘s relationship to others. Caring in nursing is ―an altruistic. Partici Competence  Having the knowledge. and motivation to respond adequately to oth Confidence  The quality that fosters trusting relationships. demeanor. Nursing as Caring (Boykin and Schoenhofer)    Suggests that the purpose of the discipline and profession of nursing is to know persons and nurture them Similar to Roach idea that all persons are caring. Comfort with self. and an informed sense of right and wrong. skills. sharing their joys.

This involves initiating and maintaining behaviors that p . Caring creates the possibilities for coping and creates possibili Caring for Self Caring for self means taking the time to nurture oneself. Caring involves 5 processes: Definition Striving to understand an event as it has meaning in life of the other Sub dimensions                       Avoiding assumptions Centering on the one cared Assessing thoroughly Seeing cues Engaging the self of both Being there Conveying ability Sharing feelings Not burdening Comforting Anticipating Performing Competently/skillful Protecting Preserving dignity Informing/explaining Supporting/allowing Focusing Generating Alternative/thinking it through Validating/giving feedback Believing in/ holding in esteem Maintaining a hope-filled attitude Offering realistic optimism ―Going the distance‖ Process Knowing Being With Being emotionally present to other Doing For Doing for the other as he/she would do for the self if it were at all possible Enabling Facilitating the other‘s passage through life transitions and unfamiliar events Maintaining belief Sustaining faith in the other‘s capacity to get through an event or transition and face a future meaning    The Primacy of Caring (Benner and Wrubel)  Caring is central to the essence of nursing.

4. Place patient in supine position with head turned away from catheter insertion site to decrease potential for contamination by patient‘s secretions.     A balanced diet Regular exercise Adequate rest and sleep Recreational Activities Meditation and prayer Changing a Central Line Catheter Dressing Sample Central Line Dressing Checklist Critical Performance Elements YES 1. Gather all necessary equipment: roll of tape. Remove present dressing carefully to minimize trauma and prevent accidental dislodgment of catheter. (Don gown if soiling is likely). c. Don mask. Discard soiled dressing in proper trash receptacle. or other mechanical problems. and central line line dressing kit. leakage. b. Alcohol swabsticks x 3 – to remove the betadine scrub. and distal portion of catheter with : a. Explain procedure to the patient and/or significant others. label. 3. insertion site. Wash hands. 8. *** Working in a circular motion from insertion site outward to edge of dressing border cleanse skin. *** Don a pair of clean gloves. 6. Place a mask over the patient‘s mouth and nose or sterile drape over ventilated or trached patient.to provide protective barrier against pathogens. 9. *** Remove soiled gloves and don sterile gloves. *** Open central line kit. Providone-iodine scrub swabsticks x 3 – to remove bacteria and fungi. Visually inspect the skin and catheter site for signs of infection. Blot excess or NO . Organize supplies and equipment at bedside to decrease the amount of time that site is open to air. Check for providone-iodine or tape allergy. Betadine solution swabsticks x 3 to cover a 3″ x 6″ area from site to periphery. 2. 7. 10. 5.

. apply elastoplast and secure edges with tape. NOTE: If 2×2 gauze used after initial insertion under occlusive (Tegaderm) dressing. date of dressing change and insertion.pooled solution. *** Dressing. 15. 12. *** Loop and secure IV tubing to dressing and arm or chest. *** Document the dressing change. 14. 13. Instruct the patient to perform Valsalva maneuver or hold his/her breath (or immediately after a ventilator delivers a breath). Document any problems encountered in nursing progress notes on. dressing must be changed in 24 hours.(Tegaderm):    do not use 2×2 skin prep is optional apply occlusive dressing according to manufacturer‘s guidelines. Wash hands. remove it with alcohol swabs after a two to five minute dwell time. cut elastoplast to fit over insertion site and sutures. b. If a tubing change is necessary: a. 11. and initials. 17. Changing and flushing a central line access cap  Check client’s chart and care plan to determine time of last access cap change. *** Must perform these critical elements for successful completion. Quickly disconnect and reconnect the IV tubing ensuring secure junction. *** Label dressing with time. Elastoplast:     place folded 2×2 over insertion site to include sutures to prevent the tape/ elastoplast from sticking to the line and sutures. the condition of the insertion site on nursing note and flow sheet. *** For patients with IODINE ALLERGY. b. Discard supplies used. paint around the edges of the gauze with skin prep and allow to dry.If 4% chlorhexidine is used. Allow to dry.may use elastoplast or occlusive dressing as follows: a. Occlusive Dressing.

slide the sleeve up over the container to rem ove the used g 3. 6. Holding the container above the client’s arm. 4. Assist the client to put the other arm into the second sleeve of the gown.      Identify client Explain procedure to client and provide privacy Gather equipment Wash your hand and don gloves Repeat procedure with the remaining access caps Remove gloves and wash hands Changing a Hospital Gown for a Client with an Intravenous Infusion 1. Rehang the container. taking care not to pull on the tubing. Slide the gown carefully over the tu bing toward the client’s hand. . Guide the client’s arm and tubing into the sleeve. Place the clean gown sleeve for the arm with the infusion over the container as if it were an extension of sleeve cuff. 5. Slip the growth completely off the arm without the infusion and onto the tubing connected to the arm wi 2. and fasten as usual.

Remove outer wrap. Select correct solution (using 5 rights of drug administration). Inspect bag carefully for tears or leaks by applying gentle pressure to the bag. Tape bag based on hourly flow rate and initial. time or according to agency policy. discoloration. Support with the knee rest prov II. To turn the patient toward you: 1. Relieve strain on the abdominal muscles and on tendons under the knees. Support the whole length of the back with pillows so that the patient can relax comfortably. Move the patient to the side of the bed away from you by putting your forearms under the body then slidi across the bed. Relieve strain on the muscles of the back by supporting it. Label bag with patient‘s name. Arrange the pillows in the order to support the weight of the shoulders and head. Flex the knees with the upper leg flexed a little more than the lower leg. In Dorsal Recumbent Position: 1. Changing the Position of the Patient I. Count the rate of flow of the infusion to make sure it is correct before leaving the bedside. Hold the bag up and examine for cloudiness. Changing Mainline IV Bag            Check physicians order. 7. small pa 3. . Support the legs by placing a pad or small pillow between them. 2. fill in the hollows with small pillows. Asses IV site again. shoulders and hips are properly adjusted. Lift and turn him gently toward you to the middle of the bed. Turning to One Side: A. explain procedure and asses IV site. 2. or any foreign matter. that the neck and shoulders are not cramped a 5. Place one of your arms across the patient‘s back reaching from the far side to the side nearer you and the 3. Identify patient. Wash Hands. See that the head. date. 6.7. 4. Discard old bag according to agency policy Record I&O and IV solution according to agency policy.

The significant observation of the patient‘s condition both mental and physical. treatment. (a) The signature should stand alone on the line just below the notations recorded by her. The incident which might have some bearing on the patient‘s condition. 3. diets and nursing care given and the reaction of the patient to this care.8. General Rules for Charting: 1. 2. A small pillow placed against the abdomen gives relief and comfort especially when the patient is sufferin B. From the side nearest you. slip one arm under the patient‘s shoulder reaching the far shoulder and place th 2. Lift and draw his far side slightly toward you so that he is gradually turned away from you. The written signature of the nurse should consist of her initial of first name and fill last name. To turn patient away from you: 1. . Charting Purpose of Charting: To make record of— 1. All recording on the chart must be printed. The medication. 2. except the written signature of the nurse.

(b) Record all start and p. individual letters in each ward. Do not write the orders of the doctor as ―Dr. 7. the original page must be filed at the back of the chart. 3. appearance of symptoms. 9. Do not use more than one space for each letter. 12. 6. legible. It is necessary to recopy. Authentic recording is essential as a chart often plays an important part in the presentation of court eviden 8. Never print the word patient when charting. 3. 8. Write the date and the day of the new day between the mid 14. 19. The midnight lines are to be drawn in red ink. 4. 7. In the ―observations‖ column: (a) Record any of all symptoms. Begin each separate notation on the horizontal line 10. record the time of treatment. Consult the superviso made an error. Properly space all printed letters and words.r. Keep all recordings within limits provided by the pale. doctor‘s visit. Do not use unnecessary curves tails or fancy strokes in making the printed letters. Printing is the most consistently legible of all forms of writing for that reason should be used for recordin Print well formed. relevant and concise. Errors in charting: (a) Do not erase errors made in charting (b) When an error has been made. Make all printed letters stand erect.(b) The signature of the nurse should be of a size that will insure legibility without attracting attention. In the hour column. A nurse making a series of statements or notations signs for the series and not for each individual stateme 4. do not make too much of a forward backward slant to the letters.‖ 18. . complaints or change in the condition of the patient. Separate printed words by a space the size of single letter. (c) Record the results and effects of the medications and treatments. Smith ordered backrest elevated two inches. draw a line through the error from the upper left hand corner to the low containing the error and write the word ―ERROR‖ under which the nurse signs her name. 2. regardless of the shape of that letter. medication. 11. All recording on the chart should be neat. General Rules for Printing: 1. Red ink should be used for recording between the hours of 11:00pm to 7:00am. treatments and medications given. intelligent and meaningful. (a) Terse statements instead of complete sentence are used. (d) Record routine nursing procedures involved in the care of the patient. The nurse should not go ―off duty‖ without making the necessary notations on the charts of each patient a 5.n. Do not use ornamental lettering for recording on the chart. 17. 5. Statements must be accurate. (c) An error in charting should not necessarily invoke recopying of the entire page. Make all printed letters conform in appearance to those in the sample alphabet. 16. Print the proper headings for all new pages or sheets to be added to the chart using blue or black ink. The chart in itself is a record for the individual patient and al kept. Blue or black ink should be used for recording between the hours of 7:00am to 11:00pm. To avoid illegibility. (e) Record each time the attending physician visits the patient. 6. (b) Correct spelling and only acceptable and official abbreviations are to be used. Arrange the different sheets on the chart in correct order. etc 15. 13. 9.

Make the use of the word ―bed‖ to remember on which side of the stem to make the loop for the letters ―b 15. TPR after. the time at which they are. 12. following surgical operation or X accidents. if there is discharge. and by whom.g. make the letter ―V‖ with art acute angle at the bottom. 2. or punctures done. kinds.10. horizontally at the upper third of its height. When recording the dressing of wound. Always make the small letter 2/3 the height of capital ones. chills. etc. 4. Equipment: 1. Make the letter ―U‖ curved at the bottom. Symptoms a. Print numbers that are to be used in charting as well as letters. Tray with bedpan brush. convulsions and when patient is very ill. All doctor‘s orders. (b2)Menstruation. Example of Data to be Charted: 1. Amount of sleep. Appetite and amount of food taken. 11. 13. Objectives: (b1)All conditions that call for particularly careful attention to their record e. bedpan swab Short-sleeved gown Can of disinfectant solution Soap or any cleanser Several pieces of dusting cloth . 16. or results of flow in case (d) Operation delivery. (c) Treatment given. 2. (a) Medicines given. time result. 14. 5. Subjective b. 5. time and effect on patient‘s condition during or after the treatment. Make each printed letter rest on the line. For practice in printing use only those letters which are illustrated in the sample alphabet. Cleaning Bedpans and Urinals I. mention and change i 3. time. 3. Cross the letter ―t‖. used to relieve a condition that should respond to trea (b) Inspections. (b3)Nature of excreta or order discharges. state condition of the letter. 4. and when.

Use brush p. Creosol solution 5%.r. Equipment:      Tray with big basin of disinfectant solution. 5.n. Cleaning Sputum Cups I. wash inside and outside with warm soapy water.II. Medicine glass A pitcher of 1% creosol solution Sputum cup brush Several pieces of dusting cloth   Sapolio or Cleanser Short-sleeved gown II. Procedure for Cleaning Bedpans and Urinals 1. 7. Wash with clean cold water. 2. 3. 4. 6. Remove any stains using the cleanser Rinse with hot water Wipe to dry with the bedpan wiper and hang it at the bedpan rack. Put on the short-sleeved gown Collect the bedpans Empty the contents one by one into the hoper. Procedure: . Follow with h Put the bedpan in the scan of disinfectant Remove after.

r.n. Put on the gown. Remove after. Empty their contents into the hopper. It is a basic compone The Communication process Referent  Or stimulus motivates a person to communicate with another. Rinse with hot water. 4. Rinse with hot water and dry the outside. 2. Collect all the sputum cups in a tray. Wash with cold water. is the person to whom the message is sent Feedback  Helps to reveal whether the meaning of the message is received . emotion. It may be an object. Channels  It means. Remove stains. auditory and tactile senses. 6. conveying messages such as through visual. 3.1. clean inside and out with soapy warm water. Place cup in basin of disinfectant solution of 5% Creosol solution for 2 hours. Sender  Also called the encoder. Use brush p. idea or act. Fill each sputum cup with 50 cc of 1% of Creosol solution and place in the trays. is the person who initiates the interpersonal communication or message Message  The information that is sent or expressed by the sender. 5. do not put Creosol solution inside their sputum cups. distribute back to each p For children and delirious patients. Communication Definition  It is the process of exchanging information or feelings between two or more people. 8. 7. Receiver  Also called the decoder.

Pace and Intonation  The manner of speech. Clarity and Brevity   A message that is direct and simple will be more effective. knowledge. Jones!‖ notices that the client is not smiling and appears distressed. E.Modes of Communication Verbal communication. E. the timing needs to be appropriate to ensure This involves sensitivity to the client‘s needs and concerns. I would be more appropriate to sa will collect it by putting a small tube into your bladder‖.g. ―the nurses will be catheterizing you tomorrow for a urinalysis‖..g. culture and client.uses the spoken or written word 1. a nurse who an enthusiastic ―Hi. To e slowly and enunciate carefully. 2. Clarity is saying precisely what is meant. Nurses need to learn to select appropriate. a client who is enmeshed in fear of canc procedures before and after gallbladder surgery. It is importa . and completeness. Simplicity   Includes the use of commonly understood words. understandable terms based on the age. 4. Adaptability  What the nurse says and how it is said must be individualized and carefully considered. 5. as in the pace or rhythm and intonation. will modify the feeling and impact of the excited client may help calm the client.. Timing and Relevance   No matter how clearly or simply words are stated or written. 3. and The goal is to communicate clearly so that all aspects of a situation or circumstances are understood. Mrs. brevity.

express concern in his facial expression while moving toward the client. something to make you more comfortable?‖ 3. Humor  The use of humor can be a positive and powerful tool in nurse. 6. Personal Appearance   When the symbolic meaning of an object is unfamiliar the nurse can inquire about its significance. A man may request a shave. Slouched posture and slow. 1. or they may occur without words to Electronic Communication. but it must be used wit client‘s perception of what is considered humorous. and reliability. Facial Expression     No part of the body is as expressive as the face Although he face may express the person‘s genuine emotions. Posture and Gait   The ways people walk and carry themselves are often reliable indicators of self-concept.g. while being to acknowledge their find someone who does‖. 7. trustworthiness. ―You look like it really hurts you to move. Credibility   Means worthiness of belief. e. Nurses should convey confidence and certainly in what they are saying. or a woman may request a shampoo and some 2. Nurses foster credibility by being consistent. Eye contact is another essential element of facial communication 4. such as gestures or facial expressions. an suggest a feeling of well being.uses other forms. E. When the message is not clear. and touch. shuffling gait suggest depression or physical The nurse clarifies the meaning of the observed behavior.g. it is important to get feedback to be sure of the intent of expressio Nurses need to be aware of their own expressions and what they are communicating to others. it is also possible to control these muscles feeling. which How a person dresses is often an indicator of how person feels. current mood.many health care agencies are moving toward electronic medical records where nu E-mail . Non-verbal Communication. It is impos to control expressions of feelings such as fear or disgust in some circumstances.client relationship. For acutely ill clients n hospital or ho that the client is feeling better. Gesture  Hand and body gestures may emphasize and clarify the spoken word.

Personal: 1 ½ to 4 feet c. mental health.    Most common form of electronic communication. minimize differences. 3. HIV status. Roles and Relationships . Development  Language. Public: 12 to 15 feet 5. Gender  Girls tend to use language to seek confirmation. psychosocial. Social: 4 to 12 feet d. and perceptions are the personal view of event. Proxemics is the study of distance between people in their interactions Communication 4 distances: a. Territoriality  Is a concept of the space and things that an individual considers as belonging to the self 6. chemical dependency) c. Advantage: It is fast. When information is urgent b. Abnormal lab data  Agencies usually develop standards and guidelines in use of e-mail Factors Influencing the Communication Process 1. Intimate: Touching to 1 ½ b. It provides a record of the date and ti Disadvantage: risk of confidentiality When Not to Use Email: a. 2. Highly confidential information (e. Boys use la within a group. 4. and intellectual development move through stages across the lifespan. efficient way to communicate and it is legible. Values and Perception  Values are the standards that influence behavior. and establish intimacy.g. Personal Space    Personal space is the distance people prefer in interactions with others.

4. when teaching a client how to care for a colost with this. 2. nonverbal. thoughts. if the nurse looks worried or disgusted while saying this. Caring and warmth convey a feeling of emotional closeness Respect is an attitude that emphasizes the other person‘s worth and individuality. Interpersonal Attitudes    Attitudes convey beliefs. sentence structure. 3. . nursing s parent and child). Feedback – is the message returned by the receiver.The nurse willingly receives the clien Communication in Nursing Communication 1.g. (E. It the means by which an individual influences the behavior of another. E. the client is less likely to tr 9. 2. Is the means to establish a helping-healing relationship. Environment  People usually communicate most effectively in a comfortable environment. Verbal Communication – use of spoken or written words. A nurse coveys respect disagrees. It may contain verbal. and symbolic languag Receiver – is the person who receives the decodes the message. 8. Congruence  The verbal and nonverbal aspects of message match. 7. Choice of words.g. Sender – is the person who encodes and delivers the message Messages – is the content of the communication. It indicates whether the meaning of the sender‘s mes Modes of Communication 1. and tone of voice vary considerably from role to role.. which leads to the successful outc Basic Elements of the Communication Process 1. 4. 3.Acceptance emphasizes neither approval nor disapproval . All behavior communication influences behavior Communication is essential to the nurse-patient relationship for the following reasons: Is the vehicle for establishing a therapeutic relationship. and feelings about people and events.‖ However.

g. Communicate both verbally and by touch c. 4. d. the nurse requires adequate knowledge ab provide accurate information. facial expressions. Avoid saying things client should not hear . brevity. place. Listen attentively. Be an attentive listener g. pictures denoting basic needs. g. Ask one question at a time e. Speak to client as though he or she could hear d. Use simple sentences and avoid long explanation.. Use visual cues (e. pictures. Allow time for understanding and response. f. call bells or alarm 2. Clients who are cognitively impaired a. muteness) a. c. Get client‘s attention prior to speaking c. Clients who cannot speak clearly (aphasia. Allow time for client to respond f. to convey confidence and certainly in what she says. Avoid talking about client to others in his or her presence g. Clarity – involves saying what is meant. b. Adaptability – Involves adjustments on what the nurse says and how it is said depending on the moods a 5. physica Characteristics of Good Communication 1. especially in subjects known to client. and objects) e. Reduce environmental distractions while conversing. To become credible. Do not shout or speak too loudly. Communicating With Clients Who Have Special Needs 1. dysarthria. body movements. and do not interrupt. Simplicity – includes uses of commonly understood. Credibility – Means worthiness of belief. Timing and Relevance – requires choice of appropriate time and consideration of the client‘s interest an answer before making another comment. d. Provide orientation to person. magic slate. b. Nonverbal Communication – use of gestures. and completeness. and time f. The nurse should also need to speak slowly and enunciate word 3. words. 3. Allow only one person to speak at a time. Explain all procedures and sensations e. Use communication aid:Pad and felt-tipped pen. 2. posture/gait. be patient. Ask simple question that require ―yes‖ and ―no‖ answers. Client who are unresponsive a. Call client by name during interactions b.2. Include family and friends in conversations.

It is also important to check the family as to how to communicate with the client f. especially children. and ref 3. written. Communicating with hearing impaired client a.4. Data recorded. Telephone or verbal orders – only RN‘s are allowed to accept telephone orders. Establish method for client o signal desire to communicate (call light or bell) c. sign-language) b. or communicated to other health care professionals are CONFIDENTIAL and m . Provide an interpreter (translator) as needed d. Always face the client when speaking e. Have dictionary (English/Spanish) available if client can read. pictures or cards. 4. As members of the health care team. or audiotape exchanges of information between caregivers. f. Is anything written or printed that is relied on as record or proof for authorized person. Avoid using family members. Establish a method of communication (pen/pencil and paper. care can become fragmented omitted. 4. 2. Develop communication board. maintain continuity of care. It may be necessary to contact the appropriate department resource person for this type of disability 5. Decrease background noise such as television d. e. Nursing documentation must be: o accurate o comprehensive o flexible enough to retrieve critical data. as interpreters. 6. reported. Incident report Documentation 1. Reports  Are oral. track client outcomes. If the care plan is not communicated to all members of the health care team. Change-in-shift report 2. Client who do not speak English a. Transfer report 5. Common reports 1. Telephone report 3. Pay attention to client‘s non-verbal cues c. Speak to client in normal tone of voice (shouting may be interpreted as anger) b. nurses need to communicate information about clients accurately an 5. Effective documentation ensures continuity of care saves time and minimizes the risk of error.

3. Factual a. It is essential to avoid the use of unnecessary words and irrelevant details 3. Nurses may not discuss a client‘s examination. feels. Current a.Confidentiality 1. c. beginning approximately 1 rates pain as 8 on a scale of 0-10. and they have the right to read those records. The information within a recorded entry or a report needs to be complete. 6. To increase accuracy and decrease unnecessary duplic client‘s bedside. It is essential that the nurse safe-guard the client‘ right to privacy by carefully protecting information of a 9. When nurses and other health care professionals have a legitimate reason to use records for data gathering authorization must be obtained according to agency policy. (example: ―Intake of 350 ml of water‖ is more accurate t b. A record must contain descriptive. which facilitate immediate documentation of information as it is collected from a client 5. throbbing pain localized along lateral side of right ankle. is not acceptable because these words suggest Example: “The client seems anxious” (the phrase seems anxious is a conclusion without supported facts. 5. observation. objective information about what a nurse sees. containing appropriate and Example: The client verbalizes sharp. Maintaining confidentiality is an important aspect of profession behavior. and apparently. Organized . such as appears. Complete a. It sends the message that the nurse cannot be trusted and damages the interpersonal relationships. Accurate a. Nurses are responsible for protecting records from all unauthorized readers. Documentation of concise data is clear and easy to understand. seems. 4. 8. 4.) 2. Timely entries are essential in the client‘s ongoing care. 7. 2. hears. Clients frequently request copies of their medical record. and smells. Sharing personal information or gossiping about others violates nursing ethical codes and practice standa 10. The use of exact measurements establishes accuracy. b. Guidelines of Quality Documentation and Reporting 1. conversation. Nurses are legally and ethically obligated to keep information about clients confidential. or treatment with other clients Only staff directly involved in a specific client’s care has legitimate access to the record. The use of vague terms.

a. be sure information is accurate. For computer documentation keep your password to yourself. and end with your signature and title. o Once logged into the computer do not leave the computer screen unattended. Chart only for yourself o Never chart for someone else. o Begin each entry with time. o You are accountable for information you enter into chart. 4. you are just as liable for prosecution as the physician 7. o Do not wait until end of shift to record important changes that occurred several hours earlier. Draw single line through error. o Chart consecutively. write word error above it and sign your name or initials. Example: An organized note describes the client’s pain. and the client’s respons Legal Guidelines for Recording 1. o Blank ink is more legible when records are photocopied or transferred to microfilm. nurse’s interventions. felt pen. o Enter only objective descriptions of client‘s behavior. 8. Avoid using generalized. Correct all errors promptly o Errors in recording can lead to errors in treatment o Avoid rushing to complete charting. If order is questioned. The nurse communicates information in a logical order.Second Step in the Nursing Process Definition   Is the 2nd step of the nursing process. o Maintain security and confidentiality. empty phrases such as ―status unchanged‖ or ―had good day‖. 3. line by line. record that clarification was sought. Do not write retaliatory or critical comments about the client or care by other health care professionals. o If you perform orders known to be incorrect. Then record note 2. nurse’s assessment. Diagnosis . o Legal Guidelines for Recording 6. draw line horizontally through it and sign your na 5. client‘s comments should be quoted. the process of reasoning or the clinical act of identifying problems . Record all entries legibly and in blank ink o Never use pencil. Be s 9. if space is left. Do not leave blank spaces in nurse‘s notes.

o Analysis – separation into components or the breaking down of the whole into its parts.Purpose    To identify health care needs and prepare a Nursing Diagnosis. 2. Problem statement/diagnostic label/definition = P 2. Data Analysis 2. . Defining characteristics/signs and symptoms = S  *Therefore may be written as 2-Part or a 3-Part statement. It states a clear and concise health problem. to reduce. Is a statement of client‘s potential or actual alterations/changes in his health status. To diagnose in nursing It means to analyze assessment information and derive meaning from this analysis. It is derived from existing evidences about the client. It is potentially amenable to nursing therapy. 4. Etiology/related factors/causes = E 3. 3. eliminate or prevent alterations/changes. Is the problem statement that the nurse makes regarding a client‘s condition which she uses to communic It uses the critical-thinking skills analysis and synthesis in order to identify client strengths & health prob independent nursing interventions. Nursing Diagnosis      Is a statement of a client‘s potential or actual health problem resulting from analysis of data. Formulation of Nursing Diagnosis Characteristics of Nursing Diagnosis 1. A statement that describes a client‘s actual or potential health problems that a nurse can identify and for w health status. It is the basis for planning and carrying out nursing care. Problem Identification 3. Components of A nursing diagnosis (PES or PE) 1. o Synthesis – the putting together of parts into whole Three Activities in Diagnosing: 1.

Possible nursing diagnosis = Problem + Etiology Qualifiers – words added to the diagnostic label/problem statement to gain additional meaning. Risk Nursing diagnosis = Problem + Risk Factors 3. It is based o Examples:          Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea. Actual Nursing Diagnosis – a client problem that is present at the time of the nursing assessment. Risk for interrupted family processes r/t mother‘s illness & unavailability to provide child care. Ineffective airway clearance r/t to viscous secretions Noncompliance (Medication) r/t unknown etiology Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis Acute Pain (Chest) r/t cough 2nrdary to pneumonia Activity Intolerance r/t general weakness. Disturbed Sleep Pattern r/t cough. Examples:    Possible nutritional deficit Possible low self-esteem r/t loss job Possible altered thought processes r/t unfamiliar surroundings 3. . Anxiety r/t difficulty of breathing & concerns over work 2. Risk Nursing diagnosis – is a clinical judgment that a problem does not exist. bu problem is only is likely to develop unless nurse intervene or do something about it. Risk for injury r/t decreased vision after cataract surgery. No subjective or objective c be more vulnerable to the problem are the etiology of a risk nursing diagnosis. Examples:      Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes. Actual nursing diagnosis = Patient problem + Etiology – replace the (+) symbol with the words ―RELAT 2. Constipation r/t long term use of laxative. Potential Nursing diagnosis – one in which evidence about a health problem is incomplete or unclear therefo factors are unknown but a problem is only considered possible to occur. Risk for Constipation r/t inactivity and insufficient fluid intake Risk for infection r/t compromised immune system. fever and pain. therefore no S/S are present. Formula in writing nursing diagnosis (PES or PE) 1.Types of Nursing Diagnosis 1.

degree. 3. incomplete ―impaired‖ – made worse. ― laundry‖). warm to touch.    ―deficient‖ . Compare data against standards Cluster or group data Data analysis after comparing with standards Identify gaps and inconsistencies in data Determine the client‘s health problems. strengths Formulate Nursing Diagnosis – prioritize nursing diagnosis based on what problem endangers the client‘s Situation: Functional Health Pattern – Activity/Exercise  Anna. 2. flush skin. 5. 35 years of laundry woman seeks consultation at the Philippine General Hospital due to fever 2 day ako giniginaw. deteriorated ―decreased‖ – lesser in size. 4. health risks. teary ey Nursing Diagnosis  Hyperthermia [related to (r/t)] environmental condition AMB T = 39°C.2°C Respiratory Rate (RR) = 35 P = 96. 2. reduced. She has 3 children she walks off to school everyday before she goes to work Vital Signs  Temperature (T) =39.inadequate in amount. damaged. with flush skin and warm to touch. ―No appetite since having cough‖ Has not eaten today. 3. quality. teary Situation: Functional Health Pattern = Nutritional/Metabolic 1. amount. degree ―ineffective‖ – not producing the desired effect Activities during diagnosis: 1. masakit ang ulo at mainit ang pakiramdam pagkatapos kong maglaba sa kabilang kanto. insufficient. weakened. States. 6. last fluids at noon today Has lost 8 lbs in past 2 weeks Nauseated x 2 days Nursing Diagnosis  Imbalanced Nutrition: Less than body Requirements r/t decreased appetite and nausea 2ndary to disease p Situation: Functional Health Pattern = Activity/Exercise . 4.

orthopnea and pain. 4. Position upright leaning on over bed table 3. Secure consent. 2. Difficulty sleeping because of cough 2. 3. Acute Pain (chest) r/t pathologic condit Situation: Functional Health Pattern = Coping/Stress 1.1. will be back next week. Secure consent Check for allergies to seafood or iodine or anesthesia NPO 6-8 hours before the test NPO until gag reflex return to prevent aspiration Thoracentesis – (Aspiration of fluid in the pleural space. Anxious State. Report pain on chest when coughing Nursing Diagnosis  Disturbed Sleep Pattern r/t a disease process. Nursing Diagnosis  Anxiety r/t difficulty of breathing and concerns over parenting roles. Diagnostic Tests PPD test 1. ―Can‘t breath lying down‖ 3.) 1. For HIV positive clients. 2. Avoid cough during insertion to prevent pleural perforation . 4. 5. in duration of 5 mm is considered positive Bronchography 1. take V/S 2. ―I can‘t breath‖ Facial muscles tense. Read result 48 – 72 hours after injection. States. 3. 2. trembling Expresses concern and worry over leaving daughter with neighbors Husband out of town.

V/S.4. After the procedure : bed rest to prevent bleeding on the site. The portable monitoring is called telemetry unit Echocardiogram 1. tingling to assess for impaired circulation. Assess client for claustrophobia . Monitor PT. 2. 3. scaly. or diaphoretic. Monitor V/S especially peripheral pulses 11. 2. in supine position slightly turned to the left side. PTT. rub the electrode with a dry 4x4 gauze to enhance electro If the area is excessively hairy. Secure consent 2. and ECG prior to test 6. Have client void before the procedure 5. Elevate the affected extremities on extended position to promote blood supply back to the heart and preve 10. coins. If the patient‘s skin is oily. Monitor extremity for color. Turn to unaffected side after the procedure to prevent leakage of fluid in the thoracic cavity 5. Holter Monitor 1. Client should remain still. The procedure will last 45-60 minute 3. weight for baseline information 4. clip it Remove client`s jewelry. NPO for 4-6 hours before the test 7. 4. This indicate trauma and should be reported to MD immediately. Check for expectoration of blood. temperature. Assess allergy to iodine. with HOB elevated 15-20 deg Electrocardiography 1. do not flex extremity 9. belt or any metal Tell client to remain still during the procedure Cardiac Catheterization 1. Apply pressure dressing over the puncture site 12. over 24 hours period 2. Shave the groin or brachial area 8. Secure consent. MRI 1. It is continuous ECG monitoring. Ultrasound to assess cardiac structure and mobility 2. shellfish 3.

Secure consent. Remove all metal items Client should remain still Tell client that he will feel nothing but may hear noises Client with pacemaker. 8. Client with cardiac and respiratory complication may be excluded Instruct client on feeling of warmth or shortness of breath if contrast medium is used during the procedur UGIS – Barium Swallow 1. 7. 3. 6. 5. 3. 2. 2. wires are not eligible for MRI. 4. Instruct client on low-residue diet 1-3 days before the procedure Administer laxative evening before the procedure NPO after midnight Administer suppository in AM Enema until clear Force fluid after the test to prevent constipation/barium impaction Liver Biopsy 1. 8. 4. check V/S 2. 7. implanted clips. prosthetic valves. 5. Vitamin K at bedside Place the client in supine at the right side of the bed Instruct client to inhale and exhale deeply for several times and then exhale and hold breath while the MD Right lateral post procedure for 4 hours to apply pressure and prevent bleeding Bed rest for 24 hours Observe for S/S of peritonitis Paracentesis 1. 6. NPO 2-4 hrs before the test Monitor PT. 7. 6. Let the patient void before the procedure to prevent puncture of the bladder . Secure consent. Instruct client on low-residue diet 1-3 days before the procedure Administer laxative evening before the procedure NPO after midnight Instruct client to drink a cup of flavored barium X-rays are taken every 30 minutes until barium advances through the small bowel Film can be taken as long as 24 hours later Force fluid after the test to prevent constipation/barium impaction LGIS – Barium Enema 1. 6. 3. 5. 4. 2.4. 5. 9.

containing concise and thorou are easy to understand 4. Accuracy – information must be accurate so that health team members have confidence in it 3. objective smells 2. Treatment fro a sudden change in status 5. Completeness – the information within a record or a report should be complete. Auditing Health Agencies . Lumbar Puncture 1. 3. Excessive loss of plasma protein may lead to hypovolemic shock. Administration of medications and treatments c. Currentness – ongoing decisions about care must be based on currently reported information. Change in status e. Obtain consent Instruct client to empty the bladder and bowel Position the client in lateral recumbent with back at the edge of the examining table Instruct client to remain still Obtain specimen per MDs order Documenting and Reporting Guidelines for Good Documentation and Reporting 1. 4. transfer. A record should contain descriptive. Preparation of diagnostic tests or surgery d. discharge or death of a client f. 5. At the time of occurrence include the following: a. Admission. Organization – the nurse communicate in a logical format or order 6. Vital signs b. 2. Fact – information about clients and their care must be factual. Communication 2. Planning Client Care 3.3. Check for serum protein. Purposes of Records 1. Confidentiality – a confidential communication is information given by one person to another with trust and disclosed Documentation  Anything written or printed that is relied on as a record of proof fro authorized persons.

Research Education Reimbursement Legal Documentation Health Care Analysis Documentation Systems 1. social & family data age ii. Source – Oriented Record a. It is convenient because care providers from each discipline can easily locate the forms on which to record d. The traditional client record b. NARRATIVE CHARTING is a traditional part of the source-oriented record 2. Problem List – derived from the database. 8. The four (4) basic components: i. they all use the problems on the problem list and may be lettered for the type of data Example: SOAP Format or SOAPIE and SOAPIER S – Subjective data O – Objective data A – Assessment P – Plan I – Intervention E – Evaluation R. Example: the admissions department has an admission sheet. 7. Problem – Oriented Medical Record (POMR) a.Revision phys sa . 6. Usually kept at the front of the chart & serves as an index to the in the order in which they are identified & the list is continually updated as new problems are identified & othe iii. The data are arranged according to the problems the client has rather than the source of the information.4. a e. Progress Notes – chart entry made by all health professionals involved in a client‘s care. Database – consists of all information known about the client when the client first enters the health care history. the physician has a physician‘s order sheet. Each person or department makes notations in a separate section or sections of the client‘s chart c. Plan of Care – care plans are generated by the person who lists the problems. 5. Established by Lawrence Weed b. Physician‘s write orders or nursing care plans iv.

add new data. PIE (Problems. Interventions. Nursing Care Plan (NCP) Two Types: . focus & progress notes 5. Incorporates three (3) key elements: i. using critical pathways. Groups information in to three (3) categories b. Case Management a. Documentation system in which only abnormal or significant findings or exceptions to norms are recorded b. Uses a multidisciplinary approach to planning & documenting client care. Developed as a way to manage the huge volume of information required in contemporary health care b. Standards of nursing care iii. Intended to make the client & client concerns & strengths the focus of care b. Focus Charting a. and Evaluation) a. FLOW SHEET – uses specific assessment criteria in a particular format. Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes 4. Emphasizes quality. such as human needs or functional d. This system consists of a client care assessment floe sheet & progress notes c. Bedside access to chart forms 6. Flow sheets ii.Advantages of POMR:   It encourages collaboration Problem list in the front of the chart alerts caregivers to the client‘s needs & makes it easier to track Disadvantages of POMR:    Caregivers differ in their ability to use the required charting format Takes constant vigilance to maintain an up-to-date problem list Somewhat inefficient because assessments & interventions that apply to more than one problem mus 3. cost-effective care delivered within an established length of stay b. create & revise care plans & document clien 7. Computerized Documentation a. Nurses use computers to store the client‘s database. Charting by Exception a. Three (3) columns fro recording are usually used: date & time.

Referral Services (e. stated goals & list of nursing approaches to meet the goals Nursing Discharge / Referral Summaries  Completed when the client is being discharged & transferred to another institution or to a home setting w Regardless of format. Traditional Care Plan – written fro each client. Restrictions that relate to activity.g. expected outcomes & 2. Comfort level 9. diet & bathing 7. Allergies 7. thereby helping to provide a high KARDEX  Widely used. it has 3 columns: nursing diagnoses. it includes some or all of the following: 1.1. social worker. List of daily treatments & procedures 5. making information quickly cards kept in a portable index file or on computer generated forms. List of IVF 4. oxygen therapy) 5. Information may be organized into sections: 1. Description of client‘s physical. Functional/self-care abilities 8. Support networks 10. mental & emotional state 2. A problem list. List of Diagnostic procedures 6. Client education provided in relation to disease process 11.g. List of medications 3. Standardized Care Plan – based on an institution‘s standards of practice. Discharge destination 12. Specific data on how the client‘s physical need is to be met 8. Treatments that can be continued (e. Unresolved continuing health problems 4. Resolved health problems 3. Pertinent information about the client 2. home health nurse) Enemas Cleansing Enemas . concise method of organizing & recording data about a client. wound care. Current medications 6.

use smaller volume of solution Prepackaged disposable enema (Fleet): Approximately 125 cc. Ethico-Moral Aspects in Nursing Ethos . or solutions that are instilled too quickly. 1 inch for infants. the feces absorb the oil and become softer and easier to pass Carminative Enema  Provides relief from gaseous distention Astringent Enema  Contracts tissue to control bleeding Key Points: Administering Enema 1. (500 cc or less for children. can cause cramping and damage to recta 2. Gently insert tubing into client‘s rectum (3 to 4 inches for adult. . Allow solution to run through the tubing so that air is removed 3.Branch of Philosophy w/c determines right and wrong Moral . Cleansing enemas are retained 10 to 15 minutes. Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile soap in 100 Tap water: Give caution o infants or to adults with altered cardiac and renal reserve Saline: For normal saline enemas. The client wil solution 8. Fill water container with 750 to 1000 cc of lukewarm solution. Raise the water container no more than 12 to 18 inches above the client 7. instruct client to hold solution for about 10 to 15 minutes 9. Allow solution to flow slowly.comes from Greek work w/c means character/culture . After you have instilled the solution. 2.Stimulate peristalsis through irrigation of colon and rectum and by distention 1. 2 to 3 inches for childr 6. the client will experience fewer cramps. 250 cc or less are too hot or too cold. Place client on left side in Sim‘s position 4. tip is pre-lubricate and does not require fu Oil-Retention Enemas  Lubricates the rectum and colon. Oil retention: enemas should be retained at least 1 hour. 4. Lubricate the tip of the tubing with water-soluble lubricant 5. 3. If the flow is slow.personal/private interpretation from what is good and bad.

Individual held upon to testify in reference to a case either for the accused or against the accused. Defects of nature maybe corrected 8.Body/agency in government wherein the administration of justice is delegated.Complainant or person who files the case (accuser) Defendant . Epikia – There is always an exemption to the rule 4. 10. Subpoena Testificandum – a writ/notice to an individual/ordering him to appear in court at a specific time b. The principle of Totality – The whole is greater than its parts 3. financ Beneficence. Plaintiff . no justice is done to him 9. Written orders of court Writ – legal notes from the court 1.for the goodness and welfare of the clients Justice – equality/fairness in terms of resources/personnel Veracity . If one is willing to cooperate in the act. Derived from an Anglo-Saxon term that m Court . No one is held to impossible Law . Subpoena Duces Tecum.Rule of conduct commanding what is right and what is wrong.Accused/respondent or person who is the subject of complaint Witness. 4. 2.the act of truthfulness Fidelity – faithfulness/loyalty to clients Moral Principles: 1. Subpoena a. 3. 5. One who acts through as agent is herself responsible – (instrument to the crime) 5. 6.Ethical Principles: 1. Autonomy – the right/freedom to decide (the patient has the right to refuse despite the explanation of the Nonmaleficence – the duty not to harm/cause harm or inflict harm to others (harm maybe physical. A little more or a little less does not change the substance of an act.notice given to a witness to appear in court to testify including all important . The end does not justify the means 7. Golden Rule 2. No one is obliged to betray herself – You cannot betray yourself 6.

body of law that deals with relationship between individuals and the State/government and governm general public. mute and ignorant Tort law .  It maybe written or oral= both equally binding Types of Contract: 1.under stated conditions allowance) 2. 3. Likewise: the hospital is expected to provide the necessary supplies. A lawful purpose – activity must be legal 4.Summon – notice to a defendant/accused ordering him to appear in court to answer the complaint against him Warrant of Arrest . insane.court order to search for properties.   Example: Nurse newly employed in a hospital is expected to be competent and to follow hospital policies written or discussed. Promise or agreement between 2 or more persons for the performance of an action or restraint from certain act 2. Compensation in the form of something of value-monetary Persons who may not enter into a contract: minor.body of law that deals with relationships among private individuals Public law . deaf. Implied – one that has not been explicitly agreed to by the parties. Private/Civil Law . Expressed –when 2 parties discuss and agree orally or in writing the terms and conditions during the creation o  Example: nurse will work at a hospital for only a stated length of time (6 months).court order to arrest or detain a person Search warrant . Mutual understanding of the terms and meaning of the contract by all. equipment needed to provide compe Feature/Characteristics/Elements of a lawful contract: 1. Contract law – involves the enforcement of agreements among private individuals or the payment of com o o Ex. Nurse and client nurse and insurance Nurse and employer client and health agency  An agreement between 2 or more competent person to do or not to do some lawful act. but that the law considers to exist. Private/Civil Law : 1.

prudent nurse under the circumstances something was done that should not have been done or nothing was done when it should have been done c. Doctrines of Negligence: a. Malpractice  stepping beyond one‘s authority 6 elements of nursing malpractice: a. Force majuere – unforeseen event. Negligence     Misconduct or practice that is below the standard expected of ordinary. financial. Causation – it must be proved that the harm occurred as a direct result of the nurse‘s failure to follow the have known that the failure to follow the standard of care could result in such harm. irresistible force 2. reasonable and prudent person Failure to do something due to lack of foresight or prudence Failure of an individual to provide care that a reasonable person would ordinarily use in a similar circums An act of omission or commission wherein a nurse fails to act in accordance with the standard of care. Person/person‘s responsible for the tort are sued for damages Is based on: o ACT OF COMMISSION –something that was done incorrectly o ACT OF OMMISION – something that should have been done but was not. Duty – the nurse must have a relationship with the client that involves providing care and following an acce b. Breach of duty    the standard of care expected in a situation was not observed by the nurse is the failure to act as a reasonable. e. Foreseeability – a link must exist between the nurse‘s act and the injury suffered d. harm/injury –physical. emotional as a result of the breach of duty to the client Example: physical i . Res ipsa loquitor – the thing speaks for itself – the injury is enough proof of negligence b. Classification of Tort Unintentional Tort 1. Respondeat Superior – let the master answer command responsibility c.   Is a civil wrong committed against a person or a person‘s property.

suffering f. Battery   Willful touching of a person. photograph for advertisements of HC a 2. If the nurse gave committing battery even if the client benefits from the nurse‘s action. person‘s clothes or something the person is carrying that may or may not ca without consent. Unreasonable intrusion – observation or taking of photograph of the client for whatever purpose without cl 3. is embarrassing or causes injury. damages – amount of money in payment of damage/harm/injury Intentional Tort   Unintentional tort – do not require intent bur do require the element of HARM Intentional tort – the act was done on PURPOSE or with INTENT o No harm/injury/damage is needed to be liable o No expert witnesses are needed Assault   An attempt or threat to touch another person unjustifiably Example: o A person who threatens someone with a club or closed fist. Example: o A nurse threatens the patient with injection if the patient refuses his meds orally. o Nurse threatens a client with an injection after refusing to take the meds orally. False Imprisonment    Unjustifiable detention of a person without legal warrant to confine the person Occurs when clients are made to wrongful believe that they cannot leave the place Example: o Telling a client no to leave the hospital until bill is paid o Use of physical or chemical restraints o False Imprisonment Forceful Restraint=Battery Invasion of Privacy   intrusion into the client‘s private domain right to be left alone Types of Invasion the client must be protected from: 1. use of client‘s name for profit without consent – using one‘s name. Public disclosure of private facts – private information is given to others who have no legitimate need for t .

4.burning or property theft – stealing sexual harassment active euthanasia illegal possession of controlled drugs Homicide – killing of any person without criminal intent may be done as self-defense Arson – willful burning of property Theft – act of stealing Evaluation Definition  Is assessment the client‘s response to nursing interventions and then comparing that response to predeterm Purpose: . Slander – defamation by the spoken word stating unprivileged (not legally protected) or false word by wh o Example:  Nurse A telling a client that nurse B is incompetent  Person defamed may bring the lawsuit  The material (nurse‘s notes) must be communicated to a 3rd party in order that the person‘ Public Law: Criminal Law – deals with actions or offenses against the safety and welfare of the public. 3. writing or picture o Example: 1. Libel – defamation by means of print.4. 5. Putting a person in a false/bad light – publishing information that is normally considered offensive but whi Defamation  communication that is false or made with a careless disregard for the truth and results in injury to the repu Types: 1. 1. 2. o writing in the chart/nurse‘s notes that doctor A is incompetent because he didn‘t respond 2. 6. homicide – self-defense arson.

To prevent bedsore II. The four possible judgments that may be made are as follows: o The goal was completely met. 2. Compare the client‘s response to goals and outcome criteria. Analyze the reasons for the outcomes. Modify plan of care as needed. Collect data about the client‘s response. o New problems & nursing diagnosis have developed. 4. o The goal was partially met. Evening Care of Patient I. Preparation of Patient and Environment A try containing:             Basin of warm water Alcohol 70% Soap in soap dish Talcum powder Hair comb or brush Bath towel & wash cloth Pitcher of warm water Mouth wash tray with Mouth wash solution Tooth brush Kidney basin Linen required . To promote muscular relaxation 3. To appraise the extent to which goals and outcome criteria of nursing care have been achieved. Purpose 1. To refresh the patient and prepare line him for sleep 2. 5. o The goal was completely unmet. 3. Activities: 1.

Protect back and camisa with towel 5. Family Structure Traditional Family  It is composed of a father.n 9. Allow patient to brush his teeth. cousins and grandparents. 4. Adjust screen or blinds and light. financial n Although the single person is not living with others. separated. If the patient is wearing a binder. married and living together in one h uncles. a mother and their children. 11. Alternate Family Structure Cohabiting Families  It includes those individuals who choose to live together for a variety of reasons: relationships. Give bedtime medicine if any. etc. Tighten beddings. These people. who provided a sense of stability and belongin Single – Parent Families  Single parents may be never – married. Fluff up pillows and replace 8.III. divorced or widowed. Remove all unnecessary things from the room: trays. Place signal cord or bell within the reach of the patient.r. hands and forearms. Brush and comb hair. unfasten her camisa and bath her back. Dust with powder 3. Empty waste basket. Fasten patient‘s camisa Move patient to one side brush crumbs or dirt from the bed. If patient is unable to help himself do 2. Most often. wash his face. Turn patient to her side. Procedure 1. 12. Massage back with alcohol 700/0 or (skin and other reddish pots on the back. Replace ice cap or hot water bag p. he or she is a part of a family of origin. 6. Inspect dressing for bleeding or in place. usually has a social n living alone are found in to age groups: the young adult who has achieved independence and enters the work forc . remove it when giving care to the back. 7. the single parent is d married men and women are choosing to become parents. are part of the extend geographic proximity to members of the extended family. Attend to all patient‘s request 10. dishes. who may or may not live with the nuclear family.

The nurse should never cut the patient‘s hair without the patient‘s permission . In combing or brushing. 6. To prevent infection. alcohol or vaseline may be use to remove the tangles. Place towel under the head of the patient extending down the chest rind shoulders. Never allow an ill patient to comb her hair. apply vaseline or oil or wet hair with alc 7. Instructions 1.spouse. Clean and disinfect brush and comb and return them into their proper places. 3. her face turned away from you. If the hair is badly tangled. 3. If the hair is too tangled. Comb gently. If the hair is long. To preserve or keep the hair in good condition during illness. comb small stands at a time. 8. 4. IV. Loose the hair and part of the middle. Purpose 1. 1989) Hair Care I. 4. But remove all tangles. 3. 2. not on the hair roots and comb the tangles from the end first. To remove tangles from the hair. 5. To observe the presence of lice without the patient‘s being aware of it. II. Move the patient‘s head near the edge of the bed.. Procedure 1.al. part down and middle and plaid into two braids shirting towards the front so that a pati across the front of the head or let them freely down helding the ends with ribbon or tape or rubber bands. (Taylor. Gather all used articles. Equipment       Patient‘s bath towel Hair comb Hairbrush Vaseline Clips Rubber bands or tapes III. Brush hair thoroughly. To ass to the comfort of the patient. Hold the strand at a time wrapping around the foref the pull comes on your baud. 2. 5. et. 2.

Hand Washing Technique .

.

Compare type and amount of solution with physician‘s order. Observe scalp in several areas by separating the hair at various locations. Scalp. inquire about any injuries Palpate the head by running the pads of the fingers over the entire surface of skull.Hanging Main Line IV and Tubing          Wash hands. Obtain needle-less cannula or adapter for the established infusion site. Select appropriate IV tubing. Time-tape and label bag. IV & VI (Oculomotor. . Hair) Face Eyebrows. Trochlear. Abducens) Ears Nose and Paranasal Sinuses Cranial Nerve I (olfactory Nerve) Neck Thorax ( Cardiovascular System) Breast Abdomen Extremities _____________________________________________________________________________________ Skull. inquire about te Observe and feel the hair condition. cloudiness or foreign matter. shape and contour of the skull. Remove the outer wrapper around the IV bag. Scalp & Hair     Observe the size. Inspect the bag carefully for tears or leaks by applying gentle pressure to bag. Head-To-Toe Assessment Preview                    Head (Skull. additives and expiration date. solution type. Check pharmacy label for client‘s identification. Eyes and Eyelashes Eye lids and Lacrimal Apparatus Conjunctivae Sclerae Cornea Anterior Chamber and Iris Pupils Cranial Nerve II (optic nerve) Cranial Nerve III. Examine for discoloration.

No tenderness or masses on palpation. Can be moist or oily. Check for corneal reflex using cotton wisp. No tenderness noted upon palpation. Lighter in color than the complexion. should be equal in both eyes. The normal response in blinking. o If both are met. 2. Neither brittle nor dry. __________________________________________________________________________________________ Face 1. Generally round. o Ask the patient to smile. No scars noted. No lesions should be noted.Normal Findings: Skull   Scalp       Hair     Can be black. brown or burgundy depending on the race. Observe the face for shape. and where she feels it. There should be bilateral Nasolabial fold (creases extending from the ang is normal. Evenly distributed covers the whole scalp (No evidences of Alopecia) Maybe thick or thin. 2. then the Face is symmetrical 3. Inspect for Symmetry. check and jaw on both sides of the face. nits and dandruff. with prominences in the frontal and occipital area. (Normocephalic). Sensory Function      Ask the client to close the eyes. Free from lice. Ask the client if he/she feel it. Run cotton wisp over the fore head. o Inspect for the palpebral fissure (distance between the eye lids). coarse or smooth. Test the functioning of Cranial Nerves that innervates the facial structures CN V (Trigeminal) 1. Motor function .

salty. . Normal Findings      Shape maybe oval or rounded. brown or blond depending on race. Motor function  Ask the client to smile. Eyes    Evenly placed and inline with each other. Face is symmetrical. _______________________________________________________________________________________ Eyebrows. frown. Normal findings Eyebrows    Symmetrical and in line with each other. None protruding. the client can identify the taste. Eyelashes  Color dependent on race. raise eye brow. No involuntary muscle movements. Equal palpebral fissure. 2. Maybe black.  Ask the client to chew or clench the jaw. sour. whistle. close eye lids. Sensory function (This nerve innervate the anterior 2/3 of the tongue). The client should be able to clench or chew with strength and force. Normally. Evenly distributed. CN VII (Facial) 1. or puff the cheeks.   Place a sweet. Intact cranial nerve V and VII. Eyes and Eyelashes  All three structures are assessed using the modality of inspection. or bitter substance near the tip of the tongue. Can move facial muscles at will.

__________________________________________________________________________________________ Conjunctivae  The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the clien the examiner should exert NO PRESSURE against the eyeball. This relaxes the levator muscles. a. whereas clo eversion.To assess the nasolacrimal duct. b. everting the upper eyelid in necessary and is done as follow: 1. Symmetrical. __________________________________________________________________________________________ Eyelids and Lacrimal Apparatus 1. the examiner presses with the index finger against the client‘s lower inner o NOSE. 3. a. Lacrimal Apparatus    Lacrimal gland is normally non palpable. Turned outward. Palpate the eyelids for the lacrimal glands. No regurgitation from the nasolacrimal duct. and sclera when eyes are open. the examiner should hold the lids a In examining the palpebral conjunctiva. this will cause regurgitation of fluid in the puncta Normal Findings Eyelids     Upper eyelids cover the small portion of the iris. th . Palpate for the nasolacrimal duct to check for obstruction. (Drooping of upper eyelids). 2. Gently grasp the upper eyelashes and pull gently downward.Inquire for any pain or tenderness.  Evenly distributed. cornea. Do not pull the lashes outward or upward. In the presence of blockage. Ask the client to look down but keep his eyes slightly open. rather. No tenderness on palpation. 2. the examiner. To examine the lacrimal gland. Meets completely when eyes are closed. lightly slide the pad of the index finger against the client‘s upp b. Inspect the eyelids for position and symmetry. No PTOSIS noted.

3. Moist No ulcers No foreign objects __________________________________________________________________________________________ Sclerae  The sclerae is easily inspected during the assessment of the conjunctivae. . Some people may have pigmented positions. There is a positive corneal reflex. __________________________________________________________________________________________ Anterior Chamber and Iris  The anterior chamber and the iris are easily inspected in conjunction with the cornea. Normal Findings     Sclerae is white in color (anicteric sclera) No yellowish discoloration (icteric sclera). Looks smooth. Place a cotton tip application about I can above the lid margin and push gently downward with the applic Hold the lashes of the everted lid against the upper ridge of the bony orbit. The features of the iris should be fully visible through the cornea. Some capillaries maybe visible. 5. With presence of many minutes capillaries. infection. neve Examine the lid for swelling. To return the lid to its normal position. The cornea is clear or transparent. move the lid slightly forward and ask the client to look up and to b Normal Findings:      Both conjunctivae are pinkish or red in color. 4. The technique of ob chamber. just beneath the eyebrow. Normal findings     There should be no irregularities on the surface. 6. __________________________________________________________________________________________ Cornea  The cornea is best inspected by directing penlight obliquely from several positions. and presence of foreign objects.

The test for papillary accommodation is the examination for the change in papillary size as it is switched from a d    Ask the client to stare at the objects across room. There should be NO cr from one side. pupils equally round. which is placed 5 – 5 inches from the Visualization of distant objects normally causes papillary dilation and visualization of nearer objects caus Normal Findings     Pupillary size ranges from 3 – 7 mm. and constrict when looking at nearer objects. Simultaneously. eye can read the lettering. both directly and consensual. which correspond to the number at the end of each letter line. including assessment of the size. brown or green). or the standard testing distance. the other eye is observed for consensual response of constriction. The chart has a standardized number at the end of each line of letters. Color of the iris depends on the person‘s race (black. . maybe used. for those who are illiterate and unfamiliar with the western al different directions. Equally round. reactive to l __________________________________________________________________________________________ Cranial Nerve II (optic nerve)      The optic nerve is assessed by testing for visual acuity and peripheral vision. Constrict briskly/sluggishly when light is directed to the eye. Visual acuity is tested using a snellen chart. No noted any visible materials. shape reaction to constriction. Then ask the client to fix his gaze on the examiner‘s index fingers. Pupils dilate when looking at distant objects. the iris should appear flat and should not be bulging forward. and are equal in size. blue. therefore the larg Measurement of 20/20 vision is an indication of either refractive error or some other optic disorder. In testing for visual acuity you may refer to the following:  The room used for this test should be well lighted. these numbers indicates the degree The numerator 20 is the distance in feet between the chart and the client.Normal Findings:     The anterior chamber is transparent. __________________________________________________________________________________________ Pupils  Examination of the pupils involves several inspections. From the side view. we document the findings using the notation PERRLA. If all of which are met.

that is The nurse moves the object in a clockwise direction hexagonally. while the examiner stares at the client‘s open eye periphery. The examiner should watch for any jerky movements of the eye (nystagmus). the other eye should be covered by an opaque card or eye cover. 2. 3. Normally the client should see the same time the examiners sees it. 5. maybe started from largest to A person who can read the largest letter on the chart (20/200) should be checked if they can perceive hand perceive the light of the penlight directed to their yes. Trochlear. The normal visual field is 180 degrees __________________________________________________________________________________________ Cranial Nerve III. since that client‘s visual Follow the steps on conducting the test: 1. discharges. Instruct the client to follow the direction the object hold by the examiner by eye movements only. 5. Inspect the auditory meatus or the ear canal for color. The examiner hold an object such as pencil or penlight. The examiner and the client sit or stand opposite each other. presence of cerumen. Abducens)  All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular Movement (EOM) or th Follow the given steps: 1. Stand directly in front of the client and hold a finger or a penlight about 1 ft from the client‘s eyes. appearance and skin color. Make the client read the chart by pointing at a letter randomly at each line. 6. Peripheral Vision or visual fields   The assessment of visual acuity is indicative of the functioning of the macular area. __________________________________________________________________________________________ Ears 1. 4. 4. The Visual field confrontation test.    A person who wears corrective lenses should be tested with and without them to check fro the adequacy o Only one eye should be tested at a time. Instruct the client to fix his gaze momentarily on the extreme position in each of the six cardinal gazes. . in his hand and gradually moves it in from the pe below. the area of central vis areas of the retina which perceive the more peripheral stimuli. The client covers the eye with opaque card. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles. Instruct the client to stare directly at the examiner‘s eye. Normally the client can hold the position and there should be no nystagmus. size position. IV & VI (Oculomotor. Inspect the auricles of the ears for parallelism. provide The performance of this test assumes that the examiner has normal visual fields. tenderness when 3. with the eyes at the same. and foreign bodie o For adult pull the pinna upward and backward to straiten the canal. 2. and the examiner covers the eye that is opposite to the client 3. horizontal level w 2.

2. The upper connection of the ear lobe is parallel with the outer canthus of the eye. __________________________________________________________________________________________ Nose and Paranasal Sinuses The external portion of the nose is inspected for the following: 1. and noting for difficulty in breathing) Flaring of alae nasi Discharge The external nares are palpated for: 1. parallel.For children pull the pinna downward and backward to straiten the canal 4. Check septum for perforation. Position of the septum. The pinna recoils when folded. There is no pain or tenderness on the palpation of the auricles and mastoid process. translucent and pearly gray in color. 2. . Placement and symmetry. For tenderness and masses The internal nares are inspected by hyper extending the neck of the client. 4. On otoscopic examination the tympanic membrane appears flat. 2. Paranasal Sinuses  Examination of the paranasal sinuses is indirectly. The nasal mucosa (turbinates) for swelling. Normal Findings           o The ear lobes are bean shaped. Displacement of bone and cartilage. No lesions noted on inspection. The auricles are has a firm cartilage on palpation. Inspect for the following: 1. Information about their condition is gained by inspecti maxillary sinuses are accessible for examination. Patency of nares (done by occluding nosetril one at a time. No discharges or lesions noted at the ear canal. Skin is same in color as in the complexion. noting the color and landmarks. the ulnar aspect of the examiners hard the tip of the nose upward while shining a light into the nares. 3. exudates and change in color. (Can also be checked by directing the lighted penlight on the side of the no 3. and symmetrical. The ear canal has normally some cerumen of inspection. Perform otoscopic examination of the tympanic membrane.

The nasal mucosa is pinkish to red in color. The examiner places aromatic and easily distinguish nose. Both nares are patent. By palpating both cheeks simultaneously. With visible margin Symmetrical in appearance and movement Pinkish in color No edema Temporomandibular Palpate while the mouth is opened wide and then closed for: . coffee). (Increased redness turbinates are typical of allergy). No tenderness noted on palpation of the paranasal sinuses. 2. Nasal septum in the mid line and not perforated. Ask the client to identify the odor. 4. __________________________________________________________________________________________ Cranial Nerve I (Olfactory Nerve) To test the adequacy of function of the olfactory nerve: 1. No tenderness noted on palpation. one can determine tenderness of the maxillary sinusitis. (E. 2. 3. Each side is tested separately. The client is asked to close his eyes and occlude. Normal Findings          Nose in the midline No Discharges. Edema Normal Findings: 1. No flaring alae nasi. Symmetry and surface abnormalities. 4. 3. Mouth and Oropharynx Lips Inspected for: 1. Color 3. ideally with two different substances.g. 2. and pre tenderness of the frontal sinuses. No bone and cartilage deviation noted on palpation.

Tenderness Normal Findings: 1. Tongue . 2. With or without malocclusions. 6. No gum bleeding 3. 4. Normal Findings: 1. No receding gums Teeth Inspected for: 1. No pain or tenderness on palpation and jaw movement. Gums Inspected for: 1. Normal Findings: 1. Tooth loss Breath should also be assessed during the process. 4. 3. No halitosis. 5. White to yellowish in color With or without dental carries and/or dental fillings. 5. 2. Deviations 3. Retraction of gums. Color 2. 28 for children and 32 for adults. Pinkish in color 2.1. or overlapping teeth). Crepitous 2. 3. Moves smoothly no crepitous. 2. No deviations noted 3. Number Color Dental carries Dental fillings Alignment and malocclusions (2 teeth in the space for 1. 7. Bleeding 3.

7. Position 2. Inflammation 2. 6. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue. Size A Grading system used to describe the size of the tonsils can be used. Surface of the tongue is rough. No varicosities on ventral surface. Moves upward and backwards when asked to say ―ah‖ Tonsils Inspected for: 1. Cranial Nerve X (Vagus nerve) – Tested by asking the client to say ―Ah‖ note that the uvula will move up Normal Findings: 1.Palpated for: 1. Grade 2 – Between pillar and uvula. No lesions noted. Gag reflex is present. Able to move the tongue freely and with strength. 5. Pinkish to red in color.     Grade 1 – Tonsils behind the pillar. 4. No swelling or lesion noted. 3. Grade 3 – Touching the uvula Grade 4 – In the midline. Color 3. Uvula Inspected for: Pinkish with white taste buds on the surface. Positioned in the mid line. 2. 4. 2. 3. 1. __________________________________________________________________________________________ . Texture Normal Findings: 1.

Slightly movable. About less than 1 cm in size. Posterior Approach: 1. 6. locate the cricoid cartilage and directly below that is the ist Ask the client to swallow while feeling for any enlargement of the thyroid isthmus. Non tender if palpable. 3.Neck  The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jug Normal Findings: 1. Let the client sit on a chair while the examiner stands behind him. Firm with smooth rounded surface. Maybe normally palpable in thin clients. Ask the patient to swallow as the procedure is being done. The trachea is palpable. Symmetrical No jugular venous distension (suggestive of cardiac congestion). 2. Pa anterior approach. 4. The examiner stands in front of the client and with the palmar surface of the middle and index finge 2. Anterior approach: 1. 2. To facilitate examination of each lobe. The neck is straight. . the client is asked to turn his head slightly toward the side to the other hand of the examiner pushes the thyroid cartilage towards the side of the thyroid lobe to b 5. The thyroid is initially observed by standing in front of the client and asking the client to swallow. 3. It is positioned in the line and straight. The neck is palpated just above the suprasternal note using Normal Findings: 1.  the thumb and the index finger. Ask the client to swallow while palpation is being done. Then the procedure is repeated on the other side. Normal Findings:       May not be palpable. The examiner may also palate for thyroid enlargement by placing the thumb deep to and behind the fingers are placed deep to and in front of the muscle. 4. No visible mass or lumps. 7. 2. Describ tenderness and fixation to surrounding tissues. In examining the isthmus of the thyroid. Lymph nodes are palpated using palmar tips of the fingers via systemic circular movements.

palpable pulsation over the aortic. Normally the thyroid is non palpable. an enlarged thyroid. The client is other of the lobe to be examined. and thrills felt over the apex. 2. There should be no lift or heaves. 2. There should be no noted abnormal heaves. 3. _____________________________________________________________________________________ Thorax (Cardiovascular System) Inspection of the Heart  The chest wall and epigastrum is inspected while the client is in supine position. 4.3. 5. beginning at the ap base of the heart. Observe for pulsatio Normal Findings: 1. 2. No. It can be used to determine b Auscultation of the Heart Anatomic areas for auscultation of the heart: . Pulsation of the apical impulse maybe visible. Isthmus maybe visible in a thin neck.  Check the Range of Movement of the neck. pulmonic. and mitral valves. Auscultation of the Thyroid is necessary when there is thyroid enlargement. Apical pulsation can be felt on palpation. Percussion of the Heart  The technique of percussion is of limited value in cardiac assessment. No nodules are palpable. the examiner palpates the area and hooks thumb and fingers around the sternocleidomastoid Normal Findings: 1. (this can give us some indication of the cardiac size). Palpation of the Heart  The entire precordium is palpated methodically using the palms and the fingers. Again. The examiner may hear bruits. Normal Findings: 1. 3. similar procedure is done as in posterior approach. In palpating the lobes of the thyroid. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be examined.

and Murmurs. with her arms abducted over the head. simultaneously eliciting contraction of th and is learning over while the examiner assists in supporting and balancing her. and is pushing her hands into her hips. May or may not be completely symmetrical at rest. . Auscultate the heart in all anatomic areas aortic. tricuspid and mitral 2. Listen for the S1 and S2 sounds (S1 closure of AV valves. Having the client seated and learning forward s best suited for hearing high-pitched sounds related t The left lateral recumbent position is best suited low-pitched sounds.    Aortic valve – Right 2nd ICS sternal border.g. S1 sound the aortric valve. through i them from upward movement in position 2 and 4.Left 5th ICS midclavicular line Positioning the client for auscultation:    If the heart sounds are faint or undetectable. S1 & S2 can be heard at all anatomic site. Mitral Valve . 2. S2 closure of semilunar valve). 3. Every client should be e 1. While the client is performing these maneuvers. 2. Murmurs. _____________________________________________________________________________________ Breast Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. The overlying the breast should be even. No abnormal heart sounds is heard (e. Listen for abnormal heart sounds e. the breasts are carefully observed for symmetry. S3 & S4). Normal Findings: 1.    The The The The client client client client is is is is seated seated seated seated with her arms on her side. Pulmonic Valve – Left 2nd ICS sternal border. S4. try listening to them with the patient seated and learn heart closer to the surface of the chest. 2. such as mitral valve problems Auscultating the heart: 1.– Left 5th ICS sternal border. 4. 3. Cardiac rate ranges from 60 – 100 bpm. pulmonic. 3. Count heart rate at the apical pulse for one full minute. Tricuspid Valve . 4. bu An abnormality may not be apparent in the breasts at rest a mass may cause the breasts. Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory Normal Findings: 1.g. S3.

3. 4. 5. 6. 7. 8. 9.

The areola is rounded or oval, with same color, (Color va,ies form light pink to dark brown dependin Nipples are rounded, everted, same size and equal in color. No ―orange peel‖ skin is noted which is present in edema. The veins maybe visible but not engorge and prominent. No obvious mass noted. Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward. No retractions or dimpling.

Palpation of the Breast   

Palpate the breast along imaginary concentric circles, following a clockwise rotary motion, from the p the breast is adequately surveyed. Breast examination is best done 1 week post menses. Each areolar areas are carefully palpated to determine the presence of underlying masses. Each nipple is gently compressed to assess for the presence of masses or discharge.

Normal Findings:    No lumps or masses are palpable. No tenderness upon palpation. No discharges from the nipples.

NOTE: The male breasts are observed by adapting the techniques used for female clients. However, the var _____________________________________________________________________________________

Abdomen

In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the clie relax abdominal muscles.

Inspection of the abdomen       Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus). Contour (flat, rounded, scapold) Distension Respiratory movement. Visible peristalsis. Pulsations

Normal Findings:       Skin color is uniform, no lesions. Some clients may have striae or scar. No venous engorgement. Contour may be flat, rounded or scapoid Thin clients may have visible peristalsis. Aortic pulsation maybe visible on thin clients.

Auscultation of the Abdomen

  

This method precedes percussion because bowel motility, and thus bowel sounds, may be increased The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds a exploring arterial murmurs and venous hum.

Peristaltic sounds 

These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Pe motility of bowel.

Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

1. Divide the abdomen in four quadrants. 2. Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of This direction ensures that we follow the direction of bowel movement. 3. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 concluding that no bowel sounds are present. 4. The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 se may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound Some factors that affect bowel sound: 1. 2. 3. 4. 5. 6. 7. Presence of food in the GI tract. State of digestion. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis). Bowel surgery Constipation or Diarrhea. Electrolyte imbalances. Bowel obstruction.

Percussion of the abdomen     

Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, an abdomen. The direction of abdominal percussion follows the auscultation site at each abdominal guardant. The entire abdomen should be percussed lightly or a general picture of the areas of tympany and du Tympany will predominate because of the presence of gas in the small and large bowel. Solid masse the 6th or 9th rib just posterior to or at the mid axillary line on the left side. Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Percussion of the liver The palms of the left hand are placed over the region of liver dullness. 1. The area is strucked lightly with a fisted right hand. 2. Normally tenderness should not be elicited by this method. 3. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis. Renal Percussion

1. Can be done by either indirect or direct method. 2. Percussion is done over the costovertebral junction. 3. Tenderness elicited by such method suggests renal inflammation. Palpation of the Abdomen Light palpation   

It is a gentle exploration performed while the client is in supine position. With the examiner’s hands The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, b This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding

Tensing of abdominal musculature may occur because of: 1. The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen. 2. The client is ticklish or guards involuntarily. 3. Presence of subjacent pathologic condition. Normal Findings: 1. No tenderness noted. 2. With smooth and consistent tension. 3. No muscles guarding. Deep Palpation    

It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of The abdominal wall may slide back and forth while the fingers move back and forth over the organ b Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses may be fel In the absence of disease, pressure produced by deep palpation may produce tenderness over the c

Liver palpation

There are two types of bi manual palpation recommended for palpation of the liver. The first one is the sup

1. Ask the patient to take 3 normal breaths. 2. Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation. 3. Press hand deeply over the RUQ The second methods: 1. 2. 3. 4. 5.

The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs. Place the examiner’s right hands parallel to the costal margin or the RUQ. An upward pressure is placed beneath the client to push the liver towards the examining right hand, Ask the client to breath deeply. As the client inspires, the liver maybe felt to slip beneath the examining fingers.

Normal Findings:

Feel for evenness of temperature. firm and non-tend _____________________________________________________________________________________ Extremities Inspection 1. Tonicity of muscle. regular in contour. Has equal contraction and even. Observe for size. Palpation 1.  The liver usually can not be palpated in a normal adult. (Can be measured by asking client to squeeze examiner’s fingers and noting for Perform range of motion. Can counter act gravity and resistance on ROM. However. it must be smooth. No edema Color is even. Can perform complete range of motion. (performed against gravity and against resistance) Table showing the Lovett scale for grading for muscle strength and functional level Functional level No evidence of contractility Evidence of slight contractility Complete ROM without gravity Complete ROM with gravity Complete range of motion against gravity with some resistance Complete range of motion against gravity with full resistance Normal Findings           Both extremities are equal in size. 2. 3. bilateral symmetry. 3. Have the same contour with prominences of joints. Look for gross deformities. Always compare both extremities. in extremely thin but otherwise we When the normal liver margin is palpated. No involuntary movements. 2. No crepitus must be noted on joints. 4. presence of trauma such as ecchymosis or other discoloration. contour. Test for muscle strength. Normally it should be even for all the extremities. Lovett Scale Zero (Z) Trace (T) Poor (P) Fair (F) Good (G) Grade Percentage of normal 0 0 1 10 2 25 3 50 4 75 100 Normal (N) 5 . edema. Temperature is warm and even. and involuntary movement.

A concern for the individual as a total system 2. Evolutionary viability refl survival and well-being. Health – Belief Model – Addresses the relationship between a person‘s belief and behaviors. Four Components     The individual is perception of susceptibility to an illness The individual‘s perception of the seriousness of the illness The perceived threat of a disease The perceived benefits of taking the necessary preventive measures 5. 3. to death which represents total energy depletion. ranging fro maximum. The model interrelates the following elements:  Life events . Agent – Host – environment Model (Leavell) – The level of health of an individual or group depends on the    Agent – any internal or external factor that disease or illness. Health-Illness Continuum (Neuman) – Degree of client wellness that exists at any point in time. 2. Host – the person or persons who may be susceptible to a particular illness or disease Environment – consists of all factors outside of the host 4. An acknowledgment of the importance of an individual‘s role in life *A dynamic state in which the individual adapts to changes in internal and external environment to maintain a sta Models of Health and Illness 1. A view of health that identifies internal and external environment 3. Evolutionary – Based Model – Illness and death serves as a evolutionary function. mental and social well- Characteristics 1. It provides a wa in relation to their health and how they will comply with health care therapies. High – Level Wellness Model (Halbert Dunn) – It is oriented toward maximizing the health potential of an i continuum of balance and purposeful direction within the environment.Health and Illness Health  As defined by the World Health Organization (WHO): state of complete physical.

2. 3. emotional. Stage of Acceptance – Turns to professional help for assistance 3. healthy state. Emphasis is on restoring the patient to independence or regain his pre-illness/predisability level of functio 5. 5. health oriented process that assists individual who is ill or disabled to achieve his greatest pos economical functioning. Patient must be an active participant in the rehabilitation goal setting an din rehabilitation process. 2. Directed at increasin client‘s participation health-promotion behaviors. anxiety. Begins during initial contact with the patient 4. dress Mobility Integrity of skin Control of bowel and bladder function Indwelling Catheter Insertion . The model focuses on three functions:    It identifies factors (demographic and socially) enhance or decrease the participation in health promotion It organizes cues into pattern to explain likelihood of a client‘s participation health-promotion behaviors It explains the reasons that individuals engage in health activities Illness  State in which a person‘s physical. A dynamic. bathing/hygiene. Health Promotion Model – A ―complimentary counterpart models of health protection‖. 3 Stages of Illness 1.     Life style determinants Evolutionary viability within the social context Control perceptions Viability emotions Health outcomes 6. 4. Abilities not disabilities are emphasized. Stage of Recovery (Rehabilitation or Convalescence) – The patient goes through of resolving loss or imp Rehabilitation 1. feeding. social developmental or spiritual functioning i deviation from a normal. Focuses of Rehabilitation 1. fear. intellectual. 2. Stage of Denial – Refusal to acknowledge illness. irritability and aggressiveness. Coping pattern Functional ability – focuses on self-care: activities of daily living (ADL). 3.

measure and record urine output on I&O bedside record. Assist client to position. Remove and discard disposable supplies in appropriate container. Provide privacy. Reposition client for comfort. Gather equipment. o *Be careful to not contaminate sterile field Cleanse client‘s perineum of antiseptic solution.            Check client‘s identaband and if able have client state name. Document procedure. knees up and out. Remove drapes. Inserting an Indwelling Catheter to a Male   Check physician‘s order. Explain procedure to client. Check client‘s identaband and if able have client state name. Wash hand.Inserting an Indwelling Catheter to a Female  Check physician‘s order. put bed in low position. .

Cleanse client‘s perineum of antiseptic solution. not side rails. Provide privacy. including gloves & discard trash in the appropriate container. Remove all equipment. put bed in low position with side rails up. Fan fold top linen down to lower extremities exposing only perineal area. Measure and record urine output on I&O bedside record.               Explain procedure to client. Prepare equipment in the same manner as demonstrated for female catheterization. Attach drainage bag to bed frame. Document procedure. Remove drapes. Wash hand. bacteria or their toxins and other organic preparations to test whether the body is sensitive to Site of Injection: . Reposition client for comfort. Gather equipment. Prepare client by placing client in supine position with knees slightly apart. Tape catheter to abdomen with 1 inch tape. Intradermal Injection (Test for Drug Sensitivity) Purpose: To introduce drugs.

antihistaminics o 50/0 Dextrose in Water 1 liter and venosel. Equipment:      Hype tray: Alcohol sponge Sterile tuberculin syringe 2 sterile needles gauge 25-27 Drug to be tested diluted to the strength which will be injected to the patient Procedure: 1. Prepare the drug in the same manner as for hypodermic injection. At all times the following m anaphylaxis or generalized reactions: o Epinephrine Hcl 1:10 00 for immediate IM o I. A positive test consists of a wheal formation with redness which appears in 10-15 minutes. Watch patient for at least 30 minutes after the injection for signs of reaction.Inner aspect of forearm or upper arm Points to Remember: 1. Precaution in all patients being injected with penicillin for the first or second time even if the sensitivity t 3. 2. Make him comfortable. 3. Explain to the patient. 2.V. Support forearm on a firm surface. Cleanse the skin area about 3 inches (diameter) on the inner aspect of the forearm midway between the w .

Prepare/Mix the medication accordingly and put it into the syringe. into the skin as superficially as possible by the needle only as far as the level edge to be Inject the solution enough to make a wheal or circumscribed elevation of the skin. Wait for 10-15 minutes. You will be needing all these supplies. o Deltoid – Patient may sit or lie with arm relaxed. Intramuscular (IM) Administration Here are the steps needed to accomplish administering IM injections. pull the needle out a little and inject th 10. 7. reaction observed. Do perineal care before collection of the urine d. Use the gauze to dab up any blood. 2. Pull back on the plunger a little. Provide sterile container c. o Dorsogluteal – Patient may lie prone with toes pointing inward or on side with upper leg flexed an 6. Inject no more than 0. 7. do not press. 12. if necessary. Laboratory and Diagnostic Examination Urine Specimen 1. Prepare the medication to be given. The site should be free of bumps and scars. gau and 1 1/2″ long. Clean-Catch mid-stream urine specimen for routine urinalysis. syringe. Spread the skin with your fingers and inject the needle straight down in a dart-like motion all the way. first voided urine b. 5. Medication can be given into the: o Ventrogluteal – Patient may lie on back or side with hip and knee flexed.1 Withdraw the needle gently. Best time to collect is in the morning. 4. and allow to dry. Allow the alcohol to dry. 6.4. time injected. Wash your hands. Do not use a blower or fan to quicken the dr 8. 5. Do not put medical or sharp waste in the 11. and cover with a bandage. alcohol prep pad. with other. Do not cleanse or massage site of injection. o Vastus lateralis – Patient may lie on the back or may assume a sitting position.) Insert the needle. 3. Wash your hands. If you see blood enter the syringe. Charting: Record drug. Evaluate results. Attach the new needle into the syringe. Feel free to read through the steps and watc 1. Discard the first flow of urine . culture and sensitivity test a. Pull the needle out and dispose of properly in a sharps container. 9. Clean the site with an alcohol pad. and usually by whom it was evaluated.

(an Orthotolidin reagent tablet) b. ask the patient to void 4. dry bed pan or a portable commode. a. h. Fecal Occult blood test  Are valuable test for detecting occult blood (hidden) which may be present in colo-rectal cancer.e. c.(filter paper impregnated with guaiac) *Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours. Discard the first urine b. odor. Soak the specimen in a container with ice d. Second-Voided urine – required to assess glucose level and for the presence of albumen in the urine. Discard the first voided urine. Secure a sterile specimen container b. Add preservative as ordered according to hospital policy 3. 24-hour urine specimen a. Hemoccult slide. detectin a. 3. and usual characteristics of the specimen. Stool culture and sensitivity test  To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics. Label the specimen properly f. 2. After few minutes. Document the time of specimen collection and transport to the lab. Instruct client not to contaminate the specimen with urine or toilet paper (urine inhibits bacterial growth and the test result. Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the bladder and adequate specimen c b. requires no smear . Collect all specimens thereafter until the following day c. Ask the pt. Document the appearance. c. Fecalysis – to assess gross appearance of stool and presence of ova or parasite a. Catheterized urine specimen a. Send the specimen immediately to the laboratory g. Colocare – a newer test. to defecate into a clean. 2. b. Clamping the drainage tube and emptying the urine into a container are contraindicated after a genitourinary Stool Specimen 1. Hematest. Give the patient a glass of water to drink c.

5. No fasting for the following tests: o CBC. inform the MD Make sure the stool in not contaminated with urine. or vascular injury. Collect early in the morning b. Hgb. serum lipid (cholesterol. Blood specimen 1. BUN. If the patient has a clotting disorder or is receiving anticoagulant coagulant therapy. Use sterile container c. perform Allen‘s test first. 4. 4. 2. Don‘t wipe off the povidine-iodine with alcohol because alcohol cancels the effect of povidine iodine.Instructions 1. Instruct the patient to hack-up sputum . soap solution or toilet paper Test sample from several portion of the stool. 3. 2. 5. 6. Never collect a venous sample from the arm or a leg that is already being use d for I. Fasting is required: o FBS. maintain pressure on Arterial puncture for ABG test 1. clotting studies. Gross appearance of the sputum a. 3. 2. If the patient is receiving oxygen. triglyceride) Sputum Specimen 1. enzyme studies. Creatinine. 4. site of previous hematoma. serum electrolytes 2. 3. Rinse the mount with plain water before collection of the specimen d. wait about 20 minutes before collecting the sample. Hct. Venipuncture Pointers 1. AV shunt. make sure that the patient‘s therapy has been underway for at least 15 m Be sure to indicate on the laboratory request slip the amount and type of oxygen therapy the patient is hav If the patient has just received a nebulizer treatment.V therapy or blood a Never collect venous sample from an infectious site because it may introduce pathogens into the vascular Never collect blood from an edematous area. Before arterial puncture. Advise client to avoid ingestion of red meat for 3 days Patient is advice on a high residue diet Avoid dark food and bismuth compound If client is on iron therapy.

To assess presence of active pulmonary tuberculosis b. Health Promotion     health education marriage counseling genetic screening good standard of nutrition adjusted to developmental phase of life Specific Protection         use of specific immunization attention to personal hygiene use of environmental sanitation protection against occupational hazards protection from accidents use of specific nutrients protections from carcinogens avoidance to allergens Secondary Prevention . To assess for presence of abnormal or cancer cells. Collect specimen before the first dose of antibiotic 3. Collect sputum in three consecutive mornings 4. Use sterile container b.2. Acid-Fast Bacilli a. Cytologic sputum exam a. Sputum culture and sensitivity test a. Leavell and Clark’s Three Levels of Prevention Primary Prevention  Seeks to prevent a disease or condition at a prepathologic state. to stop something from ever happening.

 Also known as ―Health Maintenance‖. 3. ―To maximize use of remaining capacities‘ Restoration and Rehabilitation   Work therapy in hospital Use of shelter colony Making a Recovery or Anesthetic Bed (Post-Operative Bed) I. 2. To provide warmth and comfort for the patient. To arrange the bed and other furniture in order to facilitate the transfer of the patient from stretcher to bed II. Seeks to identify specific illnesses or conditions at an early stage w prevent catastrophic effects that could occur if proper attention and treatment are not provided Early Diagnosis and Prompt Treatment      case finding measures individual and mass screening survey prevent spread of communicable disease prevent complication and sequelae shorten period of disability Disability Limitations   Adequate treatment to arrest disease process and prevent further complication and sequelae. Purpose 1. To provide protection for the bed. Equipment    The same linen as those used for making on occupied bed plus the following‖ Bath towel Small robber sheet . To establish a high-level wellness. Intent is to halt the d an optimal health status. Provision of facilities to limit disability and prevent death. Tertiary Prevention  Occurs after a disease or disability has occurred and the recovery process has begun.

8. Strip on the bed and turn the mattress. Maslow’s Hierarchy of Basic Human Needs Definition   Each individual has unique characteristics. Procedure: 1.n.  Woolen blanket 3 hot water bags w/cover p.r. Make an ordinary bed with the top sheet untucked at the foot part. Human needs are physiologic and psychologica of health or well-being. place bath blanket o inches and the bottom side folded back even with the foot of the mattress. Place the necessary articles on the bedside table and the irrigating stand. 2. Slip the pillowcase and put the pillow upright against the bars of the head of the bed. useful or necessary. Place the small rubber sheet across the hood part of the bed.n. suction machine and oxygen set9. (If weather is cold. Place the bath towel over the small rubber sheet. 3. A need is something that is desirable. Fanfold together the top sheet and blanket towards the side away from the door.r. but certain needs are common to all people. . Put the hot water bags at the foot and center of the bed if the weather is cold. Arrange unit. 4. 6. 5. Observation Sheet In the Room      Oxygen tank with complete Tubbings. On the Bedside Table:        Stethoscope Sphygmomanometer Kidney basin Swipes Padded tongue depressor p. 7. humidifier and nassal catheter Suction apparatus Stand Drainage bottles III.

The need to love and be loved The need to care and to be cared for. 3. 4. 7. 3. 2. Oxygen Fluids Nutrition Body temperature Elimination Rest and sleep Sex Safety and Security 1. institution. 5. 2.Physiologic 1. Psychological safety 3. 6. The need for shelter and freedom from harm and danger Love and belonging 1. Physical safety 2. The need for affection: to associate or to belong The need to establish fruitful and meaningful relationships with people. 4. or organization .

Is usually accurate in predicting future events 6. Is open to new ideas 11. Is highly independent. 2. create and understand or comprehend The need for harmonious relationships The need for beauty or aesthetics The need for spiritual fulfillment Characteristics of Basic Human Needs 1. Understands art. duty or vocation 9. 3. flexible. courageous. Is highly creative. loving and governed more by inner directives than by society 17. is more decisive 4. 4. Has a clear notion of right or wrong 5. task. Is self-confident and has self-respect 12. 2. listens to others carefully 8. sees life clearly and is objective about his or her observations 2. personality is integrated 13. Judges people correctly 3. desires privacy 15. Needs may be met in different ways Needs may be stimulated by external and internal factor Priorities may be deferred Needs are interrelated Maslow’s Characteristics of a Self-Actualized Person 1.Self-Esteem Needs 1. and willing to make mistakes 10. Has superior perception. The need to learn. Has low degree of self-conflict. Can appear remote or detached 16. 4. music. Can make decisions contrary to popular opinion 18. Is friendly. does not need fame. 5. 4. 2. spontaneous. Self-worth Self-identity Self-respect Body image Self-Actualization Needs 1. and possesses a feeling of self-control 14. Is problem centered rather than self-centered . Needs are universal. Is realistic. politics and philosophy 7. 3. Is dedicated to some work. 3. Possesses humility. Respect self.

RNs. Frankenburg Modified and standardized by Dr. etc) • It is not an intelligence test It is a screening instrument to determine if child‘s development is within normal Children 6 ½ years and below Purposes   Measures developmental delays Evaluates 4 aspects of development Aspects of development In the care of pediatric clients. Nurses being competent in the aspe theories and milestones are in best position to counsel clients on these aspects. Phoebe D. growth and development are not in isolation. walk and jump MMDST KIT. follow directions and to speak Gross-Motor – tasks which indicate the child‘s ability to sit. Having background knowledge o assessment skills to determine developmental delays through the aid of screening tests.19. The Metro Manila Developmental Screening Test (MMDST) is a screening test to note for normalcy of the child children 6 ½ years old and below. Williams DDST to MMDST Developed for health professionals (MDs. William K. Modified and standardized by Dr. Phoebe Williams from the original Denver Frankenburg. MMDST evaluates 4 sectors of development:     Personal-Social – tasks which indicate the child‘s ability to get along with people and to take care of him Fine-Motor Adaptive – tasks which indicate the child‘s ability to see and use his hands to pick up objects Language – tasks which indicate the child‘s ability to hear. Accepts the world for what it is Metro Manila Development Screening Test (MMDST) Definition        Simple and clinically useful tool To determine early serious developmental delays Dr. Preparation for test administration involves the nurse ensuring the completeness of the test mate be followed as specified:   MMDST manual test Form .

The strength of the superego depends on the intensity of the child‘s feeling of aggression or attachment to the parent. To proceed in the administration of the test. There are 105 test items in MMDST but not all are administered. Whereas. If the sequen personal-social then progressing to the other sectors. Failed (F). the caregiver may be asked to administer the test provided that the ex directed in the manual If the child is very shy or uncooperative. or Nor Opportunity (NO). the parents or caregivers of th test as it may be misinterpreted by them. When conducting the test. Refused (R). After computing.        bright red yarn pom-pom rattle with narrow handle eight 1-inch colored wooden blocks (red. The nurse should also establish rapport with the parent and the child to AGE & THE AGE LINE. But if the child is more than 2 yea If the child is shy or uncooperative. blue green) small clear glass/bottle with 5/8 inch opening small bell with 2 ½ inch-diameter mouth rubber ball 12 ½ inches in circumference cheese curls pencil EXPLAINING THE PROCEDURE. The age is the most crucial component of the test because it determines the test items that will be app computing by subtracting the child‘s birth date with the test date. F age is considered a developmental delay. Items that are footnoted with ―R‖ can be passed by report. He standards and character or character traits of the model parent through the process of identification. subtract the number of weeks of prematurity. the nurse is to compute for the exact age date itself. the test may be deferred Moral Theories Freud (1961)   Believed that the mechanism for right and wrong within the individual is the superego. or conscience. The examiner prioritizes items to explain to the parent or caregiver that the child is not expected to perform all the tasks correctly. SCORING. yellow. The test items are scored as either Passed (P). Erikson (1964) . draw the age line in the test f TEST ITEMS. words or dire If the child is premature. the nurse explains the procedure to the pare is not a diagnostic test but rather a screening test only. Once the materials are ready. failure of an item that is completely to the right of the child‘s CONSIDERATIONS:     Manner in which each test is administered must be exactly the same as stated in the manual.

She described three stages in the process of developing 1. At first level called the premolar or the preconventional level. i. He focused on the reason for the making of a decision. 3. moral judgment (how one reason). punishment or reward.e. people ma regard to outside authority or to the expectations of others. Moral development is usually considered to one feels). people make postconventional. and moral behavior (how one act). In addition.. Spiritual Theories Fowler (1979)   Described the development of faith. what is righ On the other hand. Peters believed that the development of character traits or virtues is an essential aspect or mo learned from others and encouraged by the example of others. then an ‗egostrength‖ or vi Kohlberg  Suggested three levels of moral development. At this level.  She believed the human see morality in the integrity of relationships and caring. tidiness. Caring for self and others. the individual is concerned about maintaining the expectation 3. Peters believed that some can be described as habits because they are in some sense automatic and chastity. 2. men consider what is right to be what is just. At the third level. the conventional level. Caring for oneself. children are responsive to cultural rules and interpret these in terms of the physical consequences of the actions. He believed that faith. Erikson‘s theory on the development of virtues or unifying strengths of the ―good man‖ suggests that mor if the conflicts of each psychosocial developmental stages favorably resolved. Caring for others. autonomous. For women. Gilligan (1982)  Included the concepts of caring and responsibility. 2. or principal level. At the second level. Also. thrift and honesty.‖ T . not 1. These involve respect for other human and bel Peter (1981)    Proposed a concept of rational morality based on principles. or the spiritual dimension is a force that gives He used the term ―faith‖ as a form of knowing a way of being in relation ―to an ultimate environment.

love. Suctioning gastric contents b. Characteristics of nasogastric drainage: o Normally is greenish-yellowish. A ch should be heard 8. Suctioning gastric contents b.made-of-being-in-relation to others in which we invest commitment. the stomach or swallowed from the lungs o Foul-smelling (fecal odor) – occurs with reverse peristalsis in bowel obstruction. 2. Prevent/decrease intestinal distention. Validating placement of tube. position the client in High-Fowler‘s position if possible. Insert the tube through the nose into the nasopharyngel area.‖ Nasogastric and Intestinal Tubes Nasogastric Tubes 1. Prior to insertion. Flex the client‘s head slightly forward. Measure the tube from the tip of the client‘s nose to the earlobe and from the nose to the xiphoid process reach the stomach 4. do not allow the tube to exert pressure on the upper inner portion of the nares 7. Use a water-soluble lubricant to facilitate insertion 3. Maintaining gastric decompression Key Points 1. . Salem Sump Tube – double lumen (smaller blue lumen vents the tube & prevents suction on the gastric muco source) a. belief. Administering tube feedings 2. ask the client to swallow. Withdraw tube immediately if client experiences respiratory distress 6. o Aspirate gastric contents via a syringe to the end of the tube o Measure ph of aspirate fluid o Place the stethoscope over the gastric area and inject a small amount of air through the NGT. with strands of mucous o Coffee-ground drainage – old blood that has been broken down in the stomach o Bright red blood – bleeding from the esophagus. this will decrease the chance of entry into the trachea 5. Secure the tube to the nose. and as the swallow into the esophagus and stomach. Levin Tube – single lumen a. increase in amou Intestinal Tubes  Provide intestinal decompression proximal to a bowel obstruction. risk and hope.

Tubes may attached to suction and left in place for several days i. Wash hands and don clean gloves. Provide regular oral and nasal hygiene. Nursing Implications a. Approximately 10 feet long ii. How to Insert a Nasogastric (NG) Tube          Check physician‘s order. if possible offer hard candy or gum to reduce thirst j. Check client‘s identaband and if able have client state name. . Double lumen iii. Miller-Abbot Tubes i.allowing normal peristalsis to propel tube through the stomach into the intestine to the point of obstructio 1. After the tube has been placed in the stomach. Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into the stom 2. May be allowed to progress through the intestines and expelled via the rectum. to facilitate movement of the tube through the intestine f. Types of Intestinal Tubes a. Single lumen iii. Remove gloves and wash hands. Cantor and Harris Tubes i. May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or mouth l. Evaluate the type of gastric secretions being aspirated g. Position client at 45 degree angle or higher with head elevated. Maintain client on strict NPO b. One lumen utilized for aspiration of intestinal contents iv. Do not tape or secure the tube until it has reached the desired position h. Gather equipment. Encourage activity. Advance the tube 2 to 4 inches at regular intervals as indicated by the physician e. Offer the client frequent oral hygiene. Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray c. Removal of the tube depends on the relief of the intestinal obstruction k. Mercury placed in rubber bag prior to tube insertion b. Discuss procedure to client. Provide privacy. Approximately 6-10 feet long ii. position client on the right side to facilitae passage through th d.

5. III. When forced feeding is necessary. In very weak patient who cannot swallow food vary well. Document procedure. In forced feeding for irrational and violet patients. Sometimes in the operation of the mouth such as carcinoma of the tongue. liquid is introduced into the stomach through a rubber catheter which is passed the esophagus. In tetanus or meningitis with a locked jaw. Definition:  In this method of feeding. 4. 3. Equipment: Tray with:  Medium size rubber catheter . 2. this method is less exhausting as the mouth does not ha II. Nasal Gavage I. 6. Therapeutic Uses: 1. When a patient is weakened and cannot swallow food. a cleft palate or fracture of the In the operation of the throat and sometimes after tracheotomy.  Position client for comfort.

not hot. Raise 3 to 4 inches above the n 7. The position of the patient may be lying down with the head turned to one side or sitting up with the head nurse with head turned away from the nurse. . Precautionary Measures While Doing the Nasal Gavage The following precautions should be strictly observe during a nasal gavage: 1. If the fluid. pinch the catheter and quickly withdraw. 5.        Sterile (No. Before pouring in the solution.2 French catheter for adult) Sterile glass syringe or a small glass funnel attached O. Even a small amount of food in the lungs would cause a severe irritation. cyanosis and later a po pass the finger to the back of the throat to sea the tube is in position. 6. Instruct the patient to make motion of sw 4. allowed to r probably lead to a lung abscess or septic pneumonia. then pour the liquid slowly at the sides. 6. 2. 3. Wait until the patient is accustomed to the presence of the tube.S Kidney basin Dressing rubber Draw sheet Lubricant A flask containing the nourishment ordered at temperature of 104 to 105°F IV. then pour the balance in very slowly. and dyspnea and if. wait until the patient is at rest. Introduce 6 to 8 inches. The catheter should first be lubricated and in inserting it should be directed toward the septum of the nose removed and inserted again in the other nostril. As the tube is soft it may become coiled upon itself in the mouth or in the throat. 3. Tell patient to open the mouth and look if the catheter has passed if patient coughs. until all distress has subsided and normal b the esophagus. Insert the curve thru the nose and backward inward the septum. 4. Pour in only few drops at first. Connect the funnel to the catheter. And will almost certainly enter the larynx causing dyspnea. if there are not symptoms of checkin 7. After all the fluid has left the funnel. there is considerable danger of its passing into the larynx therefore the patients c pouring in the solution which if the tube should be in the larynx would down the patient. Wait for a few minutes then pinch the tube and withdraw. is poured in checking and gasping. Procedure    Food consists of any liquid for which will readily pass through the tube. Expel the air and lubricate the tube. wait before moving d 5. 2. In some cases the tube is left and hold in place VI. as the lining of the nose is much sensitive than that of the mout The danger of burning the patient is greater when feeding by this method 1. As the catheter is small. The temperature should be warm. if the tube is in the trachea a whistling sound will be esophagus probably a gurgling sound will be heard.

5-16 g/dl.5-6. Female 12-16 g/dl Platelet 150.Normal Values Bleeding time 1-9 min Prothrombin time 10-13 sec Hematocrit Male 42-52% .000 RBC Male 4. indirect 0.0mg/dl .400.2 million/L.2-0. Female 36-48% Hemoglobin Male 13.4 million/L Amylase 80-180 IU/L Bilirubin(serum) direct 0-0. Female 4.4 mg/dl.3-1.2-5.8 mg/dl.000. total 0.

5.5-2.145 mEq/L Potassium 3.5 mg/dl .5.45 PaCo2 35-45 HCO3 22-26 mEq/L Pa O2 80-100 mmg SaO2 94-100% Sodium 135.5 mg/dL Chloride 98-108 mEq/L Magnesium 1.35.5.7.2.0 mEq/L Calcium 4.pH 7.

Female 50-250 mu/ml Fibrinogen 200-400 mg/dl FBS 80-120 mg/dl Glycosylated Hgb (HbA1c) 4.2 CPK-MB Male 50 –325 mu/ml.0-7.0% Uric Acid 2.1.4. Female 20-30 mm/hr Cholesterol 150.5 –8 mg/dl ESR Male 15-20 mm/hr.200 mg/dl .BUN 10-20 mg/dl Creatinine 0.

  The unique function of the nurse is to assist the individual.5. A nursing theory. Four Major Concepts . and ideas in nursing it:     It guides nurses in their practice knowing what is nursing and what is not nursing. in the performance of those activ death the client would perform unaided if he had the necessary strength. sick or well.Triglyceride 140-200 mg/dl Lactic Dehydrogenase 100-225 mu/ml Alkaline phospokinase 32-92 U/L Albumin 3. It will help define the role of the nurse in the multidisciplinary health care team.2. then. huma Barnum defines theory as ―a construct that accounts for or organizes some phenomenon. including theories of systems.5 mg/dl Nursing Theorist Nursing As defined by the INTERNATIONAL COUNCIL OF NURSES as written by Virginia Henderson. Nursing Theory Over the years. nursing has incorporated theories from non-nursing sources. concepts. It will help the people to understand the competencies and professional accountability of nurses. Help the client gain independence as rapidly as possible. With the formulation of different theories. policies and laws. will or knowledge. It helps in the formulations of standards.

Nurses have developed various theories that provide different explanations of the nursing discipline. All theories human beings. People are the recipients of nursing care; they include individuals, families, communities, and gro internally and externally. It means not only in the everyday surroundings but all setting where nursing care is pro being. The concept of Nursing is central to all nursing theories. Definitions of nursing describe what nursing is, nursing theories address each of the four central concepts implicitly or explicitly. Betty Neuman (1972, 1982, 1989, 1992) Health Care System Model

The Neuman System Model or Health Care System Model
 

Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary To address the effects of stress and reactions to it on the development and maintenance of health. The con client‘s basic structure and to obtain or maintain a maximum level of wellness. The nurse helps the client to adjust to environmental stressors and maintain client stability.

Metaparadigm Person

A client system that is composed of physiologic, psychological, sociocultural, and environmental variable

Environment

Internal and external forces surrounding humans at any time.

Health

Health or wellness exists if all parts and subparts are in harmony with the whole person.

Nursing

Nursing is a unique profession in that it is concerned with all the variables affecting an individual‘s respo

Dorothea Orem (1970, 1985) Self-Care Deficit Theory

Self-Care Deficit Theory
   

Defined Nursing: “The act of assisting others in the provision and management of self-care to maint effectiveness.” Focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-b Has a strong health promotion and maintenance focus. Identified 3 related concepts:

1. Self-care - activities an Individual performs independently throughout life to promote and mainta 2. Health - results when self-care agency (Individual‘s ability) is not adequate to meet the known sel 3. Nursing System - nursing interventions needed when Individual is unable to perform the necessa
 

Wholly compensatory - nurse provides entire self-care for the client.  Example: care of a new born, care of client recovering from surgery in a post-anest Partial compensatory - nurse and client perform care; client can perform selected self-car needs the client cannot meet independently.  Example: Nurse can assist post operative client to ambulate, Nurse can bring a mea Supportive-educative - nurse‘s actions are to help the client develop/learn their own selfencouragement.  Example: Nurse guides a mother how to breastfeed her baby, Counseling a psychia

Dorothy E. Johnson (1980) Behavioral System Model

Behavioral System Model
   

Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can mo Viewed the patient‘s behavior as a system, which is a whole with interacting parts. The nursing process is viewed as a major tool. To reduce stress so the client can recover as quickly as possible. According to Johnson, each person as a b 1. Ingestive. Taking in nourishment in socially and culturally acceptable ways. 2. Eliminated. Riddling the body of waste in socially and culturally acceptable ways. 3. Affiliative. Security seeking behavior. 4. Aggressive. Self – protective behavior. 5. Dependence. Nurturance – seeking behavior. 6. Achievement. Master of oneself and one‘s environment according to internalized standards of exc 7. Sexual role identity behavior In addition, she viewed that each person strives to achieve balance and stability both internally and extern environmental forces through learned pattern of response. Furthermore, She believed that the patient striv with social demands; who is able to modify his behavior in ways that support biologic imperatives; who i health care professional‘s knowledge and skills; and whose behavior does not give evidence of unnecessa

Metaparadigm Person

A system of interdependent parts with patterned, repetitive, and purposeful ways of behaving.

Environment

All forces that affect the person and that influence the behavioral system

Health

Focus on person, not illness. Health is a dynamic state influenced by biologic, psychological, and social f

Nursing

Promotion of behavioral system, balance and stability. An art and a science providing external assistance

Metaparadigm Person  Any individual who is receiving help from a member of the health profession or from a worker in the fiel Environment  Not specifically addressed Health  Concepts of nursing. purpose. and feelings und Faye Glenn Abdellah (1960) Twenty One Nursing Problems . thinks. All actions. practice and an art. thoughts. and feels. She believed that nurses meet the individual‘s need for help through the identification of the needs.Ernestine Wiedenbach (1964) The Helping Art of Clinical Nursing The Helping Art of Clinical Nursing    Developed the Clinical Nursing – A Helping Art Model. She advocated that the nurse‘s individual philosophy or central purpose lends credence to nursing care. and need for help and their relationships imply health-related concerns in the Nursing  The nurse is a functional human being who acts. admin Components of clinical practice: Philosophy. client.

To facilitate the maintenance of fluid and electrolyte balance 9. To create and maintain a therapeutic environment 18. exercise. 4. To promote safety. To use community resources as an aid in resolving problems arising from illness.Twenty One Nursing Problems   Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgemen Introduced Patient – Centered Approaches to Nursing Model She defined nursing as service to individ conceptualized nursing as an art and a science that molds the attitudes. To facilitate the maintenance of sensory functions 12. To facilitate the maintenance of regulatory mechanisms and functions 11. 3. and cope with their health needs. To facilitate progress toward achievement of personal spiritual goals 17. To understand the role of social problems as influencing factors Metaparadigm . To maintain good hygiene. To facilitate maintenance of nutrition 7. To identify and accept positive and negative expressions. 19. To promote the development of productive interpersonal relationship 16. sick or well. To promote optimal activity. intellectual competencies and tech to help people. To identify and accept the interrelatedness of emotions and illness. To recognize the physiologic response of the body to disease conditions 10. feelings and reactions 13. To facilitate awareness of self as an individual with varying needs. To facilitate maintenance of elimination 8. To accept the optimum possible goals 20. 21 Nursing Problems 1. To maintain good body mechanics 5. To facilitate the maintenance of a supply of oxygen 6. 21. rest and sleep. 2. 14. To facilitate the maintenance of effective verbal and non-verbal communication 15.

cleanliness/sanitation and ligh Considered a clean.Person  The recipients of nursing care having physical. efficient drainage. Some discussion indicates that clients interact with their environment. interpersonal relationships. . Nursing Florence Nightingale (1860) Environmental Theory Environmental Theory       Defined Nursing: “The act of utilizing the environment of the patient to assist him in his recovery. quiet environment essential for recovery. well-ventilated. of which nurse Health  A state when the individual has no unmet needs and no anticipated or actual impairment. rest and emotional health promotion. activity.” Focuses on changing and manipulating the environment in order to put the patient in the best possible con Identified 5 environmental factors: fresh air. the bod Developed the described the first theory of nursing. and development of self-awareness. but with a nurturing environment. emotional. Nursing  Broadly grouped in ―21 nursing problems. and sociologic needs that may be overt or cove Environment  Not clearly defined.‖ which center around needs for hygiene. Deficiencies in these 5 factors produce illness or lack of health. She f order to put the patient in the best possible conditions for nature to act. Notes on Nursing: What It Is What It Is Not. pure water. comfort.

has some self-care knowledge. The focus of this theory is on the person. Metaparadigm . Helen Erickson. Environment  External conditions that affect life and individuals development. needs simultaneously to be atta Nurses in this theory.Metaparadigm Person  An individual with vital reparative processes to deal with disease. Health  Focus is on the reparative process of getting well Nursing  Goal is to place the individual in the best condition for good healthcare Evelyn Tomlin. and Mary Ann Swa (1983) Modeling and Role Modeling Theory Modeling and Role Modeling Theory   Developed Modeling and Role Modeling Theory. They asserted that each individual unique. The nurse m interpersonal and interactive theory. nurture and accept the person unconditionally. facilitate.

‖ ―A client is one who is considered to be a legitimate member of t the planned regimen. respond to the need for help.Person  A differentiation is made between patients and clients in this theory. Orientation . mental and social well-being. Our nurse-client relationship is an interactive.‖ Health  ―Health is a state of physical.Patient relationship: 1. Nursing  ―The nurse is a facilitator. not merely the absence of disease or infirmit various subsystems [of a holistic person]‖. and who is incorporated into the planning and implementation of his or her own car Environment  ―Environment is not identified in the theory as an entity of its own.individual/family has a ―felt need‖ and seeks professional assistance from a nurse (who is a . The theorist see environment in the so both cultural and individual.‖ Hildegard Peplau (1951) Interpersonal Relations Theory Interpersonal Relations Theory    Defined Nursing: ―An interpersonal process of therapeutic interactions between an Individual who is sick educated to recognize. not an effector. Nursing is a ―maturing force and an educative instrument‖ Identified 4 phases of the Nurse . Biophysical stressors are seen as part of the environment. A patient is given treatment and inst goal is for nurses to work with clients. interpersonal pr develop his or her own strengths.

Ida Jean Orlando (1961) The Dynamic Nurse-Patient Relationship The Dynamic Nurse-Patient Relationship   Conceptualized The Dynamic Nurse – Patient Relationship Model.2. She believed that the nurse helps patients meet a perceived need that the patient cannot meet for themselv assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness. Identification .the nurse uses communication tools to offer services to the patient. Exploitation . who is expected to take 4. as patient drifts away from identifying with the nurse as the helping person. with emphas Health  Ongoing human process that implies forward movement of personality and other ongoing human process personal.where patient‘s needs have already been met by the collaborative efforts between the patient links are dissolved. . 3. a maturing force that aims to promote forward movement of personality. Resolution . Here happens the selection of appropriate professional assistance. and psychodynamic milieu receives attention.where the patient begins to have feelings of belongingness and a capacity for dealing with inner strength ensues. and community living. Nursing  Interpersonal therapeutic process that ―functions cooperatively with others human processes that make he educative instrument. Metaparadigm Person  An organism striving to reduce tension generated by needs Environment  The interpersonal process is always included.

 

She emphasized the importance of validating the need and evaluating care based on observable outcomes To interact with clients to meet immediate needs by identifying client behaviors, nurse‘s reactions, and nu

Metaparadigm Person

Unique individual behaving verbally nonverbally. Assumption is that individuals are at times able to mee

Environment

Not defined

Health

Not defined. Assumption is that being without emotional or physical discomfort and having a sense of we

Nursing

Professional nursing is conceptualized as finding out and meeting the client‘s immediate need for help.

Imogene King (1971, 1981) Goal Attainment Theory

Goal Attainment Theory
  

Nursing process is defined as dynamic interpersonal process between nurse, client and health care system Postulated the Goal Attainment Theory. She described nursing as a helping profession that assists indi health. If is this not possible, nurses help individuals die with dignity. In addition, King viewed nursing as an interaction process between client and nurse whereby during perce occurred and goals are achieved.

Metaparadigm Person

Biopsychosocial being

Environment

Internal and external environment continually interacts to assist in adjustments to change.

Health

A dynamic life experience with continued goal attainment and adjustment to stressors.

Nursing

Perceiving, thinking, relating, judging, and acting with an individual who comes to a nursing situations

Jean Watson (1979) The Philosophy and Science of Caring

The Philosophy and Science of Caring
   

Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring health. Nursing is a human science of persons and human health-illness experiences that are mediated by profess transactions She defined caring as a nurturing way or responding to a valued client towards whom the nurse feels a pe demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts the pe Carative Factors: 1. The formation of a humanistic-altruistic system of values 2. Instillation of faith-hope 3. The cultivation of sensitivity to one‘s self and others 4. The development of a helping- trust relationship

5. The promotion and acceptance of the expression of positive and negative feelings. 6. The systemic use of the scientific problem-solving method for decision making 7. The promotion of interpersonal teaching-learning 8. The provision for supportive, protective and corrective mental, physical, socio-cultural and spiritu 9. Assistance with the gratification of human needs 10. The allowance for existential phenomenological forces Metaparadigm Person

A valued being to be cared for, respected, nurtured, understood, and assisted, a fully functional, integrated

Environment

Social environment, caring and the culture of caring affect health

Health

Physical, mental, and social wellness

Nursing

A human science of people and human health; illness experiences that are mediated by professional, perso transactions.

Joyce Travelbee (1966, 1971) Interpersonal Aspects of Nursing

Interpersonal Aspects of Nursing
 

She postulated the Interpersonal Aspects of Nursing Model. She advocated that the goal of nursing indivi regaining health finding meaning in illness, or maintaining maximal degree of health. She further viewed that interpersonal process is a human-to-human relationship formed during illness and

Environment  Not defined Health  Heath includes the individual‘s perceptions of health and the absence of disease. and changing. Care and Cure Model Core. She believed that a person is a unique. Core involves the therapeutic use of self and emph to the physician‘s orders. irreplaceable individual who is in a continuous process of becomin Metaparadigm Person  A unique. The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitat . Nursing  An interpersonal process whereby the professional nurse practitioner assists an individual. Lydia Hall (1964) Core. or com suffering. evolving. family. irreplaceable individual who is in a continuous process of becoming. and if necessary. Care and Cure Model     The client is composed of the ff. to find meaning in these experiences. Core and cure are shared with the other health care providers. overlapping parts: person (core). pathologic state and treatment (cure) an Introduced the model of Nursing: What Is It? Focusing on the notion that centers around three componen Care represents nurturance and is exclusive to nursing.

Transcultural nursing as a learned subfield or branch of nursing which focuses upon the comparative st health-illness caring practices. Health  Development of a mature self-identity that assists in the conscious selection of actions that facilitate grow Nursing  Caring is the nurse‘s primary function. She advocated that nursing is a humanistic and scientific processes (cultural values. or enable individuals or groups to maintain or regain their well being (or health) in culturally m handicaps or death. and person. beliefs and values with the goal to provide meaningful and efficacious nur values and health-illness context. Nursing is a learned humanistic and scientific profession and discipline which is focused on human care p facilitate.Metaparadigm Person  Client is composed of body. People set their own goals and are capable of learning Environment  Should facilitate achievement of the client‘s personal goals. Focuses on the fact that different cultures have different caring behaviors and different health and illness . beliefs and practices) to improve or maintain a health condition. pathology. Professional nursing is most important during the recuperative per Madeleine Leininger (1978. 1984) Transcultural Care Theory and Ethnonursing Transcultural Care Theory and Ethnonursing     Developed the Transcultural Nursing Model.

language and thought Metaparadigm Person  Unitary man. moves forwa . The human being is a unified whole. The individual and the environment are continuously exchanging matter and energy with each oth 3. Martha Rogers (1970) Science of Unitary Man Science of Unitary Man    Nursing is an art and science that is humanistic and humanitarian. Awareness of the differences allows the nurse to design culture-specific nursing interventions. It is directed toward the unitary human development. The goal of nurses is to participate in the process of Nursing interventions seek to promote harmonious interaction between persons and their environment. Patterns identify human being and reflect their innovative wholeness 5. The individual is characterized by the capacity for abstraction and imagery. a four-dimensional energy field. Environment  Encompasses all that is outside any given human field. Person exchanging matter and energy. The life processes of human beings evolve irreversibly and unidirectionally along a space-time co 4. str and environmental patterns or organization to achieve maximum health. possessing individual integrity and manifesting characteristic 2. but emerges out of interaction between human and environment. Health  Not specifically addressed. 5 basic assumptions: 1.

Nursing  A learned profession that is both science and art. The human body needs energy utilization output. The social integrity of the client reflects the family and the com institutions may separate individuals from their family. includes all the individual‘s experiences . which must be preserved and enhanced by nurses. The four conservation principles are as follows: 1. Conservation of energy. The human body functions by utilizing energy. Conservation of Personal Integrity. conservation of personal integrity. 3. The nursing interventions are based on the conservation of t sense of identity. She advocated that nursing is a human interaction and pro concerned with the unity and integrity of the individual. conservation of structured integrity. Conservation of Structural Integrity. with conservation of energy as a primary concer client energy. The professional practice of nursing is creative and imag Myra Estrin Levine (1973) Conservation Model Conservation Model   Believes nursing intervention is a conservation activity. The human body has physical boundaries (skin and muco and prevent harmful agents from entering the body. It is important for nurses to consider the in Metaparadigm Person  A holistic being Environment  Broadly. self worth and self esteem. 4. 2. conservation of soc Described the Four Conversation Principles. Conservation of Social integrity.

Metaparadigm Person  A major reason for nursing existence Environment  Man and environment interchange energy to create what is in the world. and man chooses the meaning gi Health . Human becoming is freely choosing personal meaning in situation in the intersubjective process o 2. the practice of which is a performing art Three assumption about Human Becoming 1.Health  The maintenance of the client‘s unity and integrity Nursing  A discipline rooted in the organic dependency of the individual human being on his or her relationship wi Rosemarie Rizzo Parse (1981) Theory of Human Becoming Theory of Human Becoming   Nursing is a scientific discipline. Human becoming is co-transcending multidimensionality with emerging possibilities. Human becoming is co-creating rhythmic patterns or relating in mutual process in the universe 3.

or societies to adapt to change. The syste Focuses on the ability of Individuals. groups. Metaparadigm Person  Biopsychological being and the recipient of nursing care. communities. functions as a whole through interdependence of its part. Environment  All conditions. The degree of internal or external environmental change and the person‘s ability to cope with that change Nursing interventions are aimed at promoting physiologic. She viewed each person as a unified biopsychosocial system in const that the person as an adaptive system. A lived experience that is a process of being and becoming Nursing  Nursing Practice is directed toward illuminating and mobilizing family interrelationships in light of the m the co created patterns of relating. psychologic. and social functioning or adaptat To identify the types and demands placed on a client and client‘s adaptation to the demands. Presented the Adaptation Model. Sister Callista Roy (1979) Adaptation Model Adaptation Model       Viewed humans as Biopsychosocial beings constantly interacting with a changing environment and who adaptation mechanisms. and influences surrounding and affecting the development of an organism . families. circumstances.

She further believed that nursing involves assisting the client in gaining independence as rapidly as possib no longer possible. Maintaining body temperature within normal range 8.Health  The person encounters adaptation problems in changing the environment. Nursing  A theoretical system of knowledge that prescribes a process of analysis and action related to the care of th Virginia Henderson (1955) The Nature of Nursing Model The Nature of Nursing Model      Introduced The Nature of Nursing Model. Communicating with others . Breathing normally 2. will or knowledge‖. Keeping the body clean and well-groomed 9. Selecting suitable clothes 7. sick or well. Moving and maintaining desirable position 5. She identified fourteen basic needs. Sleeping and resting 6. will or knowledge. She postulated that the unique function of the nurse is to assist the clients. Identified 14 basic needs : 1. in the performanc clients would perform unaided if they had the necessary strength. Eliminating body wastes 4. sick or well. Eating and drinking adequately 3. Avoiding dangers in the environment 10. Defined Nursing: ―Assisting the individual. in the performance of those activities contributin individual would perform unaided if he had the necessary strength.

viewed in terms of the client‘s ability to perform 14 components of nursing c comfort. ensuring safety. maintaining body temperature. An examination room that is well equipped for Equipment – Hand washing is done before equipment preparation and the examination. resting clothing. Learning. Physical Examination Purposes The nurse uses physical assessment for the following reasons:     To gather baseline data about the client‘s health To supplement. discovering or satisfying the curiosity that leads to normal development and health and using ava Metaparadigm Person  Individual requiring assistance to achieve health and independence or a peaceful death. wors Nursing  Assists and supports the individual in life activities and the attainment of independence. Worshipping according to one‘s faith 12. communicating.11. sleeping. Hand washing re Client . confirm or refute data obtained in the nursing history To confirm and identify nursing diagnoses To make clinical judgments about a client‘s changing health status and management Preparation of Examination    Environment – A physical examination requires privacy. Working in such a way that one feels a sense of accomplishment 13. Playing/participating in various forms of recreation 14. Mind and body ar Environment  All external conditions and influences that affect life and development Health  Equated with independence.

Percussion – examination by striking the body‘s surface with a finger. color. the character of the sound depends on the density of the underlying tissue 4. a penlight) to inspect body cavities 2. Positioning – during the examination. compare each area inspected with the same area of the opposite side of the body o Use additional light (for example. Some sound sounds can be heard only through a stethoscope. height and weight 2. the nurse asks the clients to assume proper positions so tha Client‘s abilities to assume positions will depend on their physical strength and degree of wellness Order of Examination 1. Review of systems 3. vital signs. Psychological Preparation – clients are easily embarrassed when forced to answer sensitive ques and examined. o Bowel sounds o Breath sounds:  Vesicular  Bronchovesicular  Bronchial Examples of Adventitious Breath Sounds 1. To inspect body parts accurate o Make sure good lighting is available o Position and expose body parts so that all surface can be viewed o Inspect each areas fro size. Physical Preparation – the client‘s physical comfort is vital to the success of the examination. Palpation – the hands can make delicate and sensitive measurements of specific physical signs. so palpat nurse uses different parts of the hand to detect characteristics such as texture. Crackles (previously called rales) Rhonchi Wheeze Friction rub . position and abnormalities o If possible. temperature and the percept 3. The possibility that the examination will find something abnormal also creates anx priority before the examination 2. 3. Head to toe examination Skills in Physical Examination 1. symmetry. Be toilet. 4. vibration and sound are produced. 2. shape. 3.1. General Survey – includes observation of general appearance and behavior. Auscultation – is listening to sound created in body organs to detect variations from normal. Inspection – to detect normal characteristics or significant physical signs.

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