Introduction

FUNDAMENTALS OF NUSRING
28 February 2020 / Prof. Dennis Cuadra

OUTLINE
I. Chapter 29
A. Vital signs
B. Concepts of Nursing in
the Past and Present II. Models of a Thomasian
C. Management and Nurse
leadership A. St. Elizabeth
D. Research B. St. Thomas Aquinas
E. The Personal Qualities C. St. Martin de Porres
of a Professional Nurse
F. Core Value of a
Thomasian Nurse

1. Basal metabolism
CHAPTER 29  Energy produced at rest
2. Muscular activity
A. Vital Signs  Shivering
C.A.M.T.P 3. Stimulation of thyroid gland
 Cardinal signs  Thyroxine (chemical thermogenesis)
 Are indicators of an individual’s health status 4. Stimulation of SNS
 Monitor functions of the body  EPINEPHRINE
 TPR (temperature, pulse pressure) & BP (Blood pressure)  Norepinephrine
 Pain -5th vital sign (objective) overt
1. BMR
When do we assess vital signs? Rate of energy utilization to maintain essential activities
A.C.C.P decreases with age (younger=higher BMR)
 Admission: baseline data 2. Muscle Activity
 Change in the client’s health status Shivering, Exercise, increases metabolism
 Client reports symptoms such as chest pain, feeling hot or faint 3. Thyroxine output
 Pre and post-surgery /invasive procedure Inc rate of cellular metabolism
 Pre and post medication administration that could affect CV (chemical thermogenesis
system (90/60 edema, extra fluid in lungs where you have to dive 4. Epinephrine, norepinephrine, sympathetic stimulants
a diuretic ) Inc metabolism
 Pre and post nursing intervention that could affect vital signs (ex. 5. Inc body temp (fever_
Respiration difficulty, do not feed Maslow’s hierarchy of need, Inc metabolic rate
vital signs should be in balance before pressure point
Heat is lost through
The balance between heat produced and heat lost from the body  Radiation
T.T.H.A.P Transfer of heat from one surface to another without contact
 Thermoregulation: The balance between heat lost and heat between surfaces (ex. Aircon, extra clothes, mom easily hot so outside
procedure sun, when touched maniit yung touch)
 Thermogenesis: Heat is produced through metabolism  Conduction
thermogenesis Transfer of heat from one molecule to a molecule of lower temp and
 Hypothalamus: temperature regulating center that are in contact with one another (i.e body immersed in cold waer
 Anterior hypothalamus  Convection
 s sense if body temp is beyond the set point controls Dispersion of heat air currents (ex?
heat los  vaporation
 Posterior hypothalamus Evaporation of moisture from the resp tract and from mucosa of the
 Senses if the body is lower than the set point mouth and the skin leads to insensible water loss thus leading to
 Controls heath production insensible heat loss ( tepi sponge bath, towel, open pores heat will
escape)
Kinds of body Temperature When body temp increase, vaporization accounts for greater heat loss
CORE
 Temp of deep tissues (cranium, thorax, abdominal, cavity,
pelvic cavity Factors affecting body temperature
 Taken thru rectum, tympanic membrane, esophagus, A.E.H.S.E
pulmonary artery, urinary bladder  Age diurnal variations (circadian rhythms)
 Relatively constant 37’c  Exercise
 Hormones
SURFACE  Stress
 Temp of the skin, subcutaneous tissues, fats  Environment
 Rise and fall in response to the environment
Normal temperature
Normal body: Axillary route 36.1-37.7 C
Factors affecting heat production ADULT
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 PRELIMS FUNDAMENTALS OF NURSING
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 ORAL 37 C Newborns must be kept warm to prevent hypothermia

 AXILLA 36.5C Children
 RECTAL 37.5C Ask somebody for puic

Pyrexia:convulsions
Signs of fever
 Oneset (cold or chill stage
Alternation in body temperature Cchills
1. Pyrexia, hyperthermia, fever Feels cold
 above normal (38-40 Goose flesh
 Hyperpyrexia Shivering
 Very hgigh fever 41 C and above Raise in body temp
 Hypothermia
 Subnormal core temperature  Plaeau phase (course)
Chi;;s subside
2. Hypothermia Increase RR or PR
 Below normal level of temperature Skim warm and dry
 Severe hypothermia-decrease rate of heat production Increase thrirst
where we observe sleepiness and coma further depress the Malaise, weakness aching muscles
activity of heat control mechanism s
3. Physiologic mechanisms of hypothermia Defervescence
a. Excessive heat loss  Sweating
b. Inadequate heat production to counteract heat loss  Skin appears flushed and warm
c. Impaired hypothalamic thermoregulation  Decreased shivering

Nursing care for fever

Heat stroke  Monitor vital signs
 Prolonged exposure to sun or high environmental  Assess skin color and tempo
temperatures  Monitor lab results for signs of dehydration or infection
Signs and symptoms  Remove excess blankets when the client feels warm (to
 Hot dry skin (due to hypothalamic malfunction) escape body heat and promote
 Confusion  Provide adequate nutrition and fluid (interdependednt)
 Delirium  Measure intake and output indpenednt
 Muscle cramps  Reduce physical activity independent
 Nausea  Administer antipyretic as ordered dependent
 Very high fever as 45C  Provide oral hygiene inde
 Increase heart rate  Provide a tepid sponge bath inde
 Excess thirst  Provide dry clothing and bed illness inde
 Visual disturbances 
 incontinence Nursing Care for hypothermia
 Provide warm environment
Heat exhaustion  Provide dry clothing
 Occurs when there is profuse diaphoresis resulting to  Apply warm blankets
excess water and electrolyte loss  Keeps limbs close to body
Ss & Sx  Cover the client scalp
 Diaphoresis  Supply warm oral intravenous fluid
 Hypotension  Missing one more
 Weakness
 Normal Pulse Methods
 Oral 3min 37C
Four types of fever  Rectal 2min 37.5
 Intermittent  Axillary 5min 36.5
 Alternate fever and normal temo  Tympanic 37
 Remittent
 Fluctuation more than 2C occurs over the 24 hr period C = (f-32)x5/9
but remains above normal F = (cx5/9)+32
 Relapsing
 Febrile for a few days then with 1 or 2 days normal
temperature Sits for measuring body temperatures
 Constant  Oral
 Temp fluctuation minimally but consistent above  Most frequent /convenient
normal  36.1-37.4
 Inserted at sublingual pocket (frenulum)
Resoltuion of pyrexia by crisis, flush or deferenscenese sudden return  Duration 7-10mins
to normal (38-36.5)  If still unused: wipe from bulb to stem
Resolution of pyrexia by lysis -gradual return to normal (by 2s or one  If used: wipe form stem to bulb
so gradual)  Cotton ball rotates
 rectal
 most accurate
Temperature ;lifespan cpnsiderations  36.7-37.8
Infacts  Length of insertion:infants:0.5 cild, 1inch, adult 1-
Unstable 5inches
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 Duration 2-3mins  Patterns of beats at regular intervals

 Prep:lubricate  Irregular rhythm-arrhythmia or dysrhymia
 Axillary  Dicrotic-feels double
 Least accurate but safe  Bigeminal -normal rhythm 2 beats ffd. by a pause
 35.6-36
 Duration 10mins Pulse strength volum
 Prep, wipe armpit by patting dry first forearm Force of clood witj each beat
across chest when thermometer is inserted Full/bounding pulse- forcedul blood voume that is oliterate with
 Tympanic membrane difficulty
 Readily accesible Weak.thready/feel pulse-readily obliterate withpresire
 Involves risk of injuring the membrane
 Presence of cerumen can affect the reading
 Skin/temporal artery IODHFIUWFIWHOF
 SAFE NONINVASIVE VERY FAST
 REQUIRES
Pulse defifice
Types of thermomemters Difference bet. The apical and radial pulse rates
Ecltectonic thermometer Arterial wall elasticity
Tympanic scanner Reflecys iys espamsibilty straight, smooth, soft amd pliable
Temporal scanner
Axillary scanner
Plastic strop thermometer tempaddot (oral)
Ihewjifhqio
Chemical Meauring apical pulse
Thermopacifier
Factors affecting pulse
Age gender
Waive of blood created by contraction o the left vernicle of the heart Exercise
same as ventricular contraction of the heart of a healthy man Fver
Pulse Medication
Pulse wave represent stroke volume and compliance of the arteries s Ypovolemia
Stroke volume Stess
Amount of blood enters the arteries /each ventricular contraction Position changes
Pathology
Compliance of the arteries
 Distensibility of the arteries ability of expand and contact Acts of brathing
(loss of elasticity greater pressures required to pump the Respiration
blood into the arteries
CARDIAC OUTPUT
 Vol of blood pumped into the arteries by heart every min Phase
 Stroke volume S)X HR /min 1. Inspiration or inhalation (1-1.5 sec
 65 ML AND 70 BEATS.IN +4.55l/MIN 2. Intale pf air oxygen
 HEART PUMPS 5L/min of blood for an adult who is resting 3. Types of brething
4. Coasl /thoracic
5. Involves the external intercoasl muscle and other accessory
Peripherals pulse muscle (sternomacleidomastoid muscle
Located in the periphery of the body foot and wrist Diaphragmatic/abdominal
Apical pulse Involeves the contracitona ndrekarui
Central pulse, located at the apex of the heart
Also referred as the point of apical impulse (PMI)
Rate of pulse expressed in beats per minute (BP Breathing pattern
Extern respi
Sites Internal respi
Peripheral Tidla col
a. Temporal
b. Carotid
Branchial
Radial Inhalation
Apical
a. Taken at left mcl 4th-5th ICS 1. Diagphragmatic contracts (flattens
Dorsalis pedis 2. Ribs move upward and outward
Posterior tibial 3. Sternum moves outward
Femoral
Popliteal
Processes
Ventilation
Assessment of pulse Diffusion
Rate
 Norma; -60-100min Perfusion
 Tachycardia Exhange of 02 and co2 bet. Blood and the cell of the body
 Bradycardia
Rhythm
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 PRELIMS FUNDAMENTALS OF NURSING
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Clean thermomenter if oral cotton with water bulb to stem

Respi control mechaisms Sir is it okay if I will
Respiratory centers Place thermometer sidewards
1. Medulla oblangate Sir paki bukas ung bibig kukunin ko langyung thermometer
2. Pons Wipe stem to bulb with firm twisting motion
Chemoreceptors 36.4 then take note
1. medulla Cotton then soap and water then return
2. carotid and aorticfjwgfjwjw

B. Axillary method
Fcators affecting respiratrion Sir naglakad po ba kayo ditto
Exercise increa metabolism Napawisan po ba
Stress-readies the body for fight or fgliht Pwede pahiwas ng armpit po
Environmental temperature Sir pwede patulong lang
Increase altitufe Iseseure lang natin sa gitna ng kilikili po
Sir pwede po palagay ng arm across the body
Adult:temp, pulse, respi, blood ,pressure
Componnets of repi assessment Pediatric ,, respi rate because for new borns para hindi sila madisturb
Rate: breaths per minutes and alter the findings
Deoth -normal , deep or shallow Clean :stem to bulb
Rhythem -regular or irregular 35.8
Quality -effort of pt exerts ro breathe and sound breating Record finding
Effectiveness
Resopiratory rate
Rate C. Radial pulse
Breathes per minute 12-20 breaths per min Palm facing downward
Eupnea- normal breathing in rate and depth Index and middle finger
Bradypnea-abnormmaly slow, decrease rate and below 12/min Mas easier if whole palm and apply pressure
Tachpnya/polyobea-abnormally fast and shallow rate Quality
Hyperpnea-faster and Rate 71 normal 110 tachycardia
Less than 60 brachycardia

Dyspnea-diffilcutls and labored breathing, pt feels distressed

Orthopnea
Pulse rate and respi rate 1 full minute each
More than 20 tachynapia
Less than 12 bencniptic
Depth or volume Rhythm steady
Depth shallow
Quality of chest movement -shhalow normal, deep
Hyperventilation Blood pressure palpatory
Rappid deep breathing, causing excessive o2 in lungs overepansion of Right handed use the control index and thumb
lungs At right hands
Sir angat ko lang yung damit niyo po
March 2, 2020 Fold it in a near style
Sphygmomanometer You can waer the stethoscope na
Stethoscope Look for vagus pulse on wrsit
Alcohol Then gradual release
Cotton balls +20-30
Watch with second hand
Auscultatory
Digital thermometer Close the nub 4
Oral then axillary Wear stethoscope
Proper handle of bell and diaphragm
Inbwteen index and middle finge Br
Oral Method Place bell
Bring the stethoscope 90/60
Do not wear it on the neck immediately Then hand the stethoscope on your neck
Then roll the syphmamoter
Hand washing before meeting patient Then clean bell and diaphragm with alcohol
Check thermometerif functioning
Or at least alcohol
Good morning sir I am here from 7am to 9
I will be assessing your temp, LOWER EXTREMITY
Did you do any activites before going here Flex the thigh
Breakfast Palpate the obliquical pulse
What did you eat Middle
How long ago was that
Was it hot or cold Lower
Did you drink water Dorsalis
Was it cold or hot room temp

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 PRELIMS FUNDAMENTALS OF NURSING
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Collection and analysis of data that are used in formulating

nursing diagnostics, identifying outcomes and planning
educate and development of nursing interventions
Purpose of assessment
To establish a database concerning a client’s physical,
psychological and emotional heath in order to identify health
promoting behaviors as well as actual and or potential health
problems

Types of Assessment
1. Comprehensive assessment
 Usually completed upon admission to a health care agency
and includes complete heath history to determine current
needs of clients

2. Focused assessment
 Is limited in a scope in order to focus on a particular need or
health care problem or potential health care risks
 For short stays in the OPD, ER,LR

NURSING PROCESS

MARCH 6,2020 3.Ongoing assessment

NURSING PROCESS  Includes systematic monitoring or follow up and
 A framework for providing professional quality nursing care observation related to specific problem
 Directs activities for health promotion, health protection  Nursing care of clients at home
and disease prevention Example of focused assessment
 Dynamic (questions in order to widen their answers) and  When did your contraction begin?
requires creativity for its application  How far apart are your contractions?
 When did your water break?
PURPOSE
 Provide care for clients that is individualized, holistic, Example of ongoing Assessment
effective and efficient  What ed up to your most recent hospitalization?
 Components  What meds were prescribed to you during that time?
 Assessments,  What kind of diet were you on?
 Diagnosis,  What adaptations for your comfort and acre: have you and
 outcome identification (what are the goals) your family made since you returned home?
 planning,
 implementation, Assessment
 evaluation Sources of Data
 Clients
Benefits of nursing process to the nurse  Family
 Consistent and systematic nursing education  Interdisciplinary health care professional
 Jobs satisfaction  Medical records
 Professional growth  Interdisciplinary conference
 Avoidance of legal action  Results of diagnostic tests
 Meeting professional nursing standard  Relevant literature
 Meeting standard of accredited hospital
Step in assessment
Characteristics Of The Nursing Process  Collection of data from variety of sources
 Problem oriented comparable with problem solving  Validation of data
approach  Organizing data
 Goal-oriented  Categorizing or identify patterns of data
 Orderly, planned, step by step (systematic) =independent,  Making influences or impressions (if patient says she feeks
dependent , how do you want to relive the pain you would this way, base sa assessment , state significant findings-
give patient comfortable  Recording/reporting data
 Open to accepting new information during its application
 Interpersonal-requires that the nurses and clients devise
ways to solve health problems Critical thinking
 Cyclical -steps may overlap because they’re interrelated  Used in determining the significance of data collected
 Universal -its applicable to individuals’ families and  Distinguish between relevant and irrelevant
community  Determining if and when there are gaps in the data
 Identify patterns of cause and effect
Benefits of the nursing process to clients
 Quality patient care Data Collection
 Continuity of care (rounds to patients)  Interview
 Participation by the clients in the health care (if patient  Observation: use of senses, PE, lab results
cannot tolerate maybe she or him can suggest)  Validating: accuracy
 Organizing- clustering of facts
Assessment
Goal of Assessment
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 PRELIMS FUNDAMENTALS OF NURSING
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 The nurse possesses strong cognitive, interpersonal and  Promote client comfort
technical skills in order to elicit appropriate information and
make relevant observations
Working phase
Two type of information Focuses on the details of data collection
Subjective data Assessment interview
 Data from client point of view and include feelings Structured formall ise din situations when a large amt of info needs to
perception and concerns, because they rely on the feelings be obtauined
or opinions of the person experiencing them and can’t be Unstructured or informal ed used in innteractio that focus on apsecif
readily observed by another care of concern to the client
Objective data
 Are observable and measurable data that ae obtained Closed questions
through assessment techniques performed during physical Questions that can be answred briefly orwith one word response
exam, laboratory and diagnostic testing. These data can be Open-edned questions
seen heard or felt by someone other than the person Question d
experiencing them question

Closure
Nurse should indicate that infor ha sbeen obtained and time foe
interview is almost over
Callow slcient to rpesnet any othe rrelvant info
Subjective data vs objective data Nurse summarize what was covered and accomplished

Subjective data Helath jistory

 Reporting of faintness A revie of yje client functional helath staus /patterns pripr to current
 Complaint of dizziness contact
 Nausea
 Verbalization of self-reported fall

Objective data Health history

 Vomiting 3. reason of seeking health care
 Unsteady gait 4. perception of health stautsu
 Pale skin
 Bruises on RT. Side of face and rt arm .

Methods of data collection 8. current medication

 Observation 9,. Development level
 Interview 10.
 Health history
 Symptoms analysis Health jistory
 Physical exam and laboratory and diagnostic Review of systmpotome
Location :area pf the body
Observation Chacter: quality of the feeling
 carefully and attentively note the general appearance and Intensity
behaviors of client Tiing
 Client mood, interaction with others, physical and
emotional responses and safety consideration
 Determing client status both physical and mental Assessment techniques of IPPA
 Can detect non-verbal clues that indicate variety of Inspection
feelings Involves visual observation
Client observation first dofrm general point of biew hen the specific
Interviews attention to details
 a therapeutic interaction that has a special purpose Palpation
 Collect info about client health history and currents status Uses the snes of touch assess texture, temerpaturem moisture, organ
to determine client’s health needs location ad size vibrations and palpation tender areas performed last

 Interview preparation Data verification

 Review client’s medical needs The process through which dta are validate as being complete and
 Conservations with other health care members accurate reviewed for inconsistencsiess and omission
 Research of presenting medical diagnosis Examine a the concurrence bet, sub, and objective dta a
 Interview stages/phases
 Orientation phase/intro: establishes goals for interactions
 Introduction are made rapport is established and roles are Data organization
defined After data collection is complete and information is validated the
(data clustering ) nurse organizes or clusters the information together
Preparing the interview environment inn order to identy areas of strength and weakness
 Adequate lighting Data clustering facilitates recognition of patterns and determination
 Maintain a comfortable room temperature of further data that are needed
 Environment free from noise and distractions
 Maintain client privacy Dta interpretation
 Interview is timed appropriately
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 PRELIMS FUNDAMENTALS OF NURSING
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Dat avclustein fadcilates recognaiton of pattern and determination of o Communication

further data that are needed o Legal documentation
Is necessary for identification of nursing diagnosis o Financial bilng/reimbursement
Data documnetaiton o Reserahch
Accurate and complete recordign of assessment data are essential fpr o Statistics
coomuncation inormatio to other health care tram members o Education
Documentation is also the bais for dtermination quality of care should o Audit and quality assurance e
include o Palnning client care

Nursing diagnosis Page 24 pUPOSES -

Is the clinical jud

Quizies  Guidelines for quality Documentation

Identifu
PRS OR PES in 1. Factual

Ask pics from o −  Contains descriptive, objective information

Manjo about what a nurse observes, hears, palpates,
Angela and smells
Dianne o −  Avoid vague terms ie. Seems, appears,
apparently

2. Accurate

Comunicating with clients with special needs

Physical impairment
− Use of exact measurements 3. Complete
 Difficulty in Speaking
 Listen attentively be patient, don’t interrupt o −  Complete and contains appropriate and
 Ask questions answerable but yes or no essential information
 Use visual cues
4. Current
 Difficulty in hearing
 Check for hearing aids
 Reduce environmental stimuli o −  Timely entries are essential in a patient’s
 Face client with mouth visible ongoing care
 Do not chew gum o −  12-hour cycles vs Military time 5.
 Do not shout Organized
 Rephrase rather than repeat if understood
− Information entered facilitates communication when
 Difficulty is seeing made in a logical order
 Check for use of glasses and contact lenses
 Identity self when entering room
 Do not rely on nonverbal communication to convey
messages
 Use indirect lighting
 Use at least 14-point print

 Cognitive impairment
 Reduce environmental distractions
 Get clients attention before speaking
 Use simple sentences avoid long explanation
 Ask one question at a time
 Allow time to respond
 Be attentive
 Include family and friends in conversation

 Unresponsive
 Call client by name
 Communicate both verbally and touch
 Explain all procedure and sensations
 Provide orientation
 Avoid talking about client to others in his or her presence

Aggressive

Documentation
 Serves as a permanent record of client info and care
 Purposes
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