FUNDAMENTALS OF NURSING

JESSIE DACLIS, RN, USRN, MBAc

 TYPES OF NSG INTERVENTION

1. INDEPENDENT

2. DEPENDENT

3. INTERDEPENDENT
 Nursing Care Delivery Systems

• Functional
• Total Patient Care
• Team Nursing
• Primary Nursing
• Case Management
PATRICIA BENNER
LEAVELL
Vital Signs Table
Temperature Conversion
Diurnal Variations (circadian Rhythm)
 TYPES OF FEVER

1. Intermittent Fever
2. Relapsing
3. Constant
4. Remittent
What happens to the BP if there is
Hyperthermia?
 Management for Hypothermia
• Warm Environment
• Dry Clothing
• Warm Blankets
• Limbs close to body
• Cover scalp with cap or turban
• Warm oral or IV fluids
• Warming Pads
Hyperthermia Blanket
Heart
Important Pulse Sites
 Pulse Amplitude
0
1 faint but detectable
2 slightly more diminished than normal
3 normal
4 bounding
 Respirations
• Rate
• Volume
• Rhythm
• Breath Sounds (Normal and Adventitious)
 Normal Breath sounds
• Vesicular Breath Sounds
• Bronchial Breath sounds
• Bronchovesicular breath sounds..
 Adventitious sounds
1. Stridor
2. Wheezing
3. Rhonchi
4. Crackles/Rales
5. Pleural Friction Rub
 Chest Movements
• Intercostal retractions
• Substernal retraction
• Suprasternal retraction
 Assessing Blood Pressure
Ensure that client is rested.
OAllow to pass if the client have smoked or
ingested caffeine before taking BP.
O Use appropriate size of BP cuff.
• O Position the pt in supine or sitting position.
• O Position the arm at the level of the heart, with the
palm of the hand facing up.
• O Apply BP cuff snugly, _ above the antecubital space.
• O Inflate and deflate BP cuff slowly, at a time.
• O Wait before making further determinations.
Pulse Oximeter
• Finger probe, toe,ear probe,

• Normal reading is 95% above..if 94% below: assume

hypoxia.
• If below 90% seriously hypoxic.

• Check ABCDE from patient

• Airway
• Breathing
• Circulation
• Drugs (opioids, sedatives,muscle relaxant)
• Equipment
Pulse oximeter
 What is the normal Pulse oximeter
reading during anesthesia?
A. 85 - 89%
B. 90 - 94%
C. 95 - 99%
D. 100%
 5 factors that can affect reading
• • Nail varnish or pigment on finger
• • Bright light on the probe
• • Patient movement
• • Poor perfusion
• • Carbon monoxide poisoning
 QnA
The client’s temperature at 8am using an oral
electornic thermometer is 36.1 degree C (97.2 F). If
the respiration, pulse and blood pressure were
within normal range. What would the nurse do
next?
A. Wait 15 minutes and retake it
B. Check what the client’s temperature was the last
time it was taken.
C. Retake it using a different thermometer
D. Chart the temperature; it is normal
 QnA
When the nurse enters a client’s room to measure
routine vital signs, the client is on the phone. What
technique should the nurse use to determine the
respiratory rate?
A. Count the respirations during conversational
pauses.
B. Ask the client to end the phone call now and
resume it at a later time.
C. Wait at the client’s bedside until the phone call is
completed and then count repsirations.
D. Since there is no evidence of distress or urgency,
postpone the measurement until later.
 QnA

For a client with a previous blood pressureof

138/74 mmHg and a pulse of 64bpm,
approximately how long should the nurse take
to release the blood pressure cuff in order to
obtain an accurate reading?
A. 10-20 seconds
B. 30-45 seconds
C. 1-1.5 minutes
D. 3-3.5 mnutes
An 85 year old client has had a stroke resulting
in right sided facial drooping, difficulty
swallowing and the inability to move self or
maintain position unaided. The nurse
determines that which site are most
appropriate for taking the temperature? SATA
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal Artery
When auscultating the blood pressure, the nurse
hears: From 200 to 180 mmhg: silence; then a
thumping sound continuing down to 150
mmHg;muffled sounds continuing down to
130 mmHg; soft thumping sounds continuing
down to 105 mmHg; muffled sounds
continuing down to 95mmHg; then silence.
The nurse recods the blood pressure as :
 E. PAIN
- A sensation of physical or mental hurt or
suffering that causes distress or agony to
the one experiencing it
CLASSIFICATION OF PAIN
A. TYPES:
2. CUTANEOUS
3. SOMATIC
4. VISCERAL
5. REFERRED
6. INTRACTABLE
7. PHANTOM
8. RADIATING
 CHARACTERISTICS OF
PAIN
B. LOCATION

C. DURATION

D. QUALITY

E. INTENSITY

F. FACTORS

E. EFFECT ON ADL
Sleep
 4 techniques in PE
• I
• P
• P
• A
• Standard: IPPA
• Abdomen: IAPEPA

• Palpation:
A.Light – 1 – 2 cm
B.Deep – 4 – 5 cm
>> bimanual palpation
>> one hand while the other hand supports.
• In Percussion, we can elicit 5 sounds:
• Flatness – extremely dull sound by very dense tissue such as
muscle or bone.
• Dullness – thudlike(nahulug na bagay sa sahig)sound produced by
dense tissue. Liver, speen, heart
• Resonance – hollow sound produced by lungs filled with air.
• Hyperresonance – not normal; booming sound hear over
emphysematous lung
• Tympany – musical or drumlike sound from air filled stomach.

• Flatness reflects the most dense tissue while tympany is the least
dense tissue.
 Hair, Scalp, Eyes, Ears

• PERRLA
• Normal pupil
• Shape:
• Direct response –
• Consensual
• Accomodation
 Ears

• Rinne test Weber’s test

Romberg’s test
• Using 512Hz tuning fork.
• Rinne test – test air conduction.
• Held perpendicular to external ear.
• Webers test
- Place the base of the tuning fork in the
midline.
- -
 Eyes

• visual acuity - snellens chart

• visual field - glaucoma, macular degeneration.
Snellen’s chart
 visual acuity testing
• hold newspaper or magazine 14 inches away
and ask patient to read.

• Rosenbaum eye chart- test near vision. it

consists of paragraphs of text or characters in
different sizes.

•
Ishihara test or Hardy Rand Rittler test

• color vision testing.

Amslet Grid
Ears
Chest
 GI Assessment

• Bowel sounds
• 5 to 30 sounds/minute.
BSE
Pap smear
Diagnostic Examination
URINE
 URINE

B. BENEDICT'S TEST

C. HEAT AND ACETIC ACID TEST

 STOOL

A. ROUTINE FECALYSIS

B. CULTURE AND SENSITIVITY

C. FECAL OCCULT BLOOD TEST

 SPUTUM
A. GROSS APPEARANCE

B. CULTURE AND SENSITIVITY

C. CYTOLOGY

D. ACID FAST BACILLUS

 BLOOD

A. WITH FASTING

B. WITHOUT FASTING
FOOD PYRAMID
 Progressive Diet
• Clear Liquid Diet
• Full Liquid Diet
• Soft Diet
• Osterized Feeding
• Full Diet
• Low Residue Diet
• DASH diet
 DIET
¾ Acid Ash
¾ Alkaline Ash
¾ Bland
¾ Brat
¾ Clear liquid
¾ Diabetic
¾ Giordano
¾ Gluten Free
¾ Yin
 DIET
¾ Halal
¾ High Fiber
¾ Kosher
¾ Purine Restricted
¾ Sodium Restricted
¾ Soft
¾ Tyramine Free
¾ Vegan
• Which is a normal finding on auscultation of
the lungs?
• A. tympany over the right upper lobe.
• B. Resonance over the left upper lobe.
• C. hyperresonance over the left lower lobe
• D. dullness above the left 10th intercostal
space.
• After auscultating the abdomen, the nurse
should report which finding to the primary car
provider?
• A. bruit over the aorta
• B. absence of bowel sounds for 60 seconds.
• C. continuous bowel sounds over the ileocecal
valve.
• D. a completely irregular pattern of bowel
sounds.
• If unable to locate the client’s poplitela pulse
during a routine examination. what should
the nurse do next?
• A. check for pedal pulse
• B. check for femoral pulse
• C. take the client’s blood prssure on the thigh
• D. ask another nurse to try to locate the pulse.
 ELIMINATION

• Urine and Bowel

• Normal Urine: 60-80ml/hr
• Normal Bowel: no >3X/day -3x/week

• PROBLEM: Urinary or Fecal incontinence

• For urinary incontinence: IMPORTANT
“KEGEL’s EXERCISE”
Catheterization
OSTOMY
 OXYGEN DEVICES AND SYSTEMS

A. Low-flow Administration

1. Nasal canula
2. Simple face mask
3. Partial Rebreathing mask
4. Non-breathing mask
5. Oxygen tent
B. High-flow Administration

1. Venturi mask
2. Face mask
3. Oxygen hood
4. Incubator
 FECAL ELIMINATION

Normal Characteristic of Stool:

A. Color
B. Odor
C. Consistency

¾ ACHOLIC STOOL
¾ HEMATOCHEZIA
¾ MELENA
¾ STEATORRHEA
FECAL ELIMINATION PROBLEMS

A. DIARRHEA

B. CONSTIPATION

C. FECAL IMPACTION

D. FLATULENCE
 ADMINISTERING ENEMAS
A. CLEANSING ENEMA
¾ High Enema
¾ Low-flow Enema

B. CARMINATIVE ENEMA

C. RETENTION ENEMA

D. RETURN FLOW ENEMA

E. NON RETENTION ENEMA

 URINE ELIMINATION

Normal Characteristic of Urine:

A. Color
B. Odor
C. PH
D. Specific gravity
ALTERATIONS IN URINE COMPOSITION

A. HEMATURIA

B. BACTERIURIA

C. ALBUMINURIA / PROTEINURIA

D. GLYCOSURIA / KETONURIA
ALTERED URINE PRODUCTION

A. POLYURIA

A. OLIGURIA

A. ANURIA
 ALTERED URINARY ELIMINATION

A. FREQUENCY

B. NOCTURIA

C. URGENCY

D. DYSURIA

E. ENURESIS

F. INCONTINENCE
INCENTIVE SPIROMETER
TRACHEOSTOMY
CHEST TUBE
 MECHANICAL AIDS

• 1. Crutches

• 2. Cane

• 3. Walker
SUCTIONING
Pressure of Suction
Portable Unit:
Infant: 2 -5 mmHg
Child: 5-10 mmHg
Adult: 10-15 mmHg

Wall unit:
Infant: 50-95
Child: 95-110
Adult: 100-120 mmHg