Introduction to Nursing Theory

 Theory – organized system of accepted knowledge that is composed of concepts,

propositions, definitions and assumptions intended to explain a set of fact, event or
phenomena
 Concept – defined as an idea formulated by the mind or an experience perceived and
observed (e.g. justice, love, war, and disease).
 Proposition – explains relationships of different concepts.
 Definition – composed of various descriptions which convey a general meaning and
reduces the vagueness in understanding a set of concepts.
 Assumption – a statement that specifies the relationship or connection of factual concepts
or phenomena.

Concepts

Proposition
Theor y
Systematica lly Organized
VIEW PHENOMEN
Assumption
A
Definitions
 Nursing Theory – group of interrelated concepts that are developed from various studies
of disciplines and related experiences. This aims to view the essence of nursing care

Components of a Theory (Barnum 1994)

 Context – resembles the environment to which nursing act takes place
 Content – subject of the theory
 Process – method by which nurse acts in using nursing theory

Definition of Nursing

 ANA – “Nursing is the diagnosis and treatment of human responses to actual or

potential health problems.”
 International Council of Nurses (ICN) – “Nursing encompasses autonomous and
collaborative care of individuals of all ages, families, groups and communities, sick or
well and in all settings. Nursing includes the promotion of health, prevention of illness,
and the care of ill, disabled and dying people. Advocacy, promotion of a safe
environment, research, participation in shaping health policy and in patient and health
system management and education are also key nursing roles.”
 Henderson – “To assist in the performance of activities, contributing to health, its
recovery or peaceful death that clients will perform unaided, if they had the necessary
will, strength or knowledge.”
 ADPCN – “Nursing is a dynamic discipline. It is an art and a science of caring for
individuals, families, group, and communities geared toward promotion and restoration
of health, prevention of illness, alleviation of suffering and assisting clients to face
death with dignity and peace. It is focused on assisting the client as he or she responds
to health-illness situations, utilizing the nursing process and guided by ethico-legal
moral principles.

Nursing Paradigms – Patterns or models used to show a clear relationship among the
existing theoretical works in nursing.
 Person – The recipient of nursing care like individuals, families and communities.
  Environment – The external and internal aspects of life that influence the person
 Health – The holistic level of wellness that the person experiences.
 Nursing – The interventions of the nurse rendering care in support of, or
in cooperation with the client.

Different types of theories

 Descriptive/Factor-Isolating Theories – To know the properties and workings of
a discipline
 Explanatory/ Factor-Relating Theories – to examine how properties relate and thus affect
the discipline
 Predictive/Situation-Relating Theories – To calculate the relationships between
properties and how they occur
 Prescriptive/Situation Producing Theories – To identify under which conditions
relationships occur

Concepts – Building blocks of theory

 Abstract concepts – indirectly observed or intangible. It is independent of time and place.
 Concrete concepts – directly observed or tangible

Theoretical models or frameworks – Highly established set of concepts that are testable.
Conceptual models or frameworks – Representations of an idea or body of knowledge based
on the own understanding or perception of a person or researcher on a certain topic, phenomena
or theory.

Steps in Scientific Method:

1. Observation
2. Gathering Information/Data
3. Forming Hypothesis
4. Experimental Investigation
5. Conclusion or Theoretical Explanation

Phenomenon – Can be defined as sets of empirical data or experience that can be physically
observed or tangible such as crying or grimacing when in pain.

Deduction – From specific concepts to general conclusion

Induction – From general conclusion to specific details
 Florence Nightingale (Environmental Theory)

- Born on May 12, 1820

- “The Lady with the Lamp”
- Notes on Nursing – provides essential principles for rendering and implementing an
efficient and effective nursing care.
- Nurses should perform tasks to and for the patient as well as control the patient’s
environment to facilitate easy recovery
- Health is being well and using every power that a person has to the fullest extent
- Nurse it the one in control of patient’s environment

Nightingale’s Environmental Theory

Nightingale’s Canons Nursing Process and Thought

Ventilation and warmth - Check patient’s body temp, room temp,
ventilation and foul odors
- Create a plan to keep the room well-
ventilated and free of odor while
maintaining the patient’s body temp
Light - Check room for adequate light.
Sunlight is beneficial to the patient
- Create and implement adequate light in
the room without placing the patient in
direct light
Cleanliness - Check room for dust, dampness and
dirt
- Keep room free from dust, dirt and
dampness
Health of Houses - Check surrounding environment for
fresh air, pure water, drainage,
cleanliness and light.
Noise - Check noise level in the room and
surroundings
- Attempt to keep noise level in
minimum
Bed and Bedding - Check bed and bedding for dampness,
wrinkles and soiling

Personal Cleanliness
Variety
Chattering hopes and advices
Taking Food
Petty Management
Observation of the Sick
- Keep the bed dry, wrinkle-free and
lowest height to ensure comfort
- Attempt to keep the patient dry and
clean at all times
- Frequent assessment of the patient’s
skin is essential to maintain good skin
integrity
- Attempt to accomplish variety in the
room and with the client
- This is done with cards, flowers,
pictures and books. Also encourage
friends or relatives to engage in
stimulating activities
- Avoid talking without giving advice
that is without a fact
- Respect the patient as a person and
avoid personal talk
- Check the diet of the patient. Note the
amount of food and fluid ingested by
the patient at every meal
- This ensures continuity of care
- Document the plan of care and evaluate
the outcomes to ensure continuity
- Observe and record anything about the
patient
- Continue observation in the patient’s
environment and make changes in the
plan of care if needed
 Hildegard Peplau (Interpersonal Relations Theory)

 Psychiatric Nurse of the Century

 Born on September 1, 1901
 A man is an organism that lives in an unstable balance of a given system
 Health symbolizes movement of the personality and other ongoing human
processes that directs the person towards creative, constructive, productive and
community living.
 Nursing is a significant, therapeutic interpersonal process

Phases of Nurse-Patient Relationship

1. Orientation  The initial interaction between the

nurse and the patient wherein the
latter has a felt need and expresses
the desire for professional
assistance. The nurse assists the
patient in recognizing and
understanding the patient
experience

2. Identification  The patient and the nurse explore

the experience and the needs of the
patient which leads to a feeling of
relatedness

3. Exploitation  The patient derives the full value of

the relationship as he moves on
from a dependent role to and
independent one
 Power is shifted to the patient

4. Resolution  The patient earns independence

over his care as he gradually puts
aside old goals.

Roles of Nurses in the Nurse-Patient Relationship:

1. Stranger – Initial contact, the nurse and patient are strangers to each one another.
This role coincides with Identification Phase
2. Resource Person – The nurse provides specific answers to his queries which include
health information, advices, and a simple explanation of the healthcare team’s course
of care
3. Teacher- The nurse assumes a teaching role as she gives much importance for self-
care and in helping him understand the therapeutic plan.
4. Leader – The nurse acts as a leader in behalf of the patient’s best interest and at the
same time enable him to make decisions over his own care. This is achieved through
cooperation and active participation.
5. Surrogate – The patient’s dependency for his care give the nurse a surrogate role.
The nurse must assist the patient to make sure that her surrogate role is different and
only temporary.
 6. Counselor – Has the greatest importance and emphasis in nursing. This role
strengthens the nurse-patient relationship as the nurse becomes a listening friend, an
understanding family member, and someone who gives sound and emphatic advises.

Virginia Henderson (14 Human Basic Needs)

- First Lady of Nursing

- First Truly International Nurse
- Referred a person as patient
- Person is an individual who requires assistance to achieve health and independence or in
some cases, a peaceful death.
- Mind and body of a person is inseparable
- Health is a quality of life and is very basic for a person to function fully
- Health requires independence and interdependence
- Health promotion is more important than care of the sick
- Nurse function independently from the physician
- Special role of a nurse is to help both sick and well individuals
- Emphasized the need to view the patient and his family as a single unit

14 Basic Needs
1. Breathing Normally
2. Eating and Drinking adequately
3. Eliminating body wastes
4. Moving and maintaining a desirable position
5. Sleeping and Resting
6. Selecting suitable clothes
7. Maintaining normal body temperature by adjusting clothing and modifying the
environment
8. Keeping the body clean and well groomed to promote integument
9. Avoiding dangers in the environment and avoiding injuring others
10. Communicating with others in expressing emotions, needs, fears, or opinions
11. Worshipping according to one’s faith
12. Working in such a way that one feels a sense of accomplishment
13. Playing or participating in various forms of recreating
14. Learning, discovering or satisfying the curiosity that leads to normal development and
health, and using available health facilities.

Joyce Travelbee
(Human-to-Human Relationship Model)

- Person is defined as a human being, who is unique, irreplaceable individual who is in the
continuous process of becoming, evolving, and changing.
- Health is measured by subjective and objective health
- Nursing is an interpersonal process

Human-to-Human Relationship Model

1. Original Encounter – First impression by the nurse of the sick person and vice-versa.
The nurse and patient see each other in stereotyped or traditional roles.
 2. Emerging Identities – This phase is described by the nurse and patient perceiving each
other as unique individuals.
3. Empathy – This phase is described as the ability to share in the person’s experience.
4. Sympathy – This happens when the nurse wants to lessen the cause of the patient’s
suffering.
5. Rapport – Described as nursing interventions that lessens the patient’s suffering.

Betty Neuman (System Model)

- Main role of a nurse is to help a person adapt to environmental stimuli causing illnesses back
to a state of wellness.
- Nursing requires holistic approach, and approach that considers all factors affecting health.
- A person is an open system that works together with other parts of its body as it interacts
with the environment.
- Health is dynamic in nature.
- Environment can be an internal, external and created force that interacts with a person’s state
of health.
- Stressors are tensions that produce alterations in the normal flow of the environment.

Stressors:
- Intrapersonal – occurs within the self ad comprises of man as a psychospiritual being
- Interpersonal – occurs between one or more individual and consists of man as a social
being

Lines of Resistance
- Lines of resistance act when the Normal Line of Defense is invaded by too much stressor,
producing alterations in the client’s health. It acts to facilitate coping to overcome the
stressors that are present within the individual.

Normal Line of Defense

- This must act in coordination with the normal wellness sate. It must reflect the actual range
of responses that is normally acted by client in response to any stressors

Flexible Line of Defense

- Flexible Line of defense serves as a boundary for the Normal Line of Defense to adjust to
the situations that threaten the imbalance within the client’s stability.

Reaction
- Outcomes or produced results of certain stressors and actions of the lines resistance of a
client. It can be positive or negative depending on the degree of reaction the client produces
to adjust and adapt with the situation.
➢ Negentropy – towards stability and wellness
➢ Egentropy – disorganization of the system producing illness.

Dorothy Johnson (Behavioral System Model)

- A person has 2 major systems: the biological system and the behavioral system
- The focus of medicine is in the biological system, while nursing is to behavioral system
- Health is an elusive state that is affected by social, psychological, biological, and
physiological factors
- An individual’s behavior is influenced by all the events in the environment
- The primary goal of nursing is to cultivate the equilibrium within the individual, which
allows for the practice of nursing with individuals at any point in the health-illness
continuum.

Behavioral System Model

7 Behavioral Subsystems:
 The Attachment or Affiliative Subsystem – well-known as the earliest response system
to expand in the individual.
 The Dependency Subsystem – is distinguished from the attachment or affiliative
subsystem. Dependency behaviors are actions that trigger nurturing behaviors from other
individuals in the environment.
 The Ingestive Subsystem – relates to the behaviors surrounding the ingestion of food. It
is associated with biological system.
  Eliminative Subsystem – relates to behaviors surrounding the secretion of waste
products from the body.
 Sexual Subsystem – imitates behaviors related to procreation or reproduction.
 Aggressive Subsystem – relates to behaviors concerned with defense and self-
preservation.
 Achievement Subsystem – contains behaviors that attempt to control the environment.

Imogene King (Goal Attainment Theory)

- A person exists in an open system as a spiritual being and rational thinker who makes
choices, selects alternative courses of action, and has the ability to record their history
through their own language and symbols, unique, holistic and have different needs, wants
and goals.
- Health is the ability of a person to adjust to the stressors that the internal and external
environment exposes to the client.
- Environment is the process of balance involving internal and external interactions inside the
social system.
- Nursing is when the nurse interacts and communicates with the client

Interacting Systems Framework

- Personal – how the nurse views and integrates self based from personal goals and beliefs
- Interpersonal – how the nurse interrelates with a co-worker or patient, particularly in the
Nurse-Patient relationship
- Social – How the nurse interacts with co-workers, superiors, subordinates and the client
environment in general.

Goal Attainment Theory

- Action – means of behavior or activities that are towards the accomplishment of a certain
act.
- Reaction – Is a form of reacting or a response to certain stimuli
- Interaction – Any situation wherein the nurse relates and deals with a clientele or patient
- Open system – absence of boundary existence, where a dynamic interaction between the
internal and external environment can exchange information without barriers or hindrances.
 Dorothea Orem (Self-Care Deficit Theory)

- Human beings are very much different from other living things in terms of their capacity.
- Supports the WHO definition of health as the state of physical, mental, and social well-being
and not merely the absence of disease or infirmity.
- Environment is an external source of influence in the internal interaction of a person’s
different aspects
- Nursing is helping clients to establish or identify ways to perform self-care activities.
Self-Care – is an activity that promotes a person’s well-being. It is performed by persons who
are aware of the time frames on behalf of maintaining life, continuing personal development and
healthy functional living.
Self-Care Requisites – are insights of actions or requirements that a person must be able to meet
and perform in order to achieve well being.
Universal Self-Care Requisites – There are universally se goals that must be undertaken in
order for an individual to function in scope of a healthy living.
Developmental Self-Care Requisites
- Provision of conditions that promote development
- Engagement in self-development
- Prevention of the effects of human conditions that threatens life
Health Deviation Requisites – are required for a person to be considered as sick or ill. Disease
affects the structures within the integral part of a person and its functioning.
Therapeutic Self-Care Demand – These are summation of all activities needed to alleviate the
existing disease or illness. Controlling or managing the factors will result to appropriate care of
plan.
Self-Care Agency – These are complex set of activities required to purposively regulate the
actions needed for planning a care plan for a client.
Agent – An agent is the individual who is engage in meeting the needs of a person.
Dependent Care Agent – These are individuals who takes full responsibility of taking care of a
person who are incapable of providing care for themselves or those who are living dependently
with others aid
Nursing Agency – Set of established capabilities of a nurse who can legitimately perform
activities of care for a client.
Nursing Design – These are professional functions that must be performed by the nurse in order
to meet clients need. It serves as a guideline of needed and foreseen results.

Faye Glenn Abdellah (21 Nursing Problems)

- Individuals are beneficiaries of care

- Health is the center and purpose of nursing services
- Core of nursing is the individual
- Nursing is an all-inclusive service that is based on the disciplines of art and science that
serves individuals, sick or well, copes with their health needs.

21 Nursing Problems
- Overt- obvious or can be seen
- Covert – unseen or masked one

1. To promote good hygiene and physical comfort

2. To promote optimal activity, exercise, rest, and sleep
3. To promote safety through prevention of accidents, injury, or other trauma and
through the prevention of the spread of infection
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic responses of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional,
and developmental needs
 19. To accept the optimum possible goals in light of physical and emotional
limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of
illness

Sister Callista Roy (Adaptation Model)

- A person is a biopsychosocial being in constant interaction with a changing environment.

The person is an open, adaptive system who uses coping skills to deal with stressors.
- Environments are conditions, circumstances and influence that surround and affect
the development and behavior of the person.
- Health is the process of being and becoming an integrated and whole person.
- Nursing is the science and practice that expands adaptive abilities and enhances person and
environment transformation.

Adaptation
Adaptation is the “process and outcome whereby thinking and feeling persons as individuals or
in groups use conscious awareness and choice to create human and environmental integration.”

Internal Processes

Regulator
The regulator subsystem is a person’s physiological coping mechanism. It’s the body’s attempt
to adapt via regulation of our bodily processes, including neurochemical, and endocrine systems.

Cognator
The cognator subsystem is a person’s mental coping mechanism. A person uses his brain to cope
via self-concept, interdependence, and role function adaptive modes.

Four Adaptive Modes

The four adaptive modes of the subsystem are how the regulator and cognator mechanisms are
manifested; in other words, they are the external expressions of the above and internal processes.

Physiological-Physical Mode
Physical and chemical processes involved in the function and activities of living organisms.
These are the actual processes put in motion by the regulator subsystem.

The basic need of this mode is composed of the needs associated with oxygenation, nutrition,
elimination, activity and rest, and protection. The complex processes of this mode are associated
with the senses, fluid and electrolytes, neurologic function, and endocrine function.
Self-Concept Group Identity Mode
In this mode, the goal of coping is to have a sense of unity, meaning the purposefulness in the
universe, as well as a sense of identity integrity. This includes body image and self-ideals.

Role Function Mode

This mode focuses on the primary, secondary and tertiary roles that a person occupies in society,
and knowing where he or she stands as a member of society.

Interdependence Mode
This mode focuses on attaining relational integrity through the giving and receiving of love,
respect and value. This is achieved with effective communication and relations.

Levels of Adaptation
Integrated Process
The various modes and subsystems meet the needs of the environment. These are usually stable
processes (e.g., breathing, spiritual realization, successful relationship).

Compensatory Process
The cognator and regulator are challenged by the needs of the environment, but are working to
meet the needs (e.g., grief, starting with a new job, compensatory breathing).

Compromised Process
The modes and subsystems are not adequately meeting the environmental challenge (e.g.,
hypoxia, unresolved loss, abusive relationships).

Six-Step Nursing Process

A nurse’s role in the Adaptation Model is to manipulate stimuli by removing, decreasing,
increasing or altering stimuli so that the patient
 Madeleine Leininger (Transcultural Theory in Nursing)

- Creator of the Transcultural Subfield of Nursing

- Humans are caring and capable of being concerned about the desires, welfare, and continued
existence of others.
- Environment is the totality of an event, situation, or particular experience that gives meaning
to human expressions, interpretations, and social interactions in particular physical,
ecological, sociopolitical and/or cultural settings.
- Transcultural nursing is defined as a learned subfield or branch of nursing which focuses
upon the comparative study and analysis of cultures with respect to nursing and health-
illness caring practices, beliefs, and values with the goal to provide meaningful and
efficacious nursing care services to people according to their cultural values and health-
illness context.
- Ethnonursing is the study of nursing care beliefs, values, and practices as cognitively
perceived and known by a designated culture through their direct experience, beliefs, and
value system (Leininger, 1979).
- Nursing is defined as a learned humanistic and scientific profession and discipline which is
focused on human care phenomena and activities in order to assist, support, facilitate, or
enable individuals or groups to maintain or regain their well-being (or health) in culturally
meaningful and beneficial ways, or to help people face handicaps or death.
- Professional nursing care (caring) is defined as formal and cognitively learned professional
care knowledge and practice skills obtained through educational institutions that are used to
provide assistive, supportive, enabling, or facilitative acts to or for another individual or
group in order to improve a human health condition (or well-being), disability, lifeway, or to
work with dying clients.
- Cultural congruent (nursing) care is defined as those cognitively based assistive, supportive,
facilitative, or enabling acts or decisions that are tailor-made to fit with individual, group, or
institutional cultural values, beliefs, and lifeways in order to provide or support meaningful,
beneficial, and satisfying health care, or well-being services.
- Health is a state of well-being that is culturally defined, valued, and practiced, and which
reflects the ability of individuals (or groups) to perform their daily role activities in
culturally expressed, beneficial, and patterned lifeways.
- Human beings are believed to be caring and to be capable of being concerned about the
needs, well-being, and survival of others. Leininger also indicates that nursing as a caring
science should focus beyond traditional nurse-patient interactions and dyads to include
families, groups, communities, total cultures, and institutions.
- Society/environment is not terms that are defined by Leininger; she speaks instead of
worldview, social structure, and environmental context.
- Worldview is the way in which people look at the world, or at the universe, and form a
“picture or value stance” about the world and their lives.
- Cultural and social structure dimensions are defined as involving the dynamic patterns
and features of interrelated structural and organizational factors of a particular culture
(subculture or society) which includes religious, kinship (social), political (and legal),
economic, educational, technologic and cultural values, ethnohistorical factors, and how
these factors may be interrelated and function to influence human behavior in different
environmental contexts.
- Environmental context is the totality of an event, situation, or particular experience that
gives meaning to human expressions, interpretations, and social interactions in particular
physical, ecological, sociopolitical and/or cultural settings.
- Culture is the learned, shared and transmitted values, beliefs, norms, and lifeways of a
particular group that guides their thinking, decisions, and actions in patterned ways.
- Culture care is defined as the subjectively and objectively learned and transmitted values,
beliefs, and patterned lifeways that assist, support, facilitate, or enable another individual or
group to maintain their well-being, health, improve their human condition and lifeway, or to
deal with illness, handicaps or death.
- Culture care diversity indicates the variabilities and/or differences in meanings, patterns,
values, lifeways, or symbols of care within or between collectives that are related to
assistive, supportive, or enabling human care expressions.
- Culture care universality indicates the common, similar, or dominant uniform care
meanings, pattern, values, lifeways or symbols that are manifest among many cultures and
reflect assistive, supportive, facilitative, or enabling ways to help people.
 Margaret Jean Watson (Philosophy and Science of Caring)

- Society provides the values that determine how one should behave and what goals one
should strive toward. Watson (1979) states:

- “Caring (and nursing) has existed in every society. Every society has had some people
who have cared for others. A caring attitude is not transmitted from generation to
generation by genes. It is transmitted by the culture of the profession as a unique way of
coping with its environment.”

- Human being is a valued person to be cared for, respected, nurtured, understood, and
assisted.

- Health is the unity and harmony within the mind, body, and soul; health is associated
with the degree of congruence between the self as perceived and the self as experienced.

- Nursing is a human science of persons and human health – illness experiences that are
mediated by professional, personal, scientific, esthetic, and ethical human care
transactions.

- Actual caring occasion involves actions and choices by the nurse and the individual. The
moment of coming together in a caring occasion presents the two persons with the
opportunity to decide how to be in the relationship – what to do with the moment.

- The transpersonal concept is an intersubjective human-to-human relationship in which

the nurse affects and is affected by the person of the other. Both are fully present in the
moment and feel a union with the other; they share a phenomenal field that becomes part
of the life story of both.
 Patricia Benner (Novice to Expert)

Skill Acquisition in Nursing

- Stage 1 Novice: This would be a nursing student in his or her first year of clinical
education; behavior in the clinical setting is very limited and inflexible. Novices have a
very limited ability to predict what might happen in a particular patient situation. Signs
and symptoms, such as change in mental status, can only be recognized after a novice
nurse has had experience with patients with similar symptoms.
- Stage 2 Advanced Beginner: Those are the new grads in their first jobs; nurses have had
more experiences that enable them to recognize recurrent, meaningful components of a
situation. They have the knowledge and the know-how but not enough in-depth
experience.
- Stage 3 Competent: These nurses lack the speed and flexibility of proficient nurses, but
they have some mastery and can rely on advance planning and organizational skills.
Competent nurses recognize patterns and nature of clinical situations more quickly and
accurately than advanced beginners.
- Stage 4 Proficient: At this level, nurses are capable to see situations as "wholes" rather
than parts. Proficient nurses learn from experience what events typically occur and are
able to modify plans in response to different events.
- Stage 5 Expert: Nurses who are able to recognize demands and resources in situations
and attain their goals. These nurses know what needs to be done. They no longer rely
solely on rules to guide their actions under certain situations. They have an intuitive grasp
of the situation based on their deep knowledge and experience. Focus is on the most
relevant problems and not irrelevant ones. Analytical tools are used only when they have
no experience with an event, or when events don't occur as expected.

Historical Perspective in Nursing

I. Intuitive Nursing (Primitive Period; Ancient Civilization)

 - It is practiced since prehistoric times among primitive tribes and lasted through the early
Christian era
- Ability to see something without reason
- Spirit of nursing started
- Based on Love, Instinct and Desire
- Disease Oriented

Beliefs and Practices

- People are nomads. Philosophy in life was “the best for the most” and was ruled by the
Law of Self-Preservation.
- Nursing was a function that belonged to women
- Believed that illness is caused by evil spirits (voodoos)
- Believed in medicine man (Shaman) who practices trephening.

Contributions of different civilization during the Intuitive Period

1. Egypt
- Art of embalming
- Recognition of 250 diseases
2. China
- Pharmacology (Materia Medica)
- Use of Wax
3. Babylonia
- Code of Hammurabi
4. India
- Sushurutu – Qualification of nurses
5. Israel
- Moses is recognized as the Father of Sanitation
- Ritual Circumcision of a male child
6. Greek
- Introduced caduceus, the insignia of medical profession today
- Hippocrates was given the title of Father of Scientific Medicine
II. Apprentice Nursing
- From the founding of the Religious orders in the 11th century up to 1836 with the
establishment of the Kaiserwerth Institute for training of Deaconesses
- Period of “on-the-job training”
- Nursing performed without any formal education and by people who were
directed by more experienced nurses
- Important personalities in this period:
- St. Clare-gave nursing care to the sick and the afflicted
- St. Elizabeth of Hungary- Patrones of nurses
- St. Catherine of Siena- First lady with a lamp
- Dark period of Nursing
- From the 17th century up to 19th century
- Nursing became the work of the least desirable of women

III. Educative Nursing

- Began on June 15, 1860 when Florence Nightingale School of nursing opened St.
Thomas Hospital in London
- Development of nursing was strongly influenced by trends resulting from wars,
from an arousal of social consciousness, from the increased educational
opportunities offered to women
IV. Contemporary Nursing
- Covers the period after the World War II to the present
- Marked by scientific and technological developments as well as social changes
History of Nursing in the Philippines

- Hospital Real de Manila (1577) – it was established mainly to care for the Spanish
king’s soldiers, but also admitted Spanish civilians; founded by Gov. Francisco de Sande.
- San Lazaro Hospital (1578) – founded by Brother Juan Clemente and was administered
for many years by the Hospitalliers of San Juan de Dios; built exclusively for patients
with leprosy.
- Hospital de Indios (1586) – established by the Franciscan Order; service was in general
supported by alms and contributions from charitable persons.
- Hospital de Aguas Santas (1590) – established in Laguna; near a medicinal spring,
founded by Brother J. Baustista of the Franciscan Order.
- San Juan de Dios Hospital (1596) founded by the Brotherhood of Misericordia and
administered by the Hopsitaliers of San Juan de Dios; support was delivered from alms
and rents; rendered general health service to the public.
- Josephine Bracken, wife of Jose Rizal- installed a field hospital in an estate house in
Tejeros; provided nursing care to the wounded night and day
- Rosa Sevilla de Alvero- converted their house into quarters for the Filipino soldiers;
during the Philippine-American War that broke out in 1899
- Dona Hilaria de Aguinaldo- wife of Emilio Aguinaldo; organized that Filipino Red
Cross under the inspiration of Mabini
- Dona Maria Agoncillo de Aguinaldo- second wife of Emilio Aguinaldo; provided
nursing care to Filipino soldiers during the revolution, President of the Filipino Red Cross
branch in Batangas
- Melchora Aquino (Tandang Sora) –nursed the wounded Filipino soldiers and gave
them shelter and food
- Capitan Salome – a revolutionary leader in Nueva Ecija; provided nursing care to the
wounded when not in combat
- Agueda Kahabagan- revolutionary leader in Laguna, also provided nursing services to
her troops
- Trinidad Tecson (“Ina ng Biak-na-Bato”)- stayed in the hospital at Biak na Bato to
care for wounded soldiers
- University of Santo Tomas-College of Nursing (1946)
➢ In its first year of existence, its enrolees were consisted of students from different school
of nursing whose studied were interrupted by the war. In 1947, the Bureau of Private
Schools permitted UST to grant the title Graduate Nurse to the 21 students who were of
advance standing from 1948 up to the present. The college has offered excellent
education leading to a baccalaureate degree. Sor Taciana Trinanes was its first directress.
Presently, Associate Professor Glenda A. Vargas, RN, MAN serves as its Dean.

- Manila Central University-College of Nursing (1947)

➢ The MCU Hospital first offered BSN and Doctor of Medicine degrees in 1947 and
served as the clinical field for practice. Miss Consuelo Gimeno was its first principal.
Presently, Professor Lina A. Salarda, RN, MAN, EdD serves as its Dean.
- University of the Philippines Manila-College of Nursing (1948)
➢ The idea of opening the college began in a conference between Miss Julita Sotejo and
UP President. In April 1948, the University Council approved the curriculum, and the
Board of Regents recognized the profession as having an equal standing as Medicine,
Engineering etc. Miss Julita Sotejo was its first dean. Presently, Professor Josefina A.
Tuason, RN, MAN, DrPh is once more reappointed as the Dean of UP Manila College of
Nursing.
Basic Nursing
Procedures
 Hand Washing

- It is considered one of the most effective infection control measures.

 - It should be done before eating, after using the bedpan or toilet, after the hands have
come in contact with body substances, and before and after giving care of any kind.
- WHO recommends hand washing under a stream of water for 20 seconds using plain
granule soap, soap filled sheets, or liquid soap.
- CDC recommends using alcohol-based antiseptic hand rubs before and after giving care
aside from hand washing.

Proper application of alcohol-based products includes the following steps:

1. Apply a palmful of the product to a cupped hand
2. Rub palms against palms
3. Interlace fingers palm to palm
4. Rub palms to back of hands
5. Rub each finger individually on all sides with the other hand
6. Continue until product is dry – about 20-30 seconds.

Purposes of Hand Washing:

1. To reduce the number of microorganisms on hands
2. To reduce the risk of transmission of microorganisms to clients
3. To reduce the risk of cross-contamination among clients
4. To reduce the risk of transmission of infectious organisms to oneself

Notes when doing Hand Washing:

➢ Use warm water because warm water removes less of the protective oil of the skin.
➢ Hold hands lower than elbows (Medical Hand washing)
➢ For Surgical Hand Washing, hands should be higher than elbows
➢ Water should flow from the least contaminated to the most contaminated.
➢ Apply 2-4ml of liquid soap
➢ Use firm, rubbing, and circular movements. This should be done for at least 15 seconds
➢ Dry hands by patting – Do not rub the hands.

Bed Bath

- Bathing removes accumulated oil, perspiration, dead skin cells, and some bacteria.
- Bathing also improves circulation
- Rubbing should be done by long smooth strokes from the distal to proximal parts of
extremities.

Types of cleaning bath:

 Complete bed bath – the nurse washes the entire body of dependent client on bed
 Self-help bed bath – clients confined to bed are able to bathe themselves with help from
the nurse for washing the back and perhaps the feet.
 Partial bath (Abbreviated bath) – Only parts of the client’s body that might cause
discomfort or odor, of neglected, are washed. The face, hands, axillae, perineal area, and
back.
 Bag bath – Commercially prepared product that contains 10-12 presoaked disposable
washcloths that contain no-rinse cleanser solution. Warming time is 1 minute.
 Tub bath – often preferred to bed baths because it is easier to wash and rinse in a tub.
 Sponge bath – suggested to newborns.

- Temperature of cleansing bath should be 43-46 degrees Celsius or 110-115 degrees

Fahrenheit.
- Therapeutic baths are given for physical effects, such as to soothe irritated skin or treat an
area. Medications may be placed on water.
- Therapeutic bath s generally taken in a tub one-third or one-half full.
- Designated time is 20-30 minutes
- Temperature of therapeutic bath includes: 37.7C – 46C (100F-115F) for adults and 40.5C
(105F) for infants.

Bed Shampoo and Hair Care

- Each person has particular ways of caring for their hair

- Dark-skinned people need to oil their hair because it tends to be dry
- A wide-toothed comb is usually used because finer combs pull and break the hair
- Lanugo are fine hair on the body of the fetus, also referred as down or woolly hair
- Pubic hair usually appears in early puberty, followed in about 6 months by the growth of
axillary hair
- Alopecia is the medical term for hair loss
- Dandruff is the diffuse scaling of the scalp
 - Ticks are small gray-brown parasites that bite into tissue and suck blood. They can also
transmit diseases such as Lyme disease and Rocky Mountain spotted fever.
- Lice are parasitic insects that infest mammals. Infestation with lice is called pediculosis.

Kinds of Lice
- Pediculus capitis – head louse
- Pediculus Corporis – body louse
- Pediculus Pubis – crab louse

Scabies
- Contagious skin infestation by itch mite.
- Characteristic lesion is caused by burrowing of female mite
- Itching is more pronounce at night

Hirsutism
- Growth excessive body hair

Function of Brushing the Hair

- Stimulates circulation of blood in the scalp
- Distributes oil along the hair shaft
- Helps arrange the hair

Notes when doing hair care and bed shampoo:

- Hair is more easily combed when the patient is in sitting position
- Water used for shampoo should be 40.5C (105F)
- Massage the hair using the pads of fingertips
Bed making

Purpose:
1. To provide clean and comfortable bed for the patient
2. To reduce the risk of infection by maintaining a clean environment
3. To prevent bed sores by ensuring there are no wrinkles to cause pressure points

Notes when doing Bed Making:

- Do not let your uniform touch the bed and the floor not to contaminate yourself.
- Never throw soiled lines on the floor not to contaminate the floor.
- Staying one side of the bed until one step completely made saves steps and time
to do effectively and save the time.
- Unoccupied bed can be closed or open
- Top covers of an open bed are folded back to make it easier for a client to get in

Materials used in Bed Making:

1. 2 flat sheets or one fitted and one flat sheet
2. Draw sheet
 3. Blanket
4. Bed spread
5. Rubber Sheet
6. Pillowcase

Vital Signs

- Vital signs include body temperature, pulse, respiration, and blood pressure
- Pain is considered as the fifth vital sign
- Body temperature reflects the balance between heat produced and heat loss
- Core temperature is the temperature of the deep tissues of the body, such as
abdominal cavity and pelvic cavity
- Surface temperature is the temperature of the skin, the subcutaneous tissue, and
fat.
Temperature

Processes of Heat Loss:

1. Convection
 The flow of heat from the body surface to cooler ambient air. "baby is wrapped with a
blanket to protect them from cold"
2. Radiation
 The loss of heat from the body surface to cooler solid surface not in direct contact, but
close. "Cribs are placed away from outside windows for this"
3. Evaporation
 The loss of heat that occurs when a liquid is converted to a vapor, "occurs by failure to
dry a newborn after birth or slow drying after a bath
4. Conduction
  The loss of heat from the body to cooler surface in direct contact, “newborn is placed in a
warming crib to minimize heat loss

Measuring body temperature

 The measurement of core body temperature may seem simple, but several issues affect
the accuracy of the reading. These include the measurement site, the reliability of the
instrument and user technique (Pusnik and Miklavec, 2009). Practitioners must
understand the advantages and disadvantages associated with the chosen method so they
can explain the procedure to patients and obtain valid consent (Nursing and Midwifery
Council, 2008).

 True core temperature readings can only be measured by invasive means, such as
placing a temperature probe into the oesophagus, pulmonary artery or urinary bladder
(Childs, 2011). It is not practical, nor indeed necessary, to use such sites and methods in
all cases; they tend to be reserved for patients who are critically ill.

Non-invasive sites such as the rectum, oral cavity, axilla, temporal artery (forehead) and external
auditory canal are accessible and are believed to provide the best estimation of the core
temperature (Pusnik and Miklavec, 2009). The temperature measured between these sites can
vary greatly, so the same site ought to be used consistently and recorded on the chart with the
reading (Davie and Amoore, 2010).

1. Oral cavity
- The oral cavity temperature is considered to be reliable when the thermometer is
placed posteriorly into the sublingual pocket (Hamilton and Price, 2007). This
landmark is close to the sublingual artery, so this site tracks changes in core
body temperature (Dougherty and Lister, 2011).
- Electronic or disposable chemical thermometers may be used. Chemical
thermometers should be avoided if the patient is hypothermic (<35°C) because
their range of operation is 35.5°C-40.4°C (Fulbrook, 1997). Low-reading
thermometers may be of some use. Mercury-in-glass thermometers can no longer
be bought because of European Council rules (Medicines and Healthcare products
Regulatory Agency, 2011).
- Care must be taken to avoid the anterior region immediately posterior to the lower
incisors because the temperature here is substantially lower (Dougherty and
Lister, 2011).
- Factors affecting accuracy include recent ingestion of food or fluid, having a
respiratory rate >18 per minute and smoking (Dougherty and Lister, 2011).
Oxygen therapy, particularly with high-flow rates, may influence temperature but
this claim has been refuted by Stanhope (2006).

2. Tympanic temperature
- The tympanic thermometer senses reflected infrared emissions from the tympanic
membrane through a probe placed in the external auditory canal (Davie and
Amoore, 2010). This method is quick (<1 minute), minimally invasive and easy
to perform. It has been reported to estimate rapid fluctuations in core temperature
accurately because the tympanic membrane is close to the hypothalamus
(Stanhope, 2006).
- Although its accuracy and reliability have been questioned in many studies in the
past decade, with differing outcomes. Tympanic thermometry continues to be
 used. Operator error and poor technique are frequently cited problems (Farnell et
al, 2005), so training is recommended. Ear wax is known to reduce the accuracy
of readings, so it is recommended that the ear is inspected before measurement
(Farnell et al, 2005).
- Advantages of this site are that the measurement does not appear to be influenced
by oral fluids or diet, environmental temperature or other extraneous variables
(Robb and Shahab, 2001). If patients have been lying with their ear on a pillow,
allow 20 minutes to elapse so the temperature can normalise (Bridges and
Thomas, 2009).

3. Axillary temperature
- Temperature is measured at the axilla by placing the thermometer in the
central position and adducting the arm close to the chest wall.
- The literature suggests that this is an unreliable site for estimating core body
temperature because there are no main blood vessels around this area (Sund-
Levander and Grodzinsky, 2009). These authors also argue that the axillary
temperature can be affected by the environmental temperature and perspiration.
- Fulbrook (1997) produced convincing evidence indicating that chemical
thermometers are clinically unreliable for measuring axillary temperature. Giantin
et al (2008) suggested that electronic digital thermometers can be used at this site
as a reliable alternative in older people.

4. Rectal temperature
- Rectal temperature is said to be the most accurate method for measuring the core
temperature (Lefrant et al, 2003). However, obtaining this is more time
consuming than other methods and might be considered unfavourable for some
patients (Dzarr et al, 2009). Practitioners should pay particular attention to issues
of privacy.
- The presence of faeces prevents the thermometer from touching the wall of the
bowel and may generate inaccurate readings (Sund-Levander and Grodzinsky,
2009). Sund-Levander and Grodzinsky (2009) suggested this method does not
track immediate changes to core temperature because of the low flow of blood to
the area, so core temperature may be under- or overestimated at times of rapid
flux.

5. Temporal artery temperature

- The temporal artery thermometer is quick to use. It is held over the forehead and
senses infrared emissions radiating from the skin (Davie and Amoore, 2010).
However, its reliability and validity have not been widely tested. A single-centre
study comparing it with other methods found that, despite the infection control
advantages of this non-touch method, it underestimated body temperature
compared with the control (Duncan et al, 2008).

Pulse
- A wave of blood created by contraction of the left ventricle of the heart
- Compliance is the ability to contract and expand
- Cardiac output is the volume of blood pumped into the arteries by the heart and
equals the result of stroke volume times the heart rate.
- Use moderate pressure with three middle fingers of the hand
 - Use pads of distal aspect of finger because they are most sensitive for detecting
pulse
- Allow the client to rest for 10-15 minutes of the client performed physical
activities
- Pulse volume refers to the force of blood with each beat

Different Pulse Sites:

1. Temporal
2. Carotid
3. Apical – used for infants up to 3 years of age
4. Brachial
5. Radial
6. Femoral
7. Popliteal
8. Posterior tibial
9. Dorsalis Pedis

Respiration
- Abnormally slow respirations is termed bradypnea
- Abnormally fast respirations is termed tachypnea or polypnea
- Absence of breathing is termed apnea
- During normal inhalation and exhalation, an adult takes in about 500ml of air
- Hyperventilation refers to very deep, rapid respirations
- Hypoventilation refers to very shallow respirations
- Cheyne-Stokes breathing is rhythmic waxing and waning of respirations,
from very deep to very shallow breathing and temporary apnea
- Dyspnea is difficult and labored breathing during which the individual has a
persistent, unsatisfied need for air and feels distressed.
- Orthopnea refers to ability to breath only in upright sitting or standing positions
- Stridor – a shrill, harsh shound heard during inspiration with laryngeal obstruction
- Stertor – snoring or sonorous respiration, usually due to a partial obstruction of
the upper airway
- Wheeze – continuous, high-pitched musical squeak or whistling sound occurring
on expiration and sometimes on inspiration when air moves through a narrowed
or partially obstructed airway
- Bubbling – gurgling sounds heard as air passes through moist secretions in the
respiratory tract
- Hemoptysis – blood in the sputum
- Productive cough – a cough accompanied by expectorated secretions
- Non-productive cough – a dry, harsh cough without secretions

Blood Pressure
- Arterial blood pressure is a measure of the pressure exreted by the blood as it
flows through the arteries.
- Systolic Pressure is the pressure of the blood as a result of contraction of the
ventricles, that is, the pressure of the height of the blood wave
- Diastolic pressure is the pressure when the ventricles are at rest
- Difference between the systolic and diastolic pressure is called pulse pressure
- Normal pulse pressure is 40mmHg
 - Arteriosclerosis is when blood vessels are replaced by fibrous tissue, causing
lesser ability to constrict and dilate.
- The higher the hematocrit, the viscous the blood
- Primary hypertension is when the cause is unknown
- Secondary hypertension is when the cause is known
Application of Hot water bag/ ice cap/ hot and cold compress

- Heat is an old remedy for aches and pain, and people often equate heat with
comfort and relief.
- Heat causes vasodilation and an increase in blood flow to the area
- Heat promotes soft tissue healing and increases suppuration
- Cold causes constriction
- Cold reduces oxygen supply and metabolites to the area
- Rebound phenomenon is when the maximum therapeutic effect of the hot or cold
application is achieved and the opposite effect begins
- In cold applications, maximum vasoconstriction when affected skin reaches 15C
(60F). Below 15, vasodilation occurs
- In hot application, maximum vasodilation occurs in 20-30 minutes, tissue
congestion occurs beyond this time.
- Sitz bath is also called a hip bath; it is used to soak a client’s pelvic area. Duration
is about 15-20 minutes.

Indication for application of heat and cold

 Muscle spasm
 Inflammation
 Pain
 Contracture
 Joint Stiffness
 Traumatic Injury
 Medications

- A drug can have as much as 4 names; generic name, official name, chemical
name, and trade name
- Pharmacology is the study of the effect of drugs
- Pharmacy is the art of preparing, compounding, and dispensing of drugs
- Pharmacopoeia is book containing the list of products used in medicine
- Therapeutic effect, also known as the primary effect is the reason the drug is
prescribed
- Side effect, or the secondary effect is the one that is unintended
- Adverse effect is more severe side effect
- Drug toxicity results from overdosage, ingestion of drug intended for external use,
and buildup of the drug in the blood because of impaired metabolism or excretion.
- Drug allergy is an immunologic reaction to a drug
- Severe form of allergic reaction is anaphylactic shock, which is fatal.
- Drug tolerance is when a person developed a low physiologic response to a drug.

Routes of Drug Administration:

Drugs are introduced into the body by several routes. They may be

- Taken by mouth (orally)

- Given by injection into a vein (intravenously), into a muscle (intramuscularly),
into the space around the spinal cord (intrathecally), or beneath the skin
(subcutaneously)
- Placed under the tongue (sublingually) or between the gums and cheek (buccally)
- Inserted in the rectum (rectally) or vagina (vaginally)
- Placed in the eye (by the ocular route) or the ear (by the otic route)
- Sprayed into the nose and absorbed through the nasal membranes (nasally)
- Breathed into the lungs, usually through the mouth (by inhalation) or mouth and
nose (by nebulization)
- Applied to the skin (cutaneously) for a local (topical) or bodywide (systemic)
effect
- Delivered through the skin by a patch (transdermally) for a systemic effect
- Each route has specific purposes, advantages, and disadvantages.

Oral route:
Many drugs can be administered orally as liquids, capsules, tablets, or chewable tablets. Because
the oral route is the most convenient and usually the safest and least expensive, it is the one most
often used. However, it has limitations because of the way a drug typically moves through the
digestive tract. For drugs administered orally, absorption may begin in the mouth and stomach.
However, most drugs are usually absorbed from the small intestine. The drug passes through the
intestinal wall and travels to the liver before being transported via the bloodstream to its target
site. The intestinal wall and liver chemically alter (metabolize) many drugs, decreasing the
amount of drug reaching the bloodstream. Consequently, these drugs are often given in smaller
doses when injected intravenously to produce the same effect.

When a drug is taken orally, food and other drugs in the digestive tract may affect how much of
and how fast the drug is absorbed. Thus, some drugs should be taken on an empty stomach,
others should be taken with food, others should not be taken with certain other drugs, and still
others cannot be taken orally at all.

Some orally administered drugs irritate the digestive tract. For example, aspirin and most other
nonsteroidal anti-inflammatory drugs (NSAIDs—see Nonsteroidal Anti-Inflammatory Drugs)
can harm the lining of the stomach and small intestine to potentially cause or aggravate
preexisting ulcers (see Causes). Other drugs are absorbed poorly or erratically in the digestive
tract or are destroyed by the acid and digestive enzymes in the stomach.

Other routes of administration are required when the oral route cannot be used, for example:

When a person cannot take anything by mouth

When a drug must be administered rapidly or in a precise or very high dose
When a drug is poorly or erratically absorbed from the digestive tract
Injection routes:
Administration by injection (parenteral administration) includes the subcutaneous, intramuscular,
intravenous, and intrathecal routes. A drug product can be prepared or manufactured in ways that
prolong drug absorption from the injection site for hours, days, or longer. Such products do not
need to be administered as often as drug products with more rapid absorption.

Through the Skin

Sometimes a drug is given through the skin—by needle (subcutaneous, intramuscular, or

intravenous route), by patch (transdermal route), or by implantation.
For the subcutaneous route, a needle is inserted into fatty tissue just beneath the skin. After a
drug is injected, it then moves into small blood vessels (capillaries) and is carried away by the
bloodstream. Alternatively, a drug reaches the bloodstream through the lymphatic vessels (Fig.
1: Lymphatic System: Helping Defend Against InfectionFigures). Protein drugs that are large in
size, such as insulin, usually reach the bloodstream through the lymphatic vessels because these
drugs move slowly from the tissues into capillaries. The subcutaneous route is used for many
protein drugs because such drugs would be destroyed in the digestive tract if they were taken
orally.

Certain drugs (such as progestins used for birth control—see Hormonal Methods of
Contraception) may be given by inserting plastic capsules under the skin (implantation).
Although this route of administration is rarely used, its main advantage is to provide a long-term
therapeutic effect (for example, etonogestrel that is implanted for contraception may last up to 3
years).

The intramuscular route is preferred to the subcutaneous route when larger volumes of a drug
product are needed. Because the muscles lie below the skin and fatty tissues, a longer needle is
used. Drugs are usually injected into the muscle of the upper arm, thigh, or buttock. How quickly
the drug is absorbed into the bloodstream depends, in part, on the blood supply to the muscle:
The sparser the blood supply, the longer it takes for the drug to be absorbed.

For the intravenous route, a needle is inserted directly into a vein. A solution containing the drug
may be given in a single dose or by continuous infusion. For infusion, the solution is moved by
gravity (from a collapsible plastic bag) or, more commonly, by an infusion pump through thin
flexible tubing to a tube (catheter) inserted in a vein, usually in the forearm. Intravenous
administration is the best way to deliver a precise dose quickly and in a well-controlled manner
throughout the body. It is also used for irritating solutions, which would cause pain and damage
tissues if given by subcutaneous or intramuscular injection. An intravenous injection can be
more difficult to administer than a subcutaneous or intramuscular injection because inserting a
needle or catheter into a vein may be difficult, especially if the person is obese.

When given intravenously, a drug is delivered immediately to the bloodstream and tends to take
effect more quickly than when given by any other route. Consequently, health care practitioners
closely monitor people who receive an intravenous injection for signs that the drug is working or
is causing undesired side effects. Also, the effect of a drug given by this route tends to last for a
shorter time. Therefore, some drugs must be given by continuous infusion to keep their effect
constant.

For the intrathecal route, a needle is inserted between two vertebrae in the lower spine and into
the space around the spinal cord. The drug is then injected into the spinal canal. A small amount
of local anesthetic is often used to numb the injection site. This route is used when a drug is
needed to produce rapid or local effects on the brain, spinal cord, or the layers of tissue covering
them (meninges)—for example, to treat infections of these structures. Anesthetics and analgesics
(such as morphine) are sometimes given this way.

Sublingual and buccal routes:

A few drugs are placed under the tongue (taken sublingually) or between the gums and teeth
(bucally) so that they can dissolve and be absorbed directly into the small blood vessels that lie
beneath the tongue. These drugs are not swallowed. The sublingual route is especially good for
nitroglycerin which is used to relieve angina, because absorption is rapid and the drug
immediately enters the bloodstream without first passing through the intestinal wall and liver.
However, most drugs cannot be taken this way because they may be absorbed incompletely or
erratically.

Rectal route:
Many drugs that are administered orally can also be administered rectally as a suppository. In
this form, a drug is mixed with a waxy substance that dissolves or liquefies after it is inserted
into the rectum. Because the rectum's wall is thin and its blood supply rich, the drug is readily
absorbed. A suppository is prescribed for people who cannot take a drug orally because they
have nausea, cannot swallow, or have restrictions on eating, as is required before and after many
surgical operations.

Vaginal route:
Some drugs may be administered vaginally to women as a solution, tablet, cream, gel,
suppository, or ring. The drug is slowly absorbed through the vaginal wall. This route is often
used to give estrogen to women during menopause to relieve vaginal symptoms such as dryness,
soreness, and redness.

Ocular route:
Drugs used to treat eye disorders (such as glaucoma, conjunctivitis, and injuries) can be mixed
with inactive substances to make a liquid, gel, or ointment so that they can be applied to the eye.
Liquid eye drops are relatively easy to use but may run off the eye too quickly to be absorbed
well. Gel and ointment formulations keep the drug in contact with the eye surface longer, but
they may blur vision. Solid inserts, which release the drug continuously and slowly, are also
available, but they may be hard to put in and keep in place. Ocular drugs are almost always used
for their local effects.

Otic route:
Drugs used to treat ear inflammation and infection can be applied directly to the affected ears.
Ear drops containing solutions or suspensions are typically applied only to the outer ear canal.
Before applying ear drops, people should thoroughly clean the ear with a moist cloth and dry it.

Nasal route:
If a drug is to be breathed in and absorbed through the thin mucous membrane that lines the nasal
passages, it must be transformed into tiny droplets in air (atomized). Once absorbed, the drug
enters the bloodstream. Drugs administered by this route generally work quickly. Some of them
irritate the nasal passages.

Inhalation route:
Drugs administered by inhalation through the mouth must be atomized into smaller droplets than
those administered by the nasal route, so that the drugs can pass through the windpipe (trachea)
and into the lungs. How deeply into the lungs they go depends on the size of the droplets.
Smaller droplets go deeper, which increases the amount of drug absorbed. Inside the lungs, they
are absorbed into the bloodstream.

Relatively few drugs are administered this way because inhalation must be carefully monitored
to ensure that a person receives the right amount of drug within a specified time. In addition,
specialized equipment may be needed to give the drug by this route. Usually, this method is used
to administer drugs that act specifically on the lungs, such as aerosolized antiasthmatic drugs in
metered-dose containers (called inhalers), and to administer gases used for general anesthesia.

Cutaneous route:
Drugs applied to the skin are usually used for their local effects and thus are most commonly
used to treat superficial skin disorders, such as psoriasis, eczema, skin infections (viral, bacterial,
and fungal), itching, and dry skin. The drug is mixed with inactive substances. Depending on the
consistency of the inactive substances, the formulation may be an ointment, cream, lotion,
solution, powder, or gel (see Topical Preparations).

Transdermal route:
Some drugs are delivered bodywide through a patch on the skin. These drugs are sometimes
mixed with a chemical (such as alcohol) that enhances penetration through the skin into the
bloodstream without any injection. Through a patch, the drug can be delivered slowly and
continuously for many hours or days or even longer. As a result, levels of a drug in the blood can
be kept relatively constant. Patches are particularly useful for drugs that are quickly eliminated
from the body because such drugs, if taken in other forms, would have to be taken frequently.
However, patches may irritate the skin of some people. In addition, patches are limited by how
quickly the drug can penetrate the skin. Only drugs to be given in relatively small daily doses can
be given through patches.

Positioning, Draping, Moving, and Transfer

Basic principles when positioning the patient:
- Make sure the mattress is firm and level yet has enough give to fill in and support
natural body curvatures
- Ensure that the bed is clean and dry
- Avoid placing one body part, particularly one with bony prominences, directly on
top of another body part
- Plan a systematic 24-hour schedule for position changes

Different positions:
1. Fowlers
- Fowlers or semi-sitting position is a bed position in which the head and trunk are
raised to 45-90 degrees.
2. Orthopneic position
- The client sits either in the bed or on the side of the bed with an overbed table
across the lap. This position facilitates respiration by allowing maximum chest
expansion.
3. Dorsal Recumbent position
- The client’s head and shoulders are slightly elevated on a small pillow.
4. Prone position
- The client lies on the abdomen with the head turned to one side.
- Only bed position that allows full extension of the hip and knee joints
5. Lateral position
- The person lies on one side of the body
6. Sims’ position
- The client assumes a posture halfway between lateral and the prone positions.

Moving and Turning Clients in Bed

- Before moving a client, assess the degree of exertion permitted.
- If indicated, use pain relief modalities or medication prior to moving the client
- Prepare any needed assistive devices and supportive equipment
- Plan around encumbrances to movement such as an IV or heavy cast.
- Be alert to the effects of any medications the client takes that may impair
alertness, balance, strength, or mobility
- Obtain assistance from other persons
- Explain the procedures to the client and listen to any suggestion
- Provide privacy
- Wash hands
- Raise the height of the bed to bring the client to your center of gravity
- Lock the wheels of the bed and raise side rails to ensure safety.
- Face in the direction of movement
- Assume a broad stance
- Lean your trunk forward
- Tighten your leg muscles
- Rock from front to back when pulling and vice versa when pushing
- Determine the client’s comfort.

Transferring Clients:
- Plan what to do and how to do it
- Obtain essential equipment before starting and check function
- Remove obstacles from the area used for transfer
- Explain the transfer to the client, including what the client should do
- Explain the transfer to the nursing personnel who are helping; specify who will
give directions
- Always support or hold the client rather than the equipment and ensure the client
safety and dignity.
- During the transfer, explain step by step what the client should do
 - Make a written plan of the transfer, including the client’s tolerance.

Physical Examination

Physical examination is an important tool in assessing the client‟s health status. Approximate 15
% of the information used in the assessment comes from the physical examination. It is
performed to collect objective data and to correlate it with subjective data.
Purpose:
1. To collect objective data from the client
2. To detect the abnormalities with systematic technique early
3. To diagnose diseases
4. To determine the status of present health in health check-up and refer the client for
consultation if needed

Principles of Physical Examination:

A systematic approach should be used while doing physical examination. This helps
avoiding any duplication or omission. Generally a cephalocaudal approach (head to toe)
is used, but in the case of infant,examination of heart and lung function should be done
before the examination of other body parts, because when the infant starts crying , his/her
breath and heart rate may change.

Methods of Physical Examination:

o Inspection
o Palpation
o Percussion
o Auscultation

1. Inspection
-Inspection means looking at the client carefully to discover any signs of illness.
Inspection gives more information than other method and is therefore the most useful
method of physical examination.

2. Palpation
-Palpation means using hands to touch and feel. Different parts of hands are used for
different sensation such as temperature, texture of skin, vibration, tenderness, and etc. For
examples, finger tips are used for fine tactile surfaces, the back of fingers for feeling
temperature and the flat of the palm and fingers for feeling vibrations.

3. Percussion
-Percussion determines the density of various parts of the body from the sound produced
by them, when they are tapped with fingers. Percussion helps to find out abnormal solid
masses, fluid and gas in the body and to map out the size and borders of the certain organ
like the heart. Methods of percussion are:
a. Put the middle fingers of his/her hand of the left hand against the body part to be
percussed
b. Tap the end joint of this finger with the middle finger of the right hand
c. Give two or three taps at each area to be percussed
d. Compare the sound produced at different areas.

4. Auscultation
-Auscultation means listening to the sounds transmitted by a stethoscope which is used to
listen to the heart, lungs and bowel sounds.
 Post-mortem Care

- Rigor mortis is the stiffening of the body that occurs about 2-4 hours after
death
- Algor mortis is the gradual decrease of the body’s temperature after death.
When blood circulation terminates and the hypothalamus ceases to
function, body temperature fall bout 1C per hour until it reaches room
temperature
- Livor mortis is the discoloration due to the hemoglobin released during
RBC destruction.
- Solid areas of the body should be washed
- A mortician or undertaker is a person trained in the care of the dead
- Proper identification is very important
- Mishandling can cause distress to the family
- Grief is the total response to the emotional experience related to loss
- Bereavement is the subjective response experience by the surviving loved
ones after the death of a significant person.
- Mourning is the behavioral process through which grief is eventually
resolved or altered
- Abbreviated grief is brief but genuinely felt
- Anticipatory grief is experienced in advance of the event such as the wife
who grieves before her ailing husband dies
 - Disenfranchised grief occurs when a person is unable to acknowledge the
loss to other persons. Situations in which this may occur often relate to a
socially unacceptable loss that cannot be spoken about.
- Unhealthy grief exists when the strategies to cope with the loss are
maladaptive

Leopold’s Maneuver

Leopold’s Maneuver is preferably performed after 24 weeks gestation when fetal outline can be
already palpated.

Preparation:

- Instruct woman to empty her bladder first.

- Place woman in dorsal recumbent position, supine with knees flexed to relax abdominal
muscles. Place a small pillow under the head for comfort.
- Drape properly to maintain privacy.
- Explain procedure to the patient.
- Warms hands by rubbing together. (Cold hands can stimulate uterine contractions).
- Use the palm for palpation not the fingers.

Purpose Procedure Findings

First Maneuver or To determine fetal Using both hands, feel Head is more firm,
Fundal Grip part lying in the for the fetal part lying hard and round that
fundus. in the fundus. moves independently
To determine of the body.
presentation. Breech is less well
defined that moves
only in conjunction
with the body.
Second Maneuver or To identify location of One hand is used to Fetal back is smooth,
Umbilical Grip steady the uterus on hard, and resistant
 fetal back. one side of the surface
To determine abdomen while the Knees and elbows of
position.a other hand moves fetus feel with a
slightly on a circular number of angular
motion from top to the nodulation
lower segment of the
uterus to feel for the
fetal back and small
fetal parts.
Use gentle but deep
pressure.
Third Maneuver or To determine Using thumb and The presenting part is
Pawlik’s Grip engagement of finger, grasp the lower not engaged if it is not
presenting part. portion of the movable.
abdomen above It is not yet engaged if
symphisis pubis, press it is still movable.
in slightly and make
gentle movements
from side to side.
Fourth Maneuver or To determine the Facing foot part of the Good attitude – if
Pelvic Grip degree of flexion of woman, palpate fetal brow correspond to
fetal head. head pressing the side (2nd
To determine attitude downward about 2 maneuver) that
or habitus. inches above the contained the elbows
inguinal ligament. and knees.
Use both hands. Poor atitude – if
examining fingers will
meet an obstruction
on the same side as
fetal back
(hyperextended head)
Also palpates infant’s
anteroposterior
position. If brow is
very easily palpated,
fetus is at posterior
position (occiput
pointing towards
woman’s back)
 Perineal Care

- Perineal care is the washing of the genital and rectal areas of the body. Perineal care
should be done at least one time a day during the bed bath, shower, or tub bath. It is done
more often when a client is incontinent. Perineal care prevents infection, odors and
irritation.
- Perineal care is done when a patient has a urinary catheter in place. It is also done when
the client does not have a urinary catheter. Perineal care is done differently for men and
women.
- As with all procedures, wash your hands, put on gloves, introduce yourself to the client,
explain what you are about to do, identify the patient and maintain privacy, standard
precautions, caring, respect, comfort and safety throughout the task.
-
Perineal care for male patients without a urinary catheter has these additional steps:
o fill the bath basin with clean water at 110 degrees,
o position the male patient on their back,
o put a protective cover over the bed linen,
o wash the groin from the front to the back starting at the groin area and
then going to the inside of the thighs,
o then rinse the cloth or use a new washcloth,
o pull back the foreskin if the patient is not circumcised,
o wash and rinse the tip of the penis downward while using gentle, circular
motions and then the scrotum,
o rinse the cloth,
o turn the person on their side,
o and wash, rinse and dry the rectal area.

Perineal care for female patients without a urinary catheter has these steps:
o fill the bath basin with clean water at 110 degrees,
o position the female patient on their back,
o put a protective cover over the bed linen,
o separate the labia and wash, rinse and dry the urethral area first with short
downward strokes alternating from side to side and proceeding until the exposed
area around the urethra is done,
o then rinse the cloth or use a new washcloth,
o wash the groin on the outside of the labia from the front to the back starting
outside the labia and then going to the inside of the thighs,
o then rinse the cloth,
o turn the person on their side,
o and wash, rinse and dry the rectal area.

Perineal care for male and female patients with a urinary catheter has the above steps
followed by these additional steps:
- with a clean washcloth and soap, wash the catheter starting at the urinary opening
with short strokes to about 4 inches away from the body
 - using a new washcloth, rinse the catheter starting at the urinary opening with short
strokes to about 4 inches away from the body
Immediate Care of the Newborn

Goals:
- To establish, maintain and support respirations.
- To provide warmth and prevent hypothermia.
- To ensure safety, prevent injury and infection.
- To identify actual or potential problems that may require immediate attention.
- Establish respiration and maintain clear airway

The most important need for the newborn immediately after birth is a clear airway to enable the
newborn to breathe effectively since the placenta has ceased to function as an organ of gas
exchange. It is in the maintenance of adequate oxygen supply through effective respiration that
the survival of the newborn greatly depends.

Newborns are obligatory nose breathers. The reflex response to nasal obstruction, opening the
mouth to maintain airway, is not present in most newborns until 3 weeks after birth.

To establish and maintain respirations:

- Wipe mouth and nose of secretions after delivery of the head.

- Suction secretions from mouth and nose.
- Compress bulb syringe before inserting
- Suction mouth first, then, the nose
- Insert bulb syringe in one side of the mouth
- A crying infant is a breathing infant. Stimulate the baby to cry if baby does not
cry spontaneously, or if the cry is weak.

 Do not slap the buttocks rather rub the soles of the feet.
 Stimulate to cry after secretions are removed.
 The normal infant cry is loud and husky. Observe for the following abnormal cry:
 High, pitched cry – indicates hypoglycemia, increased intracranial pressure.
 Weak cry – prematurity
 Hoarse cry – laryngeal stridor
 Oral mucous may cause the newborn, to choke, cough or gag during the first 12 to 18
hours of life. Place the infant in a position that would promote drainage of secretions.

 Trendelenburg position – head lower than the body

  Side lying position – If trendelenburg position is contraindicated, place infant in side
lying position to permit drainage of mucus from the mouth.
 Place a small pillow or rolled towel at the back to prevent newborn from rolling back to
supine position.
 Keep the nares patent. Remove mucus and other particles that may be cause obstruction.
Newborns are obligatory nose breathers until they are about 3 weeks old.

Care of the Eyes

 It is part of the routine care of the newborn to give prophylactic eye treatment against
gonorrhea conjunctivitis or opthalmia neonatorum. Neisseria gonorrhea, the causative
agent, may be passed on the fetus from the vaginal canal during delivery. This practice
was introduced by Crede, a German gynecologist in1884. Silver nitrate, erythromycin
and tetracycline ophthalmic ointments are the drugs used for this purpose.

 Erythromycin or tetracycline Opthalmic Ointment:

 These ointments are the ones commonly used now a days for eye prophylaxis because
they do not cause eye irritation and are more effective against Chlamydial conjunctivitis.
 Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over
the eyes.

Vitamin K or Aquamephyton
 The newborn has a sterile intestine at birth, hence, the newborn does not possess the
intestinal bacteria that manufactures vitamin K which is necessary for the formation of
clotting factors. This makes the newborn prone to bleeding. As a preventive measure, .5
(preterm) and 1 mg (full term) Vitamin K or aquamephyton is injected IM in the
newborn’s vastus lateralis (lateral anterior thigh) muscle.

 The cord is clamped and cut approximately within 30 seconds after birth. In the delivery
room, the cord is clamped twice about 8 inches from the abdomen and cut in between.
When the newborn is brought to the nursery, another clamp is applied ½ to 1 inch from
the abdomen and the cord is cut at second time. The cord and the area around it are
cleansed with antiseptic solution. The manner of cord care depends on hospital protocol.
What is important is that the principles are followed. Cord clamp maybe removed after
48 hours when the cord has dried. The cord stump usually dries and falls within 7 to 10
days leaving a granulating area that heals on the next 7 to 10 days.

Instruction to the mother on cord care:

 No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that
cord does not get wet by water or urine.
 Do not apply anything on the cord such as baby powder or antibiotic, except the
prescribed antiseptic solution which is 70% alcohol.
 Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not
get wet when the diaper soaks with urine.
 Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord
dries and separates more rapidly if it is exposed to air.
 If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose
and fasten.
Report any unusual signs and symptoms which indicate infection:
 Foul odor in the cord
  Presence of discharge
 Redness around the cord
 The cord remains wet and does not fall off within 7 to 10 days
 Newborn fever

THE APGAR SCORING SYSTEM

The APGAR Scoring System was developed by Dr. Virginia Apgar as a method of assessing the
newborn’s adjustment to extrauterine life. It is taken at one minute and five minutes after birth.
With depressed infants, repeat the scoring every five minutes as needed. The one minute score
indicates the necessity for resuscitation. The five minute score is more reliable in predicting
mortality and neurologic deficits. The most important is the heart rate, then the respiratory rate,
the muscle tone, reflex irritability and color follows in decreasing order. A heart rate below 100
signifies an asphyxiated baby and a heart rate above 160 signifies distress.

MMDST

- Simple and clinically useful tool to determine early serious developmental delays

Purposes
- Measures developmental delays
- Evaluates 4 aspects of development
Aspects of development
In the care of pediatric clients, growth and development are not in isolation. Nurses being
competent in the aspects of growth and development particularly principles, theories and
milestones are in best position to counsel clients on these aspects. Having background
knowledge on growth and development, nurses are equipped with assessment skills to determine
developmental delays through the aid of screening tests.

The Metro Manila Developmental Screening Test (MMDST) is a screening test to note for
normalcy of the child’s development and to determine any delays as well in children 6 ½ years
old and below. Modified and standardized by Dr. Phoebe Williams from the original Denver
Developmental Screening Test (DDST) by Dr. William K. 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 himself
Fine-Motor Adaptive – tasks which indicate the child’s ability to see and use his hands to
pick up objects and to draw
Language – tasks which indicate the child’s ability to hear, follow directions and to
speak Gross-Motor – tasks which indicate the child’s ability to sit, walk and jump

MMDST KIT. Preparation for test administration involves the nurse ensuring the completeness
of the test materials contained in the MMDST Kit. These materials should be followed as
specified:

MMDST manual
o test Form
o bright red yarn pom-pom
o rattle with narrow handle
o eight 1-inch colored wooden blocks (red, yellow, blue green)
o small clear glass/bottle with 5/8 inch opening
o small bell with 2 ½ inch-diameter mouth
o rubber ball 12 ½ inches in circumference
o cheese curls
o pencil

EXPLAINING THE PROCEDURE. Once the materials are ready, the nurse explains the
procedure to the parent or caregiver of the child. It has to be emphasized that this is not a
diagnostic test but rather a screening test only. When conducting the test, the parents or
caregivers of the child under study should be informed that it is not an IQ test as it may be
misinterpreted by them. The nurse should also establish rapport with the parent and the child to
ensure cooperation.

AGE & THE AGE LINE. To proceed in the administration of the test, the nurse is to compute
for the exact age of the child, meaning the age of the child during the test date itself. The age is
the most crucial component of the test because it determines the test items that will be
applicable/ administered to the child. The exact age is computing by subtracting the child’s birth
date with the test date. After computing, draw the age line in the test form.

TEST ITEMS. There are 105 test items in MMDST but not all are administered. The examiner
prioritizes items that the age line passes through. It is however imperative to explain to the
parent or caregiver that the child is not expected to perform all the tasks correctly. If the
sequence were to be followed, the examiner should start with personal-social then progressing to
the other sectors. Items that are footnoted with “R” can be passed by report.
SCORING. The test items are scored as either Passed (P), Failed (F), Refused (R), or Nor
Opportunity (NO). Failure of an item that is completely to the left of the child’s age is
considered a developmental delay. Whereas, failure of an item that is completely to the right of
the child’s age line is acceptable and not a delay.

CONSIDERATIONS:

 Manner in which each test is administered must be exactly the same as stated in the
manual, words or direction may not be changed
 If the child is premature, subtract the number of weeks of prematurity. But if the child is
more than 2 years of age during the test, subtracting may not be necessary
 If the child is shy or uncooperative, the caregiver may be asked to administer the test
provided that the examiner instructs the caregiver to administer it exactly as directed in
the manual
 If the child is very shy or uncooperative, the test may be deferred

Bag Technique

The bag technique is a tool by which the nurse, during her visit will enable her to perform a
nursing procedure with ease and deftness, to save time and effort with the end view of rendering
effective nursing care to clients.
The public health bag is an essential and indispensable equipment of a public health nurse which
she has to carry along during her home visits. It contains basic medication and articles which are
necessary for giving care.

Principles
-Performing the bag technique will minimize, if not, prevent the spread of any
infection.
- It saves time and effort in the performance of nursing procedures.
- The bag technique can be performed in a variety of ways depending on the
agency’s policy, the home situation, or as long as principles of avoiding transfer
of infection is always observed.
The following are the contents of a Public Health Nurse bag:
- Paper lining
- Extra paper for making waste bag
- Plastic/linen lining
- Apron
- Hand towel
- Soap in a soap dish
- Thermometers (oral and rectal)
- 2 pairs of scissors (surgical and bandage)
- 2 pairs of forceps (curved and straight)
- Disposable syringes with needles (g. 23 & 25)
- Hypodermic needles (g. 19, 22, 23, 25)
- Sterile dressing
- Cotton balls
- Cord clamp
- Micropore plaster
- Tape measure
- 1 pair of sterile gloves
- Baby’s scale
- Alcohol lamp
- 2 test tubes
- Test tube
holders
Solutions of:
- Betadine
- 70% alcohol
- Zephiran solution
- Hydrogen peroxide
- Spirit of ammnonia
- Ophthalmic ointment
- Acetic acid
- Benedict’s solution
- *BP apparatus and stethoscope are carried separately and are never placed in the
bag.

Points to consider
- The bag should contain all the necessary articles, supplies and equipment that will
be used to answer the emergency needs
- The bag and its contents should be cleaned very often, the supplies replaced and
ready for use anytime.
- The bag and its contents should be well protected from contact with any article in
the patient’s home.
- Consider the bag and its contents clean and sterile, while articles that belong to
the patients as dirty and contaminated.
- The arrangement of the contents of the bag should be the one most convenient to
the user, to facilitate efficiency and avoid confusion.