FUNDAMENTALS OF NURSING

By: Joshua James Diao, RN, CRN, CDE, USRN HISTORY OF NURSING PERIODS OF NURSING INTUITIVE NURSING/ PRIMITIVE NURSING/ INSTINCTIVE NURSING (Primitive times – 6th century) PRIMITIVE TIMES - Women practice nursing because of low status in society. - Took care of children and sick members of the family. - Personalistic cause of disease. - Sickness is due to active intervention of: a. human – caused by witchcraft. b. non human – caused by ghosts. c. superhuman beings – caused by deities. - Superstitious and believes in magic. - Slave society “slave nurses” - Wet nursing, take care of babies/children of their masters - Women also practices midwifery. - Masters/healers are the people who are responsible in decision making when it comes to health. 6th CENTURY - Founding of religious orders. 3 Attributes of Nurses 1. Self denial 2. Devotion to hard work and duty. 3. With spiritual calling. Main Guiding Principles 1. “Love thy neighbor as thy self”. 2. Parable of the Good Samaritan. - Beneficence (doing good to others). 2 Types of Beneficence 1. Ordinary – doing good to others. 2. Ideal – entails sacrifice. APPRENTICE NURSING PERIOD (6th Century – 18th Century) 6TH CENTURY - founding of religious orders. - women practiced nursing. - Daughters of Charity/Sisters of Charity founded by St. Vincent de Paul and Augustinian Sisters. CRUSADES - Men practiced nursing. - Knights of St. Lazarus a. established a standard among hospitals in Europe. b. took care of clients with skin problems like leprosy. - Knights of St. John of Jerusalem a. also known as Knights Hospitalers. b. founded hospitals. 18TH CENTURY 1836 - Theodore Fleidner reestablished order of Deaconesses. - Founded school of nursing in Kaisserwerth, Germany where Florence Nightingale was the most known student. 1854-1856 (CRIMEAN WAR) - Florence Nightingale was known as the Lady with a Lamp. - Compiled the “Notes on Nursing: What it is and What is not” and became the first nurse theorist.

EDUCATIONAL NURSING PERIOD (18th Century – 20th Century) 18TH CENTURY - Florence Nightingale established a nursing school in St. Thomas Hospital in London which adopted the Nightingale System. - Made Florence Nightingale the mother of modern nursing. Philosophy of Nightingale System 1. Government funds should be allotted to nursing education. - earned her the title of being the first nurse political activist. 2. Training schools of nursing should be in close affiliation. 3. Professional nurses should train nurses. 4. Nursing students should be provided with residence near their training hospitals. - written orders of doctors insisted. - nurses should go with doctors during rounds. LATE 20TH CENTURY - Specialization in medicine. - Conceptualization of the role of clinical nurse specialist. - Increase clinical content of education (1900’s). CONTEMPORARY PERIOD (21st Century) - Globalization of nursing. - Period after world war II. - Borderless nursing or transcultural nursing. - Professionalization of nursing. PROFESSION – a special calling that requires special, skills, knowledge and attitudes. 7 CRITICAL ATTRIBUTES OF PROFESSION 1. Specialized education 2. Code of ethics 3. Research of orientation 4. Autonomy 5. Body of knowledge 6. Service orientation 7. Professional Organization SOCIALIZATION – process where a person learns the ways and means or skills, knowledge, attitudes of the group to which he belongs to. BENNER LEVEL OF PROFICIENCY 1. Novice – student nurse entering a clinical setting where he has no experience at all. 2. Advance – nurse who demonstrates a marginally acceptable performance: depends on rules and maxims. 3. Competent – 2 – 3 years experience demonstrates organizational ability but lacks speed and flexibility of a proficient nurse. 4. Proficient – concerned with long term goals, performance is fluid and flexible compared to competent nurse - has a wholistic view of the client. 5. Expert – no longer relies on maxims, performance is highly proficient, fluid flexible and has a wholistic view. - has high perceptual acuity or a clinical eye. DIMENSIONS OF NURSING 1. Nursing Practice 2. Nursing Education 3. Nursing Research FOCUS OF NURSING 1. Health Promotion – improve clients well being. 2. Health Maintenance 3. Health Instauration – help clients with illness to recover. 4. Care of the Dying – clients with cancer. ROLE – patterns of behavior expected of person assuming a status/position in society or a group. TASK – specific activities required of a person.

ROLES OF NURSE 1. 6. Population Groups – special groups with special needs attributed to the following: a. Occupation – commercial sex workers are more prone to STD’s. Researcher – research process 8. Affective – interest/emotion 2. Environment .Attends to physical/emotional (mostly physical) needs of the client. Individual/Person 2. 3.- PATIENT Has a disease Very dependent on health professional - CLIENT Not necessarily sick Health promotion act till disease prevention Client collaborates with health professional LEVELS OF CLIENTELE 1. Cognitive – knowledge aspect b. Facilitator THEORIES – relationship between concepts 4 CONCEPTS OF NURSING THEORIES 1. Nurse Educator . Community 4. Manager . Caregiver . Organizing (delegating tasks/tasking) c. Nurses as Leader . Health 4. PROCESS OF MANAGEMENT a. Nursing 3. Family 3. Controlling – evaluation of output against standards. Developmental stage c. 5. Psychomotor – skills c. Change agent – improvement in organization.3 domains of learning a. Cultural characteristics – indigenous people. Planning (resources) b.Organizational goals/works within an organization. Directing (motivating people) d. b. 4.Process of influencing people to work towards the attainment of goals. Client advocate – protects rights of clients. Individual 2. 7.

Participate in recreation 14. Worship according to ones faith 12. Nutrition 7. Learn to satisfy the curiosity that leads to normal development 1-9 PHYSIOLOGIC 10 – 14 PSYCHOLOGICAL 12 – 13 SOCIOLOGIC 11 SPIRITUAL/MORAL . Eliminate body waste 4. Cleanliness 5. GOALS . NIGHTINGALE’S ENVIRONMENTAL THEORY . Variety – change in environment for patient. drink adequately 3. Noise – due to nurses clothing or roaming around. 6. Move and maintain desirable posture 5. . NURSE. Chattering hopes – deals with social aspect. 3. Communicate with others 11. Breathe normally 2. 8.Role of nurse is complimentary.Supplementary . Health of houses – environmental sanitation. 2. 4. talk about positive things. Eat. Keep body clean and well groomed 9. Work for accomplishment 13. 9. Avoid dangers in environment 10. VIRGINIA HENDERSON’S DEFINITION OF NURSING . Air – importance to have moving air in room of patient to contribute in proper ventilation. complete and individual being. Sleep and rest 6. Ventilation – promote warming. 10. . 10 ELEMENTS FOUND IN ENVIRONMENT 1.Assisting individuals sick or well in the performance of activity. Maintain body temperature 8.Individual person is a whole. 2. Select suitable clothes 7.NURSING THEORIES A. Beddings – change linens/beddings in patients room to promote comfort.PERSON INTERACTION INDEPENDENCE KNOWLEDGE RESTORATION MAINTENANCE STRENGTH NURSES WILL PERSON PEACEFUL DEATH ENVIRONMENT 14 BASIC COMPONENTS OF NURSING CARE 1. GENERAL THEORIES 1.Nursing Action: manipulation of elements in the environment to contribute to reparative process. Light – patient should be near windows to be able to see sunlight and give hope.What nursing has to do is to put the individual in best position for nature to work on him. nurse should be cautious with words when at bedside.

Life patterns identify individuals. . Nursing is humanistic science B. Sufficient intake of food 4.Man is an integrated whole. Focal . . intellectual. deficits. Sufficient intake of air 2. Time spent alone balanced with time spent with others 7.Input and output: matter. Contextual – other internal and external factors 3. Wholly compensatory – nurse acts for patient. Prevention of danger 8.3. STIMULI 1. partly supportive-educative. SISTER CALLISTA ROY’S ADAPTATION MODEL . UNIVERSAL SELF CARE REQUISITES 1. Individual and environment are continuously exchanging matter and energy. 5. information.Whole: physical. Sufficient intake of water 3. Activity balanced with rest 6. 3. . developmental. . symbolically and socially. GENERAL SYSTEM THEORY . HEATH DEVIATION . . Satisfactory eliminative functions 5. Supportive-Educative – patient able to perform self care. 4. Parallel with Ludwig von Bertalanffy’s General System Theory C.Additional demands for health care due to illness. B. 3.Person is adaptive system with coping mechanism. Humans have the capacity for absorption and imagery.Nursing is a service. 3. . spiritual. Lifecycle evolves irreversibly and uni-directionally along space and time continuum. psychological. sensation and emotion. language and thought. biologically. energy. 2. 3 SUB THEORIES 1.Specialized expression of universal self-care requisites for development process. 2.immediate 2. art and technology. . THEORY OF NURSING SYSTEM 1. SYSTEM THEORIES 5.Grounded on humanism.Goal of nursing is to promote persons adaptation. Being normal DEVELOPMENT OF SELF CARE REQUISITES . 2. 5 assumptions about human beings 1. disease or injury. . MARTHA ROGER’S SCIENCE OF UNITARY HUMAN BEINGS A.Man is self reliant and responsible for self care. capabilities. Self Care Deficit – demands.Man is requisite for all. Man is a unified whole – whole not equal to sum of parts. DOROTHEA OREM’S SELF CARE DEFICIT THEORY . Partly compensatory – both nurse and patient. Theory of Nursing Systems – wholly compensatory. 4.A set of interacting parts/ components with a boundary that filters the input and output from and to the environment. Self Care – universal self care. Residual – may or may not have effect like attitudes and beliefs.

CLIENT Flexible – keeps system free from stressor reaction or symptom-matology.Nursing focus: behavior modification to foster equilibrium. B.Interacting components are personal.Adaptive/effective response . transaction role.Physiologic – adaptive mode . 8.Environment can also be source of resources that may help client cope with stressors. 4 CONCEPTS A.Interdependence mode . . peer pressure. stress. . radiation. . client. b. HEALTH D.COPING MECHANISMS 1. microorganisms.Primary: protection of normal line of defense. C. demonstrate behavior commensurate to social demands. . 7. communication.Environment has potential to alter system stability due to internal and external stressors. Ex. .Organization. Line of Resistance – consist of internal defensive processes. each person perceive the other and situation and explore the means to achieve them. energy conservation .Maladaptive/ineffective response 6. Extra personal – unemployment. reaction to stress. space.Nursing focus: human interact with the environment. .Biological subsystem: addressed by medical intervention.Elements: interaction. power. benefit from physicians skill and knowledge. STRESSORS CAN BE 1. c.Perception. DOROTHY JOHNSON’S BEHAVIORAL SYSTEMS MODEL Mans subsystem .Self concept mode . status. social. ADAPTIVE MODES . learning time. community) is an open system in interaction with environment. NURSING . COMPONENTS PERSONAL SYSTEM .Based on 2 components stress. Goal of Nursing a. financial condition. Treatment of symptoms. physical abilities. interpersonal.Tertiary: promotion of reconstitution by supporting existing strengths and resources. Intra personal – anger. 2.Role function mode . . d. Ex. Regulator – neural – chemical – endocrine.Client (individual. IMOGENE KING’S GOAL-ATTAINMENT THEORY . . modify behavior to support biological needs.Nursing Goal: humanistic maintenance of individuals and groups. Immune response. decision making. . Cognator – processed through cognition.Behavioral subsystem: addressed by nursing intervention. self. Inter personal – between 2 or more individual (parent expectations).Humans are open systems in constant interaction with their environment. 2. . BETTY NEUMAN’S HEALTH CARE SYSTEMS MODEL .Secondary: protection of basic structure by strengthening internal line of resistance. group. . ENVIRONMENT . 3.Nursing is a process of human interaction between the nurse. demonstrate behavior that does not give evidence of unnecessary trauma. . growth and development. authority. image.

physical.Culture: way of life. Assistance with the gratification of human. Exploitation – client takes control of the situation by extracting help from nurse.purpose of nursing is to educate and to be a nurturing force to a patient for him to get a new view of himself.Caring is more healthogenic than caring. 10 CARATIVE FACTORS 1. Orientation – leveling off between nurse and client in term of expectation. INTERPERSONAL/CARING THEORIES 9. both positive and negative. Identification – selective response of the client to those who can meet his needs. FAYE GLEN ABDELLAH’S 21 NURSING PROBLEMS .diversities: cultural peculiarities (caring ). 8. Allowance for existential phenomenological factors. 2.Nursing in the use of the problem solving approach .Types of nursing response: deliberate action(based on correct identification of patients needs) and automatic action. . 3. 4. 9. Faith – hope 3. Formation of a humanistic-altruistic value system. (First 3 factors are the foundations for caring) 4. 12 JEAN WATSON’S PHILOSOPHY AND SCIENCE OF CARING . IDA JEAN ORLANDO’S DYNAMIC NURSE-CLIENT RELATIONSHIP . MADELEINE LEININGER’S TRANSCULTURAL CARE THEORY .Covert: psychological problem . Establishing a helping trust relation 5. . 10. Cultivation of sensitivity to self and others.C. diminish. 6. nutritional needs). D. 11.Nursing is the science of caring. relieve individual’s sense of helplessness. . 2.Nursing disciplined professional response. Provisions for a supportive. Nurse Counselor – identify stressor Resource Person – health educator Surrogate – acts as caregiver Congruent Goals PHASE OF NURSE – PATIENT RELATIONSHIP 1. 7. Promotion of interpersonal teaching-learning. CLIENT CENTERED THEORIES 13. . Expression of feelings. . HILDEGARD PEPLAU’S INTERPERSONAL RELATIONSHIP IN NURSING .interaction is a maturing force.Main focus of nursing is on curative factors that are derived from humanistic perspectives combined with a scientific base.has universalities: same as other culture (hygiene. . affected by clients belief. Resolution – evaluation of care and discharge of client. 10. sociocultural and spiritual environment.Overt: obvious (physical manifestations of health problems) Patient (with a need) . protective and corrective mental. Research and systematic problem solving. total of all the material and non material’s produced by the people at their level of social development.nursing function is concerned with providing direct assistance to individuals in whatever setting to avoid. .

PENDER’S HEALTH PROMOTION MODEL .Nursing operates in all 3 elements . NOLA J.Care: the body.Core: the person.By improving the clients patterns of adaptive response CONSERVATION OF Energy Structural Integrity Personal Integrity Social Integrity Promotion of “wholeness” of the client towards health maintenance or health restoration. CARE. LYDIA HALL’S THEORY OF CORE. CONSERVATION .Defends wholeness of living systems by ensuring their ability to confront change 16.Example: 6 – 8 hours of sleep . person . Mass media Perceived benefits of health promoting behaviors Cues to action Perceived barriers of health promoting behaviors .Example: BCG vaccination COGNITIVE PERCEPTUAL FACTORS Importance of health MODIFYING FACTORS Demographic character Perceived control of health Perceived self efficacy Biologic Interpersonal influences Depth of health Situational factors LIKELIHOOD IN ENGAGING IN HEALTH PROMOTING BEHAVIORS Perceived health status Behavioral factor Ex.Patient is composed of 3 elements: body. CURE . therapeutic use of self . medical care (client advocate) 15. intimate body care (nurturing component) . .Disease prevention/Health protection: action directed towards decreasing the probability of experiencing illness by active protection of the body against pathological stressors.Directed towards increasing the level of well being and self actualization of a given individual or group .Nursing is helping clients move in the direction of self awareness . pathology.Cure: the disease. MYRA ESTRINE LEVINE’S FOUR CONSERVATION PRINCIPLES OF NURSING .Promotion of the wholeness of the person .14.

affect. water.HEALTHY LIFESTYLE .Moderate intake of alcohol CONCEPT OF MAN Atomistic – whole or sum of parts Holistic – the whole is not equal to the sum of parts Physiologic – genetic character. elimination.Positive outlook in life HEALTH . . language Intellectual – perception.persons sense of achievement and independence. Universal 2.Meeting unmet needs restore health Physiologic . harmony and vitality engaging in attitudes and behaviors that enhance the quality of life and maximizes personal potential. organs and functioning Psychological – emotions. mental and social well-being and not merely the absence of disease or infirmity. clothing.Health is a state of complete physical.Balance between rest and activity .Presence: prevent illness/signal health . Love and Belongingness .State of well being . cognition Spiritual – faith (unquestioning belief in someone. rest and sleep Safety and Security .Regular exercise 3 times a week .nurturance with affection Self Esteem . family. Interrelated 6. nutrition.Accepts himself .Need: anything that is essential to the survival of man .Adequate nutrition 3 times a day .Subjective perception of balance. serves to unite humans). shelter.sex. merciful Socio-cultural – socialization. charity Charity – outward expression of love for others BASIC HUMAN NEEDS 1.physical freedom from harm. confidence and strength Self Actualization .Absence: may cause illness . Maybe differed 5. psychological knowing what to expect from others and what others expect from you. WELLNESS . Met in different ways 3.Not smoking .Open mind . rationality. Priorities maybe altered MASLOW’S HEIRARCHY OF NEEDS . hope.Framework: basic need is something whose . Stimulated by external and internal factors 4.not all people attain self actualization (attained by only 15%) . competence.

fitness of organ structures and functioning . career development .Emotional: able to manage stress. family.Spiritual: faith and hope .Physical: ADL.Social: interact successfully with others.DIMENSION OF WELLNESS . High level wellness (in an unfavorable environment) Environmental axis Very Unfavorable Environment Both physical and social cultural environment . tolerant of people with different beliefs MODELS OF HEALTH AND WELLNESS LEAVELL AND CLARKS AGENT – HOST ENVIRONMENT MODEL OR ECOLOGICAL MODEL/EPIDEMIOLOGIC Agent Host Environment DUNN’S HIGH LEVEL WELLNESS GRID Very Favorable Environment Protected poor health ( in favorable environment) High level wellness (in favorable environment) HEALTH AXIS Death Poor health (in an unfavorable environment) Peak Wellness Energetic.Intellectual: use knowledge for personal. social. express feelings and emotions appropriately .

Highly personal state in which the person feels unhealthy or ill. Developmental – resulting to exposure to virus or chemicals during pregnancy 3. electricity. radiation 5. movement to the left of the neutral point indicates a progressively decrease state of health HEALTH BELIEF MODEL . friction) 7.TRAVIS ILLNESS – WELLNESS CONTINUUM Wellness model . . . may or may not be related to disease DISEASE . . Expected to get well in the shortest possible time . Chemical – alcohol. Faulty Chemical or Metabolic Processes – excessive or insufficient production of hormones.Based on the motivational theory . protozoa. High Level Wellness Awareness/ Education/ Growth Treatment Models Neutral Point (no discernable illness or wellness) . bacteria. Physical – temperature extremes. enzymes IGUN’S 11 STAGES OF HEALTH SEEKING . In contrast. .Movement to the right of the neutral point indicates high level of health and well being for an individual and this may be achieved through awareness and education and growth. Premature Death Disability Symptoms/Signs . fungi) and their toxins and helminthes 4. Biologic – microorganisms (virus. genetic defects 2.Any activity undertaken by a person who feels ill in order to define his state of health and seek a suitable remedy Stage 1: Symptom experience Stage 2: Self treatment or self medication Stage 3: Communication to others Stage 4: Assessment of symptoms Stage 5: Sick-role assumption Characteristics of Sick Role a. drugs 6.Alteration in body function resulting in a reduction of capacities or a shortening of the normal lifespan CAUSES OF DISEASE 1. Expected to seek competent help b. strong acid and base. Genetic – inherited.Intended to predict whether individuals would or would not use preventive measure .Assumption: Good health is a motivation common to all people ILLNESS . Physiologic and Emotional reaction to stress 8. Mechanical – generalized tissue response to injury or irritation (trauma shearing force.

Person is not blamed for his disease d.Physical experience of the symptoms .Clients are obliged to seek competent help Stage III: Medical Care Contact .People are excused from normal duties and role expectations .For permanent disability.c.Seeking medical advice to ask for the following o Validation of real illness o Explanation of symptoms in understandable terms o Reassurance that they will be fine or for a prediction of what the outcome would be .Client may accept or deny diagnosis Stage IV: Dependent Client Role . Exempted from usual task Stage 6: Concern Stage 7: Efficacy of treatment Stage 8: Selection of treatment Stage 9: Treatment Stage 10: Assessment of effectiveness of treatment Stage 11: Recovery and rehabilitation SUCHMAN’S 5 STAGES OF ILLNESS Stage I: Symptom Experience . .Clients are not held responsible for their condition .Cognitive aspect: interpretation of the symptoms .Clients are obliged to get well and resume normal activity .Person believes that something is wrong .The client is dependent on the professional for help and give up their independence .Client relinquishes role and resumes former role and responsibilities . this may require therapy to learn how to make major adjustments in functioning.Emotional response: fear or anxiety Stage II: Assumption of Sick Role .Client accepts treatment plan Stage V: recovery or Rehabilitation .

Sleep rest – describes pattern of sleep. leisure and recreation 5. Interpersonal and collaborative – depends on open and meaningful communication between client and the nurse 4.Nursing diagnosis describe a continuum of health states. members of health team FOR NURSING HISTORY USE GORDON’S TYPOLOGY OF 11 FUNCTIONAL PATTERN 1. body image. Elimination – describes pattern of excretory function (bowel.Changes from day to day as client responses change Healthy Responses MEDICAL DIAGNOSIS . 4. Secondary – relatives. Universally applicable – can be used with clients of any age at any point of the wellness – illness continuum and useful in a variety of settings 5. .Focus on identifying human responses to health and illness . Actual Potential Health Problem NURSING DIAGNOSIS .CHARACTERISTICS OF NURSING PROCESS 1. Nutritional – metabolic pattern – describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply. family or community responses to actual and potential health problems . Cognitive perceptual – describes sensory perceptual and cognitive system 6.Describe problems for which the physician directs the primary treatment . 7. Value belief – patterns of values. bladder and skin). Health perception – health management pattern – describes clients perceived pattern of health and well being and how health is managed. Cyclic and dynamic rather than static 2.Remains the same for as long as the disease is present .Describe problems treated by nurses within the scope of independent nursing practice . Coping stress tolerance – general coping pattern and effectiveness of the pattern in terms of stress tolerance. Primary – client 2.Clinical judgment about an individual. Self perception – self concept – self concept pattern and perceptions of self (body comfort.Objective (physical exam) and subjective (nursing history) SOURCES OF DATA 1. 11. Sexual reproductive – client patterns of satisfaction and dissatisfaction with sexuality: describes reproductive pattern 10. Adaptation of problem solving techniques and system theory based on the scientific method 6.Professional nurses are responsible for making nursing diagnosis. activity. beliefs (including spiritual) or goals that guide choices of decisions. 2. rest and recreation. Role relationship – describes pattern of role engagements and relationships 9. It can be viewed as parallel to but separate from the medical process ASSESSMENT . 8. Client centered – nurse organizes plan of care according to client problems rather that nursing goals 3. feeling state). Activity – exercise – describes pattern of exercise.Identifies disease . NURSING DIAGNOSIS . 3.

the length of the stage and the effects of each stage vary with the person. The pace of growth and development is asynchronous or uneven. Syndrome nursing diagnosis – comprises of a cluster of problems Format: 1 part statement (rape trauma syndrome) 6. 5. .Periods of very rapid growth rate: pre – natal. Risk nursing diagnosis – clinical judgment about a clients vulnerability to develop a problem Format: 2 part statement (diagnostic label related to risk factors) 3.The behavioral aspect of growth PRINCIPLES OF DEVELOPMENT 1 Growth and development are continuous orderly. 7.Physical change .Should be SMART. heart beat.Conclusion and supporting data . Alfaro’s rule for a collaborative problem – focus on potential complications Format: potential problem + related to + list of complications that may occur First Priority – is any threat to the vital functions of breathing.Increase in size . sequential process influenced by maturational environment and genetic factors 2.Goal partially met . client centered. Growth and development occur in cephalocaudal direction. OBJECTIVES .Increase in complexity of function and skill progression .Goal met . Possible nursing diagnosis – evidence about a certain problem is unclear and need to gather more data to support it Format: 2 part statement 4. blood pressure. Actual nursing diagnosis – judgment about a clients response to a health problem at the time of assessment and is signified by the presence of associated signs and symptoms. adolescence DEVELOPMENT . Medium Priority – health-threatening problems that may result in delayed development or cause destructive physical or emotional changes.Goal not met GROWTH . neonatal. 8. begins with generalized response and progresses to a skilled specific response. 4. statement of a single human response EVALUATION . Development occurs from simple to complex or from single acts to integrated acts. The sequence of each stage is predictable although the time of onset.6 TYPES OF NURSING DIAGNOSIS 1. Development becomes increasingly differentiated. All humans follow the same pattern of growth 3. Format: 2 part (problem related to etiology) 3 part (problem. family and community in transition from a specific level of wellness to a higher level of wellness Format: potential + desired higher level of wellness Readiness for + higher level of wellness 5. Wellness nursing diagnosis – clinical judgment about an individual. Growth and development occur in a proximal to distal direction 6. infancy. Low Priority – problems that arise from normal development needs or those that require minimal nursing support. etiology and signs and symptoms format) 2.

legalistic orientation (middle age or older adult) . .Action is taken to satisfy ones needs. . (toddler – 7 years) activity is right if one is not punished. Middle old (75 – 84) – adaptation to decline in speed of movement. Old old (85 – over) – increase physical problems.Right behavior is obeying the law and follow the rules . Level II: Conventional (Societal Focus) Stage 3 Interpersonal concordance.Standard of behavior is based on adhering laws that protect the welfare and rights of others: violating the rights of others is avoided: personal values and opinions are recognized.Universal moral principles are internalized.Activity is wrong if one is punished. 3.Action is taken to please another and gain approvals.KOHLBERG’S STAGES OF MORAL DEVELOPMENT LEVEL AND STAGE Level I: Pre Conventional (Egocentric Focus) Stage 1 Punishment and obedience orientation . nice girl (6 years thru adult years) Stage 4 Law and order orientation (adolescent – adult) Level III: Post Conventional or Principled Level (Universal Focus) Stage 5 Social contract. good boy. chronic illness may develop. Stage 6 Universal ethical principles (middles age or older adult) TYPES OF OLDER ADULT 1. person respects other humans and believes that relationship are based on mutual trust. reaction time and sensory abilities: increasing dependence in others. Stage 2 Instrumental – Relativist Orientation (4 – 12 years) . Young old (65 – 74) – adaptation to retirement and changing physical abilities. 2. .

Develop concepts necessary for everyday living .Preparing for marriage and family life .Developing adult leisure time activity .Learning to get along with age mates .Taking on civic responsibility .Getting started in an occupation . to talk.Learning to relate emotionally to parents.Selecting and preparing for an occupation .Starting a family and rearing children . siblings and others .Achieving adult civic and social responsibility .Achieving masculine/feminine social role .Achieving new and more mature relations with age mates of both sexes . sex differences and sexual modes .Assisting teenage children to become responsible and happy adults .Learning an appropriate masculine or feminine social role .Learning to form concepts of social and physical reality .Learning to distinguish right from wrong and developing a conscience .Achieving emotional independence from parents .Developing intellectual skills necessary for civic competence .Acquiring a set of values and an ethical system as a guide to behavior .Accepting ones physique and using the body effectively .Accepting and adjusting the physiologic Middle Childhood Adolescence Early Adulthood (20 – 40 yrs) Middle Age (Emptiness Stage) .Establishing and maintaining an economic standard of living .Selecting a mate .Building wholesome attitude towards oneself . writing and calculating .Achieving personal independence . to control elimination of body wastes. to taste solid foods.Finding a congenial social group .DEVELOPMENTAL TASK AND WHOLISTIC APROACH BY ROBERT HAVIGHURST AGE PERIOD Infancy and Early Childhood DEVELOPMENTAL TASK .Learning physical skills for ordinary games .Learning to live with a partner .Managing a home .Developing fundamental skills in reading.Learning to walk.

Intimate .Evaluation of care given by nurse COMMUNICATION . Ability of communicator – ability to speak. one that sends the message 4. Feedback – answer to questions. values. Receiver – decoder 6. hear. Personal space – distance people prefer in interactions with one another Four distances a. sets tone for rest of relationship . Social .Adjusting to retirement and reduced income .Best distance c.Human function that enables people to relate with each other MODES Verbal – spoken language Non-Verbal – symbols. low vocalization . Message – idea. feelings and emotions 3. visual: symbols.Testing behavior (orientation) resisting behavior (non compliance) Phase III: Working .4 feet to 12 feet .Threatening to client b.1 ½ feet to 4 feet .No face-to-face interaction with client Phase II: Introductory/Orientation .Meeting social and civic obligations .changes of middle age . whether receiver understood or not FACTORS THAT AFFECT COMMUNICATION PROCESS 1. Stimulus – reason why people communicate.Adjusting to death of a spouse .Helping relationship for growth PHASES OF NURSE – CLIENT RELATIONSHIP Phase I: Pre Interaction .Adjusting to decrease physical strength . sign language ELEMENTS OF COMMUNICATION 1. Personal .Physical contact to 1 ½ feet characterized by body contact heightened sensation of body heat and smell. Channels – kinesthetic: tactile stimulus. Sender – also known as encoder. life experiences 3.View as unique individuals . feeling) referent 2. motivation with each other (object.Discharge phase . see and comprehend stimulus 2. auditory: spoken language 5. contract setting.Establishing satisfactory living arrangements NURSE – CLIENT RELATIONSHIP .Rapport setting.Characterized by ambivalence on both nurse and client .Implementation of nursing care plans . ideas. Perceptions – each has a unique trait.Employ decision-making and technical skills and communication skills Phase IV: Termination .Less overwhelming than intimate distance .Adjusting to aging parent Late Maturity .Usual distance between nurse and client .

Time – events that precede and follow interactions 7. Used when communication is rambling or when paraphrasing is difficult Helping the client clarify an event situation or happening with respect to time Suggesting ones presence.Mass health education 4.Often misused by nurse d. communication is more effective 8. specific factual Providing general leads Being specific and tentative Using open ended questions Using touch Restating/Rephrasing Seeking clarification Clarifying time or Sequence Offering self Giving information Acknowledging Giving recognition in a non judgmental way of a. nurse should be sensitive to difference in attitude’s practice of clients self Actively listening for the client’s basic message then repeats those thoughts and/or feelings in similar words.Communication is non-formal . contribution to a communicator Helping client differentiate real from unreal Helping the client expand on and develop a topic of Presenting reality . however.. interest or wish to understand the client without making any demands that could make client comply to suggestion A simple and information direct manner.12 feet and beyond . Roles and Relationships 6. choose a topic of conversation Statements that are specific rather than general and tentative rather than absolute Specify only topic to be discussed and invite answers longer than one or two words Touch reinforces caring feelings. Territoriality – concept of space and things that an individual considers as belonging to the self 5. effort the client has made c. Environment – environment is comfortable. Attitudes THERAPEUTIC COMMUNICATION Using silence RATIONALE Accepting pauses or silences without interjecting any verbal response Using statements or questions that a.Individuality is lost . change in behavior b. encourage client to verbalize b. Public .Allows more activity and movement back and forth .

questions or content back to clients to enable them to explore their own feelings Summarizing and Planning Perception checking Stating the main points of discussion to clarify relevant parts discussed Verifies meaning of specific words than overall meaning of a message RATIONALE Offering generalized and over simplified beliefs about groups of people Akin to judgmental responses implies client is either right or wrong Attempting to protect a person Giving response that makes client prove their statement or point of view Asking information chiefly out of curiosity rather than intent Question than make a client admit something Directing communication into areas of self intent Using clichés or comforting statements of advice as a means to reassure the client Giving opinions and approving or disapproving response Telling client what to do NON THERAPEUTIC COMMUNICATION Stereotyping Agreeing and Disagreeing Being defensive Challenging Probing Testing Changing topic Unwarranted reassurance Passing judgment Giving common advice VITAL SIGNS TEMPERATURE 1.Directing ideas.6 o F . Axila .Normal value: 37 o C – 98. feelings.Most accessible and convenient .2 – 3 minutes 2.Most reliable .5 o F .3 – 5 minutes 3. Rectal .6 o F .5 – 10 minutes 4.Less accurate .Normal value: 37.Normal value: 36. Tympanic membrane .Directly reflects core temperature .Focusing Reflecting importance The focus may be an idea or a feeling.7 o C – 99.4 o C – 97. Oral .

Adult: 12 – 20 c/min . Popliteal 3. Brachial 9.Fahrenheit to Celsius = (F-32) x 5/9 .9 o F .False high systolic blood pressure. false low diastolic blood pressure . Carotid 7.False low systolic bp and diastolic bp .Normal value: 37. and maximum of 3 takes same arm and if still inaudible rest arm for 5 – 15 minutes)  Multiple examiner using different Kortkoff sounds for diastolic readings  Failure to use the same arm consistently Effects  Erroneously high readings False low systolic and false high diastolic .Celsius to Fahrenheit = (C x 9/5) + 32 PULSE SITE 1. Femoral 2.False low diastolic reading .Automatic results CONVERSION .Erroneously high readings .. Posterior tibial 4.False low reading . Apical 8.Newborn – 30 – 60 c/min ERRORS IN TAKING RESPIRATORY RATE Patient Factor  Insufficient rest before assessing  Assessing immediately after a meal or while client smokes or has pain Equipment Factor  Stethoscope fits poorly or hearing impaired  Bladder or cuff too wide  Bladder or cuff too narrow Errors in technique  Arm unsupported  Arm above heart level and not perpendicular to the body  Cuff wrapped to loosely  Deflating cuff to slowly  Deflating cuff to quick  Failure to identify auscultatory gap Auscultatory gap  Temporary cessation of sounds after initiation  Gap of 10 – 40 mmHg  Common among hypertensive  Repeating assessment too quickly (wait for 2 – 3 minutes after taking again the bp.7 o C – 99. Temporal 6.False high readings .False high diastolic reading . Dorsalis pedis 5.False high reading .Erroneously low readings . Radial  When palpating for pulse use 2 – 3 fingers except when taking the apical pulse use stethoscope  Apical pulse is in the 5th intercostals space  Landmark is the angle of Louie  4th intercostals space left mid clavicular line child apical pulse  When using the stethoscope use the flat part when looking for high pitch sounds like (lung and bowel sounds) and use the bell for vascular or heart sounds RESPIRATION .

Sound decrease in intensity when compared to Korotkoff one 4. Swooshing. thump and tapping sound 2. Inaccurate interpretation  Inconsistent measurements  For a client who’s blood pressure is to be taken for the first time. whoosing sound 3.in children record Korotkoff 1 and Korotkoff 4 HYPERTENSION Average of 2 or more diastolic reading on at least 2 subsequent visits is 90 mmHg or higher or when an average of 2 or more systolic readings on at least 2 visits is higher than 140 mmHg Optimal/ Normal Above Normal Hypertension Grade 1 (Mild) Grade 2 (Moderate) Grade 3 (Severe) SYSTOLIC 120 – 129 130 – 139 140 – 159 160 – 179 Greater than 180 Greater than 140Less 80 DIASTOLIC 80 – 84 85 – 89 90 – 99 100 – 109 Greater than 110 Less 90 . Characterized by a thud. take the blood pressure of both arms  Difference of blood pressure for both arms should only be 10 mm Hg  Use higher value as baseline PALPATORY SYSTOLIC PRESSURE  Point of pulsation stops with the use of stethoscope  Maximum pressure + 30 mmHg that is you limit when taking the blood pressure KOROTKOFF SOUNDS Phases 1. Muffling sound 5. Disappearance of sound .in adults record Korotkoff 1 and Korotkoff 5 of able to hear Korotkoff 4 record also .

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