FUNDAMENTALS

WEEK 1 LECTURE: REVIEW OF NURSING PROFESSION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

○ Started because of shortages of doctors

HISTORICAL AND CONTEMPORARY NURSING PRACTICE ● Baccalaureate Degree Program (BSN)
● Master’s Degree Program (MAN / MSN)
● Historical Perspective ● Doctoral Program (PhDN)
○ Women’s Role
■ Traditional female roles of wife, mother, daughter and
NURSING
sister have always included the care and nurturing of
other family members ● Is the protection, promotion, and optimization of health and
■ Nursing could be said to have its roots in “the home” abilities, prevention of illness and injury, alleviation of
○ Religion suffering through the diagnosis and treatment of response, and
■ Christian value of “love thy neighbor as thyself” advocacy in the care of individuals, families, communities.
■ Christ parable Good Samaritan – had significant impact (ANA 2010b)
on the development of western nursing ● As a Profession
■ Commitment to these values result in exploitation and ○ Not simply a collection of specific skills, and you are not
few monetary rewards simply a person trained to perform specific task
○ Societal Attitudes ■ Clinical practice
■ 1800s – nursing was without organization, education, ■ Education
or social status ■ Research
■ Prevailing attitude – woman’s place was in the home ■ Management
and no respectable woman should have a career ■ Administration
■ Nurses in hospitals are poorly educated ■ Entrepreneurship
○ “The patient is the center of your practice”
NURSING LEADERS ● As SCIENCE
○ Based on body of knowledge that is continually changing
● Florence Nightingale with new discoveries and innovations
○ Lady with a lamp ● As an ART
○ Mother of Modern Nursing ○ Delivering care artfully with compassion, caring, and
○ Known for Handwashing and Aseptic Technique respect for each patient’s dignity or personhood
● Clara Barton ● STANDARDS OF PRACTICE
○ School teacher who volunteered as a nurse during ○ Describes a competent level of nursing care
American Civil War ○ The levels of care are demonstrated by critical thinking
○ Established American Red Cross model known as NURSING PROCESS
● Linda Richards ○ NURSING PROCESS - foundation of clinical decision
○ First Trained nurse making and includes all significant actions taken by nurses
○ Doctor’s Order and Nurse’s notes in providing care to patients
○ Pioneered Psychiatric and Industrial nursing ● CODE OF ETHICS
○ Initiated the practice of nurses wearing uniform ○ The code of ethics is the philosophical ideals of right and
● Mary Mahoney wrong that define the principles you will used to provide
○ First African American Prof nurse care to your patients
○ Constantly worked for the acceptance of african american
nursing

SCOPE AND STANDARDS OF PRACTICE

MEN IN NURSING
● When giving care, it is essential to provide a specified service
● Worked before the crusades according to standards of practice and to follow a code of
● 1880’s – 1969 : School for male nurses existed ethics
● ANA denied membership to male nurses until 1930 ○ When providing care, it is important to follow established
standards and a code of ethics
NURSING EDUCATION ● Professional practice includes knowledge from social and
behavioral sciences, biological and physiological sciences, and
● Licensed Practical (Vocational) Nursing Program
nursing theories
○ Advanced; can diagnose, treat, and prescribe
medication like a doctor

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 1
 FUNDAMENTALS
WEEK 1 LECTURE: REVIEW OF NURSING PROFESSION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

CRITERIA OF A PROFESSION

● Specialized Education
● Body of Knowledge
○ Well defined body of knowledge and expertise
● Service Orientation
○ Service to others
● Ongoing Research
○ Increasing research in nursing is contributing to nursing
practice
● Code of ethics
○ The nursing profession requires integrity of its members
○ That is a member is expected to do what is considered
right regardless of the personal cost
● Autonomy
○ Independence at work, responsibility, and
accountability for one's actions
● Professional Organization
○ Professional organization that advances the nursing
profession by fostering high standards of nursing
practice, promoting the rights of the nurses in the
workplace

ROLES AND FUNCTION OF THE NURSE

● Caregiver
● Communicator
● Teacher
● Client Advocate
● Counselor
● Change Agent
● Leader
● Manager
● Case Manager
● Research consumer

EXPANDED CAREER ROLES

● Nurse practitioner
● Nurse anesthetist
● Nurse Educator
● Nurse midwife
● Nurse researcher
● Nurse administrator

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 2
 FUNDAMENTALS
WEEK 1 LECTURE: MEDICAL ASEPSIS AND SURGICAL ASEPSIS OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

■ Fever
TERMINOLOGIES ● BACTEREMIA
○ Presence of bacteria in the bloodstream
● COMMUNICABLE DISEASE ● SEPTICEMIA
○ An illness caused by an infectious agent or its toxins that ○ If bacteremia results in systemic infection
occurs through the direct and indirect transmission of ● COLONIZATION
infectious agent or its product from an infected individual ○ Microorganisms become resident flora
or via animal, vector, or the inanimate environment to a ○ Can grow and multiply but will not make you sick
susceptible animal or human host ● IATROGENIC INFECTION
○ Illness caused by an infectious agent that can spread from ○ Are the direct result of diagnostic or therapeutic
an infected person, animal, insect, or object to another procedures
person or animal. This spread can happen through direct ● QUARANTINE
contact or indirect means such as through the air, bites ○ Limitation of the freedom of movement of persons or
from insects, or touching contaminated surface animals which have been exposed to a communicable
● VIRULENCE disease for a period of time equivalent to the longest
○ Severity or harmfulness of the disease incubation period of that disease
● INFECTION
○ Implantation and successful replication of an organism in
the tissue of the host resulting in signs and symptoms
ASEPSIS
○ INFECTIOUS AGENT
■ Bacteria ● Freedom of disease causing microorganisms or pathogens
■ Fungi ● 2 TYPES
■ Parasites ○ MEDICAL ASEPSIS (CLEAN TECHNIQUE)
■ Viruses ■ Practices intended to confine or reduce
○ TYPES OF INFECTION microorganisms
■ LOCAL INFECTION - Limited to specific part of the ■ Used for non invasive practices
body where the microorganism remain ○ SURGICAL ASEPSIS (STERILE TECHNIQUE)
■ SYSTEMIC INFECTION - Spread of infection to ■ Practices that keep an area or an object free from all
different parts of the body microorganisms
■ ACUTE INFECTION - Generally appear suddenly or ■ Used for invasive practices
last a short time
■ CHRONIC INFECTION - May occur slowly, over a very NOSOCOMIAL INFECTIONS
long period of time, may last for months or years
● PATHOGENICITY ● CLABSI (CENTRAL IV LINE ASSOCIATED BLOOD INFECTION)
○ Ability of a microorganism to produce a disease ○ Improper tubing and site care technique
● PATHOGEN ○ Inadequate hand hygiene
○ Microorganisms that causes disease ● CAUTI (CATHETER ASSOCIATED UTI)
○ 2 TYPES ○ Improper catheterization technique
■ True Pathogen - Affects healthy and ○ Contamination of closed drainage system
immunosuppressed individuals ○ Inadequate hand hygiene
■ Opportunistic Pathogen -Affects immunosuppressed ● SSI (SURGICAL SITE INFECTION)
individuals ○ Improper dressing change
● SEPSIS ○ Inadequate hand hygiene
○ Condition in which acute organ dysfunction occurs ● VAP (VENTILATOR ASSOCIATED PNEUMONIA)
secondary to infection ○ Improper suctioning
○ A sudden failure of organ happens because of an infection ○ Inadequate hand hygiene
● SEPTIC SHOCK
○ When the infection causes low bp and organ failure
○ SIGNS AND SYMPTOMS 5 MOMENTS OF HAND WASHING
■ Hypotension
● Before touching the client
■ Tachypnea
● Before clean or aseptic procedure
■ Tachycardia
● After body fluid exposure

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 3
 FUNDAMENTALS
WEEK 1 LECTURE: MEDICAL ASEPSIS AND SURGICAL ASEPSIS OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

● After touching the client ○ Mouth

● After touching the client’s environment ○ Nose
○ Eyes
○
CHAIN OF INFECTION ○Cuts through the skin
TO BREAK
● Etiologic Agent ■ Aseptic technique for invasive procedures
○ Any microbe capable of producing disease ■ Place used needles and syringes in puncture resistant
TO BREAK containers
■ Articles cleaned and disinfected before use ■ Provide clients with their own personal care items
● Reservoir ■ PPE
○ Where organism survive and multiplies ● Susceptible Host
○ Carrier can be human or animal reservoir ○ Any individual who is at risk of infection
TO BREAK ○ TO BREAK:
■ Change dressing when soiled ■ Maintain the integrity of the skin
■ Skin and oral hygiene ■ Well-balanced diet
■ Dispose feces and urine in appropriate receptacles ■ Immunization
■ Duction and drainage bottles covered ■ Encourage deep, slow, full breathing
■ Empty suction and drainage bottles per shift ■ Ambulation and movement
● Portal of Exit ■ Stress management
○ Coughing
○ Sneezing
○ Bodily secretions
○ Feces
TO BREAK: COUGHING
■ Cover mouth and nose when sneezing
● Mode of Transmission
○ Direct Transmission
■ Individual to individual
■ Droplet - form of direct transmission
● Can occur only if within 1m (3ft)
○ Indirect Transmission
■ Vehicle borne Transmission
● Fomites
● Inanimate materials or objects
■ Vector borne Transmission
● Animal or flying or crawling insects
○ Airborne Transmission
● Residue of evaporated droplets
● Remains in air for long periods BODY DEFENSES AGAINST INFECTION
TO BREAK:
● NON SPECIFIC
■ Handwashing
○ Protects the individuals against ALL microorganisms
■ Wear gloves when handling secretions
■ Anatomic and Physiologic Barriers
■ Wear gown if there is danger of soiling clothing with
■ Inflammation
body substance
● SPECIFIC
■ Hold used bedpans steadily to prevent spillage
○ Specific defense against pathogens
■ Wear mask and eye protection when in close contacts
■ Antibody mediated
with patients who have infections transmitted by
■ Cell mediated
droplets
■ Implement INFECTION PREVENTION STRATEGIES for
all clients
● Portal of Entry NON SPECIFIC

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 4
 FUNDAMENTALS
WEEK 1 LECTURE: MEDICAL ASEPSIS AND SURGICAL ASEPSIS OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

● ANATOMIC AND PHYSIOLOGIC BARRIERS SPECIFIC

○ Intact skin and mucous membranes
○ CIlia ● Antibody mediated
○ Lungs (Large Phagocytes ○ Active Immunity
○ Saliva “LAway” (Lactoferrin, Lysozymes, IgA) ○ Passive Immunity
○ Eyes (Tears) ● Cell mediated
○ High acidity of stomach ○ Helper T cells - Help in the functions of the immune system
○ Vagina (pH 3.5 to 4.5) ○ Cytotoxic T cells - Attack and kill m.o and sometimes the
○ Urine flow (Flushing and bacteriostatic) body’s own cells
● INFLAMMATORY RESPONSE ○ Suppressor T cells - suppress the functions of helper T cells
○ Redness (Rubor) and the cytotoxic T cells
○ Heat (Calor)
○ Swelling (Tumor) DISINFECTION AND STERILIZATION
○ Pain (Dolor(
○ Concurrent - Done while the individual is still the source of
○ Loss of function
infection
● STAGES OF INFLAMMATION (VER)
○ Terminal - The patient is no longer the source of infection
○ Vascular and Cellular Responses
● Disinfection
■ Blood vessels at injury site constrict (VAS.)
○ Process of elimination of pathogenic microorganisms
■ Blood vessels dilate due to histamine release
EXCEPT spores
● Histamine is a chemical in our immune system
● Sterilization
responsible for increasing permeability of the
○ Process of complete elimination of ALL forms of microbial
blood vessels, to make it easier for the white
life
blood cells to go into the infected tissue
■ Fluids proteins and leukocytes leak into surrounding
tissue causing swelling (tumor) pressure on nerve
INFECTION PREVENTION AND CONTROL
endings resulting in pain (dolor) (CEL.)
■ Increase in leukocytes ISOLATION - Measures designed to prevent the spread of infections
○ Exudate formation or potentially infectious microorganisms to health personnel, clients,
■ Injurious agent is overcome, the exudate is cleared and visitors
away by the lymphatic drainage ○ ISOLATION CATEGORIES
■ TYPES OF EXUDATES ■ Strict Isolation - Designed to prevent highly
● Serous Exudates - chiefly serum (blister from a contagious or virulent infection (private room, hand
burn) washing, PPEs)
● Purulent Exudates - Thicker than serous ■ Contact Isolation - Prevent infections transmitted
(contains pus) primarily by direct contact
● Sanguineous (Hemorrhagic) Exudates - large ■ Respiratory Isolation - Prevent transmission over a
amount of RBC (wounds) short distance through the air
● Bright Sanguineous - fresh bleeding ■ Enteric Isolation - prevent the spread through direct
● Dark Sanguineous - Older bleeding contact from feces
● Serosanguineous - Clear and blood tinged ● Sterilization
drainage (Surg, incision) ○ Process of complete elimination of ALL forms of microbial
● Purosanguineous - consist of pus and blood life
(new wound that is infected)
○ Reparative Phase STANDARD PRECAUTIONS / UNIVERSAL PRECAUTIONS
■ Replacement of destroyed tissue cells by cells that
are identical or similar in structure and function ● Designed for ALL clients in hospital
■ When regeneration is not possible, repair occurs by ● Practices:
scar/cicatrix ○ Hand hygiene
■ Granulation tissue - fragile gelatinous tissue, ○ Gloves (when touching blood or bodily fluids)
appearing pink or red because of many newly formed ○ Mask, eye protection, face shield
capillaries ○ Water resistant gown (If splashes or sprays of blood, bodily
fluids)

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 5
 FUNDAMENTALS
WEEK 1 LECTURE: MEDICAL ASEPSIS AND SURGICAL ASEPSIS OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

○ Needles and sharps placed into puncture-proof containers ■ After hand hygiene, DO NOT touch possibly
● Applies to: contaminated surface
○ Blood ○ Wear gown if the client is:
○ All body fluids ■ Incontinent
○ Excretions and secretions (except sweat) ■ Has diarrhea
○ Non intact skin ■ Colostomy
○ Mucous membranes ■ Wound drainage without drainage

TRANSMISSION BASED PRECAUTIONS Remove gown in the clients room and make sure uniform
does not contact possible contaminated surface
● AIRBORNE PRECAUTIONS
○ AIRBORNE INFECTION ISOLATION ROOM (AIIR) – private ○ Dedicate use of noncritical client care equipment to a single
room that has negative air pressure client or to client with the same infecting microorganisms
○ If AIIR is not available, place client with another client who
is infected with the same microorganisms
PERSONAL PROTECTIVE EQUIPMENT
○ Wear an N95 respirator mask (primary tuberculosis)
○ Susceptible individuals SHOULD NOT enter the room of a ● LEVEL A
client with RUBEOLA (measles) or VARICELLA (chicken ○ Self-rebreathing apparatus with garment totally
pox). If they must enter, they should wear a respirator encapsulated chemical suit
mask ○ Gives the highest protection
○ Place a surgical mask on the client during transport ● LEVEL B
○ PRECAUTIONS APPLICABLE FOR MTVHSC ○ Positive pressure with non encapsulated chemical suit
■ Measles (Rubeola) ● LEVEL C
■ Tuberculosis (suspected tuberculosis) ○ Air purifying respirator
■ Varicella (chicken pox) ● LEVEL D
■ Herpes Zoster ○ Standard work clothes without a respirator
■ Smallpox, SARS ● MASK
■ Covid ○ Mask should fit tightly to the face, covering the nose and
● DROPLET PRECAUTIONS the mouth
○ Place client in private room ○ They should lose their effectiveness if they are WET, WORN
○ If private room is not available, place client with another for a long periods, and when they are not changed after
client who is infected with the same microorganism caring for each client
○ Wear a mask if working within 1m (3ft) of the client ● GOWNS
○ PRECAUTIONS APPLICABLE FOR DROPETISM ○ SHould be worn when caregiver’s clothing is likely to be
■ Diphtheria soiled by infected material
■ Rubella ○ Use it only once and discard them
■ Oral Pharyngitis ● CAP AND SHOE COVER
■ Pneumonia, Pertussis ○ Caps are used to cover the hair, special covers are available
■ Erythema Infectiosum for shoes
■ Tonsillitis ○ These shield body parts from accidental exposure to
■ Influenza contaminated body secretions
■ Scarlet fever ● GLOVES
■ Meningitis ○ Protect the hands from acquiring infective organisms
● CONTACT PRECAUTIONS
○ Place client in private room
○ If private room is not available, place the client with TYPES OF WASTE OR DISPOSALS
another client who is infected with the same
microorganisms ● INFECTIOUS WASTE (YELLOW)
○ Wear gloves ○ Blood and body products
■ Change gloves after contact ○ Pathology laboratory specimen
■ Remove gloves before leaving client’s room ○ Laboratory cultures
■ Clean hands immediately. Use antimicrobial agent ○ Contaminated equipment

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 6
 FUNDAMENTALS
WEEK 1 LECTURE: MEDICAL ASEPSIS AND SURGICAL ASEPSIS OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

○ Food
○ Infant and Adult diapers
● INJURIOUS WASTE
○ Needles
○ Scalpel
○ Blades
○ Lancets
○ Broken glass
● HAZARDOUS WASTE (RED)
○ Radioactive materials
○ Chemotherapy solutions and their containers
○ Other caustic chemicals

LEVELS OF PREVENTIVE CARE

● PRIMARY PREVENTION
○ “True prevention”
○ Applied to clients that are healthy
○ Health promotion, Health education, immunization,
nutrition , physical fitness
● SECONDARY PREVENTION
○ Focuses on ill or sick individuals and those at risk of
developing complications
○ Directed towards diagnosis and intervention
○ Screenings, surgery, medications
● TERTIARY PREVENTION
○ Focuses on permanent or irreversible disability
○ MInimizing the long term effect of illness
○ Rehabilitation (PT)

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 7
 FUNDAMENTALS
WEEK 1 LECTURE: THERAPEUTIC COMMUNICATION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

■Friendship - warmth touch involves hug in greeting,

THERAPEUTIC COMMUNICATION arm thrown around the shoulder of a good friend.
Back slapping
● Exchange of information between the client and the nurse that ■ Love - tight hugs and kisses between lovers or close
promotes positive behavioral change relatives
● During the assessment, it is very important to establish a good ■ Sexual - arousal touch is used by lovers
relationship with the client ● ACTIVE LISTENING AND OBSERVATION
○ This helps the client feel comfortable and share more ○ Passive listening
information ■ Sitting quietly and letting the patient talk, does not
● How well they communicate depends on: focus or guide
○ Preparation ■ Thought process of patient does not foster
○ Nurse’s attitude and communication technique therapeutic relationship
○ Client’s experiences and environment ○ Active Listening
■ Nurse focus on what the patient is saying to
interpret and respond to the message objectively
ELEMENTS OF THERAPEUTIC COMMUNICATION ● COMMUNICATION SKILLS
● TRUST
○ Nurse should be consistent in words and actions MODES OF THERAPEUTIC COMMUNICATION
○ Being friendly, caring, interested, understanding, and ● DO’s
consistent ○ APPEARANCE
● GENUINE INTEREST ■ Comfortable and neat uniform
○ Self disclosure (sharing personal experiences) ■ Hair should be neet and pulled back (if long)
○ Self awareness ■ Fingernails should be short and neat
○ Patient can tell if someone is being fake or not ■ Minimal jewelry
● EMPATHY ○ DEMEANOR
○ Understand the client’s feelings and what they mean ■ Professional and poise
○ Listening carefully and sensing the situation ■ Greet client calmly and with proper references
○ Being open, non judgemental, and understanding ■ DO NOT be overwhelmingly friendly or touchy
● POSITIVE REGARDS ■ Maintain professional distance
○ Unconditional, non judgemental attitude ○ FACIAL EXPRESSION
● ACCEPTANCE ■ Closely monitor facial expressions
○ Not easily upset and avoiding judgment ■ DIsplay a Neutral expression
○ ATTITUDE
WAYS TO THERAPEUTIC RELATIONSHIP ■ Nonjudgmental attitude
■ All clients should be accepted, regardless of beliefs,
● PRIVACY AND RESPECTING BOUNDARIES
ethnicity, lifestyle, and health care practices
○ Defining limits on individuals boundaries (personal, social
○ SILENCE
and professional)
■ Allows the nurse and client to reflect and organize
○ PROXEMICS:
thoughts, which facilitates more accurate reporting
■ Study of distance zones between people during
and data collections
communication
○ LISTENING
■ 4 DISTANCE ZONE:
■ Demonstrate Active listening
● Intimate: 6 - 18 inches
■ Maintain good eye contact
● Personal: 18 - 47 inches
■ Appropriate facial expression
● Social: 47 inches - 3 yard
■ Open body position (Arms, hands)
● Public: over 3 yard
■ Lean forward
● TOUCH
○ 5 TYPES OF TOUCH
● DON'TS
■ Functional - used in examinations or procedures
○ Excessive or insufficient eye contact
■ Social - polite touch is used in greeting (handshake &
■ Excessive - makes client uncomfortable
air kisses)
■ Insufficient - make client think ur hiding something

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 8
 FUNDAMENTALS
WEEK 1 LECTURE: THERAPEUTIC COMMUNICATION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO <3

○ DISTRACTION AND DISTANCE

■ Avoid being occupied with something else while you SPECIAL CONSIDERATIONS DURING THE INTERVIEW
are asking questions during interview
■ Try to avoid physical distance exceeding 2 - 3 ft ● COMMUNICATING WITH THE ELDERLY
during the interview ○ Consider the hearing ability of the client
■ Rapport and trust are established when the client ○ Speak clearly
senses your focus and concern are solely on the client ○ Use straightforward language
and client’s health ○ If the old client is confused or forgetful, interview the client
○ STANDING with significant others
■ Avoid standing while the client is seated during the ● COMMUNICATING WITH CHILDREN
interview ○ Interview toddlers, preschoolers and schoolers with their
■ Standing puts you and the client at different levels parents
■ Can be perceived as the superior, making the client ○ Use simple words
inferior ○ Maintain eye contact and same eye level with the child
● COMMUNICATING WITH THE PEOPLE OF DIFFERENT CULTURE
○ REluctance to reveal personal information to strangers for
VERBAL COMMUNICATION
various culturally-based reasons
● DO’s ○ Variation in meaning conveyed by language
○ OPEN ENDED QUESTION ○ Variation in use and meaning of non-verbal communication
■ Used to elicit the client’s feelings and perceptions ■ Eye contact
○ CLOSE ENDED QUESTION ■ Stance gestures
■ Used to obtain facts and to focus on specific ■ Demeanor
information ○ Variation in disease/illness perception
○ LAUNDRY LIST ○ Variation in family roles
■ Providing clients with a list of words to choose from ○ Variation in cultural health practices
in describing symptoms, conditions, or feelings ● COMMUNICATING WITH HIGHLY EMOTIONAL CLIENTS
○ REPHRASING ○ Clients’ emotions vary for number of reasons
■ Helps to clarify information the client has stated ○ CLients’ may have some sensitive issues which they are
grappling
PHASES OF INTERVIEW

● PRE-INTRODUCTORY PHASE
○ Nurse prepares herself for the interview
○ Nurse reviews the medical record before meeting with the
client
● INTRODUCTORY PHASE
○ Nurse introduce herself to the client
○ Nurse explains the purpose of the interview, the types of
questions, reasons for taking notes
○ Nurse assures the client that confidential information will
remain confidential
● WORKING PHASE
○ The nurse gets the client’s comments about major
biographical data, reasons for seeking care, health history,
review of body system for current health problems, lifestyle
and health practices and developmental levels
● SUMMARY AND CLOSING PHASE
○ Nurse summarizes information obtained during working
phases and validates problems and goals with the client
○ Nurse identifies and discusses possible plans to resolve the
problem with the client

FUNDAMENTALS OF NURSING REVIEW OF NURSING PROFESSION, MEDICAL & SURGICAL ASEPSIS, THERAPEUTIC COMMUNICATION 9
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WEEK 1 LABORATORY: BED BATH OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○Nursing personnel on the night shift provide basic hygiene

BED BATH to patients getting ready for breakfast, scheduled test, or
early morning surgery
● PURPOSE ○ “AM CARE” includes offering a bedpan or urinal if the
○ To remove: patient is not ambulatory, washing the patient’s hands and
■ Transient Microorganisms face, and helping with oral care
■ Body secretions and Excretions ● ROUTINE MORNING CARE
■ Dead skin cells ○ After breakfast help by offering bedpan or urinal to patients
○ To stimulate circulation confined to bed
○ To produce a sense of well being ○ Provide a full or patial bath or shower, including:
○ To promote relaxation and comfort ■ Perineal care
○ To prevent unpleasant odor ■ Oral care
○ Provides mild exercise ■ Foot care
○ Allows assessment of skin condition, joint mobility and ■ Nail care
muscle strength ■ Hair care
○ Change patient’s gown and bed linens
BATHING PROCEDURE ○ Often referred to as “COMPLETE AM CARE”
● AFTERNOON CARE
● Water Temperature: 35.5 - 36.5 (96-98F)
○ Hospitalized patients often undergo many exhausting
● Preparation
diagnostic test or procedures in the morning
○ Place the bed in high position
○ AFternoon hygiene care includes:
○ Ask the client to move near you
■ Washing hands and face
● Bathing Steps:
■ Helping with oral care
○ Face: Inner to outer eye
■ Offering bedpan or urinal
○ Extremities: Use long firm strokes (proximal to distal in the
■ Straightening bed linen
direction of venous flow) to increase the venous return
● EVENING OR HOUR BEFORE SLEEP CARE (PM CARE)
○ Chest and Abdomen
○ Before bed time offer personal hygiene care that helps
○ Legs and Feet
patients relax and promotes sleeps
○ The back and the perineum
○ Includes:
■ Changing soiled linens and gowns
MATERIALS
■ Helping patients wash the face and hands
● Basin or sink with warm water ■ Providing oral hygiene
● Soap and soap dish or liquid chlorhexidine gluconate (CHG) ■ Giving back massage
(CHG cloths optional) TYPES OF BED BATH
● Linens:
● COMPLETE BED BATH
○ Bath blanket
○ Bath administered to totally dependent patient in bed
○ Two bath towels
● PARTIAL BED BATH
○ Washcloth
○ Bed bath that consist of bathing only body parts that would
○ Clean gown
cause discomfort if left unbathed
○ Pajamas or clothes PRN
■ Hands
○ Additional bed linens and towels if required
■ Face
● Gloves if appropriate
■ Axillae
● Personal hygiene articles
■ Perineal
● Shaving equipment needed
○ May also include washing back and providing back rub
● Table for bathing equipment
○ Provide partial bath to dependent patients in need of
● Laundry hamper
partial hygiene or self sufficient bedridden patients who
HYGIENE CARE SCHEDULE IN ACUTE AND LONG TERM CARE
are unable to reach all body parts
SETTINGS
● SPONGE BATH
● EARLY MORNING CARE ○ Involves bathing from a bath basin or sink with patient
sitting in a chair
○ Patient is able to perform part of bath independently

FUNDAMENTALS OF NURSING REVIEWER FOR BED BATH, ORAL HYGIENE, MASSAGING AND BED MAKING 1
 FUNDAMENTALS
WEEK 1 LABORATORY: BED BATH OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○ Assistance is needed for hard to reach areas

● TUB BATH
○ Involves immersion in a tub of water that allows more
thorough washing and rinsing than a bed bath
● SHOWER
○ Patient sits or stands under a continuous stream of water.
○ Provides more thorough cleaning than a bed bath but can
cause fatigue
● CHLORHEXIDINE GLUCONATE (CHG) BATH
○ This antimicrobial bath wipe is used to decrease the
frequency of hospital acquired infections on skin, invasive
lines, and catheters

FUNDAMENTALS OF NURSING REVIEWER FOR BED BATH, ORAL HYGIENE, MASSAGING AND BED MAKING 2
 FUNDAMENTALS
WEEK 1 LABORATORY: ORAL HYGIENE OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○ Toothpaste
ORAL HYGIENE ○ Sink or small basin
○ Floss
● Maintaining cleanliness of the oral cavity ○ Mouthwash
● ABNORMALITIES ○ Gloves
○ Dental caries ○ Towel
○ Periodontal diseases
○ Plaque ORAL HYGIENE FOR DENTURES
○ Tartar
○ Flossing ● MATERIALS
● WHY IS IT IMPORTANT? ○ Denture cup
○ Maintains the healthy state of the mouth ○ Small basin
■ Cleanses teeth of food particles, plaque, and bacteria ○ Tissues
■ Massages the gums ○ Denture toothpaste
○ Relieves discomfort from unpleasant odors and tastes ○ Towel
○ Refreshes the mouth and gives a sense of well being and ○ Mouthwash
thus can stimulate appetite ○ Denture solution or tablets
○ Reduces the risk for cavities ○ Hand gloves

ORAL HYGIENE ASSESSMENT ORAL DENTURE CARE

● FREQUENCY ● Clean dentures as frequently as natural teeth

○ Depends on the condition of the patient’s mouth ● Dentures are the patient's personal property and should be
○ Some patients with dry mouth or lips need care every 2 handled with care because they can be easily broken
HOURS ● Remove before going to bed – allows gums to rest and
○ Usually done twice a day or after each meal prevents buildup of bacteria
● ASSISTANCE NEEDED ● Store in a labeled container covered with water or denture
○ Does the patient need assistance to do oral care cleaner if available
○ The nurse can help patients maintain good oral hygiene by
■ Teaching them correct techniques UNCONSCIOUS PATIENT
■ Actual performing for weakened or disabled patients
● ABNORMALITIES ● PREVENT ASPIRATION
○ Loose or missing teeth ○ Positioning
○ Swelling and bleeding of gums ■ Lateral position with head turned to the side or side
○ Unusual mouth odor lying
○ Pain or stinging in mouth structures ■ Position back of the head on a pillow so the face tips
forwards and fluid/secretions will flow out of the
BRUSHING mouth not back into the throat
■ Place a bulb syringe or suction machine with suction
● MAJOR CONCERNS ARE: equipment nearby
○ Thoroughness in cleansing ● KEEPING THE MOUTH OPEN
○ Maintaining of the oral mucosa ○ Never place your hand in the patient’s mouth or open with
● POSITIONING your fingers. Oral stimulation often causes the biting down
○ Conscious patient – upright reflex and serious injury can occur
○ Unconscious patient – side lying ○ Use a padded tongue blade to open the patient's mouth
■ Recommended side is the left lateral recumbent and separate the upper and lower teeth
position – in this position, the person is lying on their
left side with arm extended and the leg bent at right
angle to provide stability
● MATERIALS
○ Water

FUNDAMENTALS OF NURSING REVIEWER FOR BED BATH, ORAL HYGIENE, MASSAGING AND BED MAKING 3
 FUNDAMENTALS
WEEK 1 LABORATORY: ORAL HYGIENE OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

IMPORTANT NOTES

● Mouth care should be given before and or after meals in the

morning and at night before the person goes to sleep
● When a person is unconscious, they may need oral care every
two hours
● Oral care keeps the mouth and teeth clean and without odors
● It prevents cavities, infection, gum disease, and bad breath. It is
a very important part of care
● IF YOU NOTICE ANY THINGS BELOW DURING ORAL CARE,
THEY MUST BE REPORTED AND DOCUMENTED
○ Sores
○ Redness or bleeding in the mouth on the gums, cheeks, or
lops
○ Pain during mouth care
○ Coating of the tongue or cheeks
○ Broken teeth or dentures
○ Bad breath

FUNDAMENTALS OF NURSING REVIEWER FOR BED BATH, ORAL HYGIENE, MASSAGING AND BED MAKING 4
 FUNDAMENTALS
WEEK 1 LABORATORY: BACK RUB OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

● Note any areas of redness or impairment

BACK RUB ● Report any areas of skin breakdown to the health care team

● Means massaging patient’s back while paying attention to

pressure points
● It promotes relaxation, relieves muscular tension. And
decreases perception of pain
● PURPOSES
○ To promote circulation to the back
○ To reduce anxiety
○ To relieve fatigue. Pain, and stress
○ To help induce sleep
○ To prevent bedsore
○ To provide comfort]

BACK RUB MATERIALS

● Face towel
● Drapes
● Bath towel
● Oil or Lotion

TYPES OF MASSAGE

● EFFLEURAGE (STROKING)
○ A long , sweeping, movements using the palm of the hand
to follow the shape of the area being massage (such as
neck)
○ The thumb and fingers are also used
○ Known to help reduce anxiety, heart rate, and respiratory
rate
● PETRISSAGE (KNEADING)
○ Using the edge of the palm to rest on the surface while the
fingers and thumb grasp and knead the skin and underlying
tissues
○ Helps improve blood circulation, speed up recovery, stretch
and loosen muscle fibers, and increase range of movement
● TAPOTEMENT (FRICTION)
○ Rapid, percussive tapping, slapping and cupping of the
patient’s back
○ It is used to strengthen deep tissue muscles

NURSING CONSIDERATIONS

● Do not massage patient’s legs or calf muscle to avoid the risk of

dislodging a vascular clot
● Have the patient relax, by instructing to take slow deep
breaths
● Ask patient to rate level of pain
● Note any areas of muscle pain or tension

FUNDAMENTALS OF NURSING REVIEWER FOR BED BATH, ORAL HYGIENE, MASSAGING AND BED MAKING 5
 FUNDAMENTALS
WEEK 1 LABORATORY: BED MAKING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

■ Fanfold means to fold sheets in accordion pleats

BED MAKING ■ Done to welcome a new patient or for patients who
are ambulatory or out of bed
● It is a technique of preparing different types of bed in making a ● OCCUPIED BED
patient comfortable or his position suitable for a particular ○ Bed is made while patient is in it
condition ○ Usually done after morning bath
● PURPOSE ● BED WITH CRADLE
○ To provide the client with a safe and comfortable bed to ○ Cradle placed on bed under the top sheet
take rest and sleep ○ Prevents top sheet from touching parts of the patient's
body
○ To keep the ward neat and tidy
○ To adapt to the needs of the client and to be ready for any ○ Used for burns, skin ulcers, lesions, blood clots, fracture or
emergency or critical condition of illness surgery
○ To economize time, material, and effort ○ Some cradles have light bulls to provide heat for special
treatments
○ To accommodate the patient’s needs
○ To prevent bed sores ● SURGICAL BED
○ To observe the client ○ To facilitate easy transfer of the patient from stretcher to
bed
○ For patient comfort
○ To prevent cross infection
○ For treatment of certain conditions COMMONLY USED BED POSITIONS

PARTS OF THE BED ● FLAT / SUPINE

● SEMI FOWLER’S POSITION
● MATTRESSES ● FOWLER’S POSITION
○ Mattresses used for the client should be firm thick and ● TRENDELENBURG’S POSITION
smooth ● REVERSE TRENDELENBURG’S POSITION
○ It gives support to the client
○ All should have a washable cover PATIENT POSITIONING
○ Size is 190 cm width
● SIDE RAILS ● HIGH FOWLER'S POSITION
○ Serve as a safe and effective means of preventing clients ○ HOB at 60 - 90 degrees, patient sitting up
from falling out of bed ○ Used during respiratory distress, tube insertion, or with
● FOOTBOARD feeding precautions
○ Used to support the immobilized client’s foot in a normal ○ NURSING CONCERNS
right angle to the legs to prevent plantar flexion ■ Can be uncomfortable long term
contractures ■ Risk of slumping if the patient lacks strength
● BED CRADLES ■ Prevent pressure ulcer (repositioning q2h)
○ Is a device designed to keep the top bedclothes off the feet, ○ Knees can be bent straight. May need to float heels (may
legs,and even abdomen of a client need to float heels means the patient heels should be
● INTRAVENOUS RODS / IV POLE elevated off the bed to prevent pressure ulcer)
○ Usually made of metal, support intravenous infusion ● FOWLER’S POSITION / STANDARD FOWLER’s
containers while fluid is being administered to a client ○ HOB at 45 to 60 degrees, patient reclined
○ Helps with breathing difficulty, feeding, and postpartum
TYPES OF BED MAKING rest
○ Minimal nursing concerns
● UNOCCUPIED BED ○ Knees can be bent or straight. May need to float heels
○ Closed Bed ● SEMI FOWLER’S POSITION
■ Made following discharge of patient ○ HOB at 15 to 30 degrees, patient lying on back
■ To keep the bed clean until new patient is admitted ○ Used after surgery for cardiac / neuro issues and with
feeding tubes
○ Open Bed
■ Fanfold top sheet to foot of bed to convert closed ○ NURSING CONCERNS
bed to open bed ■ Watch for tube feeding issues or aspiration risks

FUNDAMENTALS OF NURSING REVIEWER FOR BED BATH, ORAL HYGIENE, MASSAGING AND BED MAKING 6
 FUNDAMENTALS
WEEK 1 LABORATORY: BED MAKING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○ May need to float heels

● SUPINE POSITION
○ HOB flat, patient on back
○ Used for post procedures to maintain hemostasis,
common for many surgeries
○ NURSING CONCERNS
■ RIsk for pressure sores
■ Must be diligent in turning patient
■ May be uncomfortable for sleep apnea patients
■ Watch for added pressure on the vena cava and
hypotension
○ Frequent turning is essential
● PRONE POSITION
○ HOB flat, patient on stomach with head to one side
○ Used therapeutically advanced ARDS (acute respiratory
distress syndrome) and some surgeries
○ NURSING CONCERNS
■ Uncomfortable for long periods
■ Not easy to use with tubes/lines
○ Monitor respiratory effort closely
● TRENDELENBURG POSITION
○ Flat on back, feet raised higher than head by 15 - 30
degrees
○ Used during CVC (central venous catheter) placement, for
suspected air embolism, to increase perfusion during
distress
○ NURSING CONCERNS
■ Not ideal with increased intracranial pressure
■ Can be uncomfortable and may increase fall risk in
confused patients
○ Used for hypotension management but evidence is mixed
● REVERSE TRENDELENBURG POSITION
○ Flat on back, head raised higher than feet by 15 - 30
degrees
○ Used for pre surgery or procedures, facilitates respiration in
some patients, reduces GERD symptoms
○ NURSING CONCERNS
■ Uncomfortable for long periods
■ Challenging for confused patient
○ Watch for patient safety and comfort

FUNDAMENTALS OF NURSING REVIEWER FOR BED BATH, ORAL HYGIENE, MASSAGING AND BED MAKING 7
 FUNDAMENTALS
WEEK 2 LECTURE: NURSING PROCESS AND ASSESSMENT OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○The nursing process is a dynamic, cyclical process in which

NURSING PROCESS each phase interacts with and is influenced by other phases
● REQUIRES CRITICAL THINKING
● It is defined as a systematic (based on agreed set of methods ○ The use of nursing process requires critical thinking which is
or organized plan), rational method (Based on clear thought a vital skill required for nurses in identifying client
and reason) of planning that guides all nursing actions in problems and implementing interventions to promote
delivering holistic and patient-focused care effective care outcomes
● The nursing process is a form of scientific reasoning and
requires the nurse’s critical thinking to provide the best care as NURSING PROCESS STEPS
possible
● PURPOSE: ● The nursing process consist of five steps: ADPIE
○ To identify the client’s health status and actual or ○ Assessment
potential healthcare problems or needs (through ○ Diagnosis
assessment) ○ Planning
○ To establish plans to meet the identified needs ○ Implementation
○ To deliver specific nursing interventions to meet those ○ Evaluation
needs ● Nurses need to learn how to apply the process step by step
○ To apply best available caregiving evidence and promote ● Critical thinking develops through experience, they learn how
human function and responses to health and illness to move back and forth among the steps of nursing process
○ To protect nurses against legal problems related to nursing ● The steps of the nursing process are not separate entities but
care when the standards of nursing process are followed overlapping, continuing subprocesses
correctly ● The nurse promotes awareness of defining characteristics and
○ To help the nurse perform in a systematically organized way behaviors of the diagnoses, related factors to the selected
their practice nursing diagnoses and interventions suited for treating
○ To establish database about the client’s health status, diagnoses
health concerns, response to illness, and the ability to
manage healthcare needs NURSING ASSESSMENT

CHARACTERISTICS OF THE NURSING PROCESS

● PATIENT CENTERED ■ FOUR MAJOR ACTIVITY ASSOCIATED WITH ASSESS

○ Requires care respectful of and responsive to the ING PHASE
individual patient’s needs, preferences, and values. ■ DIFFERENTIATE SUBJECTIVE AND OBJECTIVE DATA
○ The nurse functions as a patient advocate by keeping the ■ IDENTIFY 3 METHODS OF DATA COLLECTION
patient’s right to practice informed decision making and
maintaining patient centered engagement in the health
care settings
● INTERPERSONAL
○ Provides the basis for the therapeutic process in which the ● ASSESSING
nurse and patient respect each others as individuals ○ First step of nursing process
○ Both of them are learning and growing due to the ○ Systematic and continuous collection, organization,
interaction validation, and documentation of data
○ It involves the interaction between the nurse and the ○ Focuses on client’s responses to a health problem
patient with a common goal
● COLLABORATIVE TYPES OF ASSESSMENT
○ The nursing process functions effectively in nursing and
inter-professional teams, promoting open communication,
● INITIAL / ASSESSMENT
mutual respect, and shared decision making to achieve
○ Perform within a specified time – after admission to a
quality patient care health care agency
● DYNAMIC AND CYCLICAL ○ To establish a complete database for problem identification,
reference, and future comparison

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 1
 FUNDAMENTALS
WEEK 2 LECTURE: NURSING PROCESS AND ASSESSMENT OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○ The nurse during admission will perform this type of TYPES OF DATA
assessment
● PROBLEM FOCUSED ASSESSMENT
● Subjective data/Covert Data/Symptoms
○ Ongoing process integrated with nursing care ○ Can be described or verified only by that individual
○ To determine the status of a specific problem identified in ○ Itching, pain, and feelings of worry
an earlier assessment
○ Feelings, values, beliefs, attitude
○ EXAMPLE: ○ Cannot be observed, Concealed, Hidden
■ Hourly assessment of fluid intake and urinary output ● Objective data/Overt Data/Signs
in an intensive care unit (ICU)
○ Can be observed or can be measured or tested against an
● EMERGENCY ASSESSMENT accepted standard
○ During any physiologic or psychological crisis of the client ○ Discoloration of the skin, blood pressure
○ To identify life-threatening problems ● Constant Data
○ To identify new or overlooked problems ○ Information that does not change over time
○ EXAMPLE: ■ Race
■ Rapid assessment of ABCs during a cardiac arrest ■ Blood type
■ Assessment of suicidal tendencies or potential for ● Variable data
violence
○ Data can change quickly, frequently, or rarely
● TIME LAPSED ASSESSMENT
■ Blood pressure
○ Several months after initial assessment ■ Level of pain
○ To compare the client’s current status to baseline data ■ Age
previously obtained
○ EXAMPLE:
SOURCES OF DATA
■ Reassessment of a client’s functional health patterns
in a home care
● 3 TYPES OF ASSESSMENT Primary
○ Comprehensive Assessment ○ Client is the primary sources of data
■ Performed upon admission ○ All sources than the client are considered secondary
■ Includes complete health history sources
○ Focused Assessment ○ CLIENT
■ Focused on a particular need or healthcare problem ■ Best source of data unless the client is too ill, young,
○ Ongoing Assessment confused to communicate clearly
■ Systematic monitoring and observation related to ■ Some client cannot or do not wish to provide
specific problems accurate data
■ If the client is hesitant to provide data, remind the
client that the privacy of all data collected is
COLLECTION OF DATA
protected
● Secondary
● Is the process of gathering of information about the client’s
○ Family members or other support persons
health status
○ Health care professionals
● Systematic and continuous to prevent the omission/gap of ○ Records and reports
significant data and reflect a client’s changing health status
○ All data from secondary sources should be validated if
● TERMINOLOGIES: possible
○ Database - contains all information about the client ○ SUPPORT PEOPLE
■ Nursing health history ■ Family members, friends, and caregivers
■ Physical assessment ■ They give information on client’s response to:
■ Primary care provider’s history ● Illness
■ Physical examination ● The stresses the client was experiencing before
■ Results of laboratory and diagnostic tests the illness
■ Material contributed by other healthcare personnel ● Family attitudes on illness and health
● Client’s home environment
■ Important source of data for a client who is very
young, unconscious, or confused

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 2
 FUNDAMENTALS
WEEK 2 LECTURE: NURSING PROCESS AND ASSESSMENT OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

■ The nurse should indicate on the nursing history that ● Lung and heart sounds
the data were obtained from a support person ● Bowel sounds
○ CLIENT RECORDS ● Ability to communicate
■ Include information documented by various health ● Language spoken
care professionals ● Orientation to time, person and place
■ Types of client record includes: MRL ■ TOUCH
● Medical records ● Skin temperature and moisture
● Records of therapies ● Muscle strength (hand grip)
● Laboratory records ● Pulse rate, rhythm, and volume
○ HEALTHCARE PROFESSIONALS ● Palpable lesions (lumps, masses, nodules)
■ Nurses, social workers, primary care providers
■ Sharing of information is important to ensure INTERVIEWING
continuity of care when clients are transferred to and
from home and healthcare agencies
● INTERVIEWING - planned communication with a purpose
○ LITERATURE
○ 2 APPROACHES TO INTERVIEWING
■ Professional journals and reference texts ■ Directive Interview
■ Includes ● Highly structured
● Standard to compare findings ● Elicit specific information
● Cultural and social health practices ● Purpose of interview is established
● Spiritual beliefs ● Limited opportunity to discuss concerns
● Assessment data needed for specific client ● Example: Emergency situation
conditions
■ Non directive Interview
● Rapport building interview
DATA COLLECTION METHODS (OIE( ● Allows the client to control the purpose,
subject matter and the pacing
OBSERVING ○ TYPES OF INTERVIEW QUESTIONS
■ CLOSED QUESTIONS
● OBSERVING - using senses ● Used during directive interview
○ Nursing observation must be organized so nothing ● Answerable by short factual answers or “yes or
significant is missed no”
○ OBSERVATION ORDER (CSEE) ● Examples:
■ Clinical signs of client distress (pallor, labored ○ “What medication did you take?”
breathing, and behavior indicating pain) ○ “Are you in pain now?”
■ Threats to the client’s safety, real or anticipated ○ “How old are you?”
(lowered side rail) ○ “When did you fall?”
■ The presence and functioning of equipment (IV and ■ OPEN ENDED QUESTIONS
oxygen) ● Used during non directed interview
■ The immediate environment including the people in ● To elaborate, clarify, or illustrate their
it thoughts and feelings
○ USING SENSES TO OBSERVE CLIENT DATA ● Examples:
■ VISION ○ “How have you been feeling lately?”
● Overall appearance (body, size, posture, ○ “What brought you to the hospital?”
grooming) ○ “How did you feel in that situation?”
● Signs of distress or discomfort ■ NEUTRAL QUESTIONS
● Facial and body gestures ● Is a question the client can answer without
direction or pressure from the nurse
● Skin color and lesions
● Religious or cultural artifacts (books, icons, ● Open ended
candles, beads) ● Non directive interview
■ SMELL ● Examples:
● Body or breath odors ○ “How do you feel about that?”
■ HEARING ○ “What do you think led to the operation?”

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 3
 FUNDAMENTALS
WEEK 2 LECTURE: NURSING PROCESS AND ASSESSMENT OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

■ LEADING QUESTION
● DIrects the client’s answer ORGANIZING DATA
● Directive interview ● The nurse uses a written (or electronic) format that organizes
● Example the assessment data systematically
○ “You will take your medicine, won’t you?” ● Gordon’s Framework – helps in organizing information into 11
health patterns for better understanding and care planning
PLANNING THE INTERVIEW AND SETTING ○ HEALTH PATTERNS AND PATIENT DATA
● TIME 1. Health perception and Health Management
○ Client (comfortable and free of pain) 2. Nutritional Metabolic
○ Minimal interruptions 3. Elimination
● PLACE 4. Activity-exercise
○ Well lit 5. Sleep-rest
○ Well ventilated room 6. Cognitive-perceptual
○ Free from noise and distractions 7. Self perception and Self concept
● SEATING ARRANGEMENT 8. Role relationships
○ The nurse sit at 45 degree angle to the bed 9. Sexuality reproductive
● DISTANCE 10. Coping Stress tolerance
○ Maintain a distance of 2 - 3 feet during an interview 11. Value belief
● LANGUAGE
○ Convert complicated medical term to common language VALIDATING DATA
● The act of “double checking” or verifying data to confirm that
STAGES OF AN INTERVIEW it is accurate and factual
● OPENING ● The nurse validates data when there is discrepancies between
○ “Introduction” – most important part of the interview data obtained in nursing interview (subjective data) and the
○ To establish rapport and orient interviewee physical examination (objective data) or when client’s
○ Explain the purpose and nature of interview statements vary at different times in the assessment
○ Tell the client how the info will be used ● CUES - subjective or objective data that is observed by the
● BODY nurse
○ The client communicates in response to the questions ○ EXAMPLE: Incision is red, hot, swollen
from the nurse ● INFERENCES - nurse’s interpretation or conclusions made based
○ Listen attentively, speak slowly and clearly on the cues
○ Ask one question at a time ○ EXAMPLE: The nurse makes the inference that the incision
○ Non verbally convey respect, concern, interest and is infected
acceptance ● NOT ALL DATA REQUIRED VALIDATION
● CLOSING ○ Height
○ Nurse terminates the interview when the needed info has ○ Weight
been obtained ○ Birth date
○ In some cases, a client terminates it ○ Most laboratory studies
○ Offer to answer questions
○ Conclude – that’s all I need to know for now WAYS TO VALIDATE DATA
○ Thank the client ● Compare Covert and Overt data to verify client’s statement
○ Express concern ○ “Feeling hot” = Check body temperature
○ Plan next meeting and provide summary ● Clarify ambiguous or vague statement
○ Client: “I felt sick on and off for 6 weeks”
EXAMINING ○ Nurse: “ Describe what your sickness is like. Tell me what do
● EXAMINING - use of IAPAPE (PHYSICAL EXAMINATION_ you mean by on and off”
○ Carried out systematically ● Be sure your data consist of cues not inferences
○ Organized (head to toe, cephalocaudal, body system ○ Observation: Dry skin and reduced skin turgor
approach) ○ Inference: Dehydration
○ A screening examination/review of systems is a brief review ○ Action: collect additional data that are needed to make the
of essential functioning of various body parts or system inference in the diagnosing phase

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 4
 FUNDAMENTALS
WEEK 2 LECTURE: NURSING PROCESS AND ASSESSMENT OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○EXAMPLE: Determine the client’s fluid intake, amount and

appearance of urine, and blood pressure
● Double check data that are extremely abnormal
○ Observation: resting pulse rate of 30 bpm and BP of 120/95
mmHG
○ Action: Repeat the measurement
■ Use another piece of equipment needed to confirm
abnormalities
■ Ask someone else to collect the same data
● Determine factors that may interfere with accurate
measurements
○ Crying infant may have abnormal RR and will need quieting
before an accurate assessment can be made
● Use references (Textbooks, journals, research reports) to
explain phenomena
○ Nurse considers tiny purple or bluish black swollen areas
under the tongue of an older adult client to be normal until
reading about physical changes of aging. Such varicosities
are common

DOCUMENTING DATA
● To complete the assessment phase, the nurse records client
data
● Data are recorded in a factual manner and not interpreted by
the nurse
● Example: record the client’s breakfast intake (objective data)
as:
○ “Coffee 240 mL, juice 120mL, 1 egg, and 1 slice of toast”
rather than as “appetite good” (a judgment)

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 5
 FUNDAMENTALS
WEEK 2 LECTURE: DIAGNOSING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

STATUS OF NURSING DIAGNOSIS (AHR SW)

NURSING DIAGNOSIS / PROBLEM IDENTIFICATION ● ACTUAL NURSING DIAGNOSIS
○ Also known as problem-based diagnosis
○ Client problem that is present at the time of the nursing
assessment
● Identify components of nursing Diagnosis ○ Example:
■ Altered respiratory status
■ Impaired ability to cope
● Identify Basic steps in Diagnostic process ● HEALTH PROMOTION DIAGNOSIS
○ Clients’ preparedness to implement behaviors to improve
their health condition
● Guidelines for writing nursing diagnosis statement ○ Example:
■ Willingness to learn about health maintenance
■ Willingness to change health practices
● RISK NURSING DIAGNOSIS
○ A clinical judgment does not exist, but presence of risk
● Pivotal second phase of the nursing process factors indicate a problem is likely to develop unless nurses
● Clinical judgment about the client’s response to actual and intervene
potential health problem or life processes ○ Example:
● Use critical thinking skills to interpret assessment data and ■ Risk for or Potential for impaired breathing patterns
identify client strengths and problem ● SYNDROME DIAGNOSIS
● A nursing diagnosis is a judgment made only after thorough, ○ Several similar nursing diagnosis
systematic data collection ○ Group of problem that occurs together
● Helps define the scope of nursing practice by describing ○ Example:
conditions that nurse can independently treat ■ Impaired respiratory status related to increased
● Highlights critical thinking and decision making and provides secretions and restricted to pulmonary airflow related to
consistent universally understood terminology among nurses lack of alveoli elasticity
working on various settings ● WELLNESS DIAGNOSIS
○ Person’s condition as state of being healthy that may be
TIMELINE OF NANDA DEVELOPMENT enhanced by deliberate health promoting activities
● 1973 ○ Consist of one part statement (no ‘caused by’ phrase)
○ Kristine Gebbie and Mary Ann Lavin – faculty members of ○ Example:
st. louis university, perceived a need to identify nurses’ roles ■ Readiness for enhanced spiritual well being
● 1975
○ Held national conference COMPONENTS OF NURSING DIAGNOSIS (PES)
● 1977 ● THE PROBLEM AND ITS DEFINITION
○ 1st canadian conference (International Recognition) ○ Describes the client’s health problem or response to the
● 1980 nursing therapy
○ Held a national conference and established a routine of ○ Describes the client’s health status clearly and concisely in a
holding the conference every 2 years thereafter few words
● 1982 ○ QUALIFIERS - words added to the nursing diagnosis
○ Accepted as the North American Nursing Diagnosis ■ Inadequate in amount. Quality or degree
Association ■ Incomplete
● MAY 1987 ■ Made worse
○ International Nursing conference (Canada) ■ Weakened
● 2002 ■ Damaged. Reduced, deteriorated
○ NANDA International ■ Vulnerable to threat
○ The purpose of the problem is to direct the formation of
client goals and desired outcomes
○ It may also suggest some nursing interventions

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 6
 FUNDAMENTALS
WEEK 2 LECTURE: DIAGNOSING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

● THE ETIOLOGY ○ This format can’t be used for risk diagnosis because the
○ Identifies one or more probable causes of the health client does not have signs and symptoms of the diagnosis
problem ○ PROBLEM
○ Give direction to required nursing therapy ■ Statement of the client’s response (nursing diagnosis
○ Enables the nurse to individualize the client’s care label)
○ EXAMPLE: ○ ETIOLOGY
■ Impaired activity: Decreased physical ability to engage in ■ Factors contributing to or probable causes of the
activities of daily living related to shortness of breath response
● THE DEFINING CHARACTERISTICS (SIGNS AND SYMPTOMS) ○ SIGNS AND SYMPTOMS
○ Are the cluster of signs and symptoms that indicate the ■ Defining characteristics manifested by the client
presence of a particular diagnostic label ○ EXAMPLE:
○ For actual nursing diagnosis ■ Impaired self esteem related to feelings of rejection by
■ The defining characteristics are the client’s signs and husband as manifested by hypersensitivity to criticism;
symptoms states “I don’t know if I can manage by myself” and
○ For risk nursing diagnosis rejects positive feedback
■ No subjective and objective signs are present ● TWO PART STATEMENT
○ PROBLEM
DIAGNOSTIC PROCESS ○ ETIOLOGY
○ EXAMPLE
■ Non adherence (diabetic diet) related to denial of having
ANALYZE DATA
disease
● COMPARE DATA AGAINST STANDARDS (IDENTIFY SIGNIFICANT ■ Anxiety related to threat to physiologic integrity: possible
CUES) cancer diagnosis
○ 17 months old infant. Child has not yet attempted to speak ● ONE PART STATEMENT
○ NORMAL: Children usually speak their first word by 10 - 12 ○ Wellness statements – consist of nursing diagnosis only
months of age ○ Etiology may not be needed
● CLUSTER THE CUES (TENTATIVE HYPOTHESES) ○ EXAMPLE:
○ Last fluids at noon today ■ Readiness for enhanced community coping
○ Oral temp 39.4 deg cel ■ Readiness for enhanced spiritual well being
○ Skin hot and pale, cheeks flushed
○ Poor skin turgor
GUIDELINES FOR WRITING NURSING DIAGNOSIS
○ Inference: Alteration in fluid volume
○ Nursing Diagnosis: Alteration in fluid volume related to ● STATE IN TERMS OF PROBLEM NOT A NEED
intake insufficient to replace fluid loss secondary to fever, ○ Alteration in fluid volume r/t fever (/)
diaphoresis, anorexia ○ Fluid Replacement r/t fever (X)
● IDENTIFY GAPS AND INCONSISTENCIES ● WORD THE STATEMENT SO THAT IT IS LEGALLY ADVISABLE
○ Inconsistencies are conflicting data (measurement error and ○ Altered skin integrity r/t immobility (/)
inconsistent or unreliable reports) ○ Altered skin integrity r/t impro[er positioning(X)
● UNSE NON JUDGMENTAL STATEMENTS
○ Impaired spirituality r/t inability to attend church services
IDENTIFY HEALTH PROBLEMS, RISK AND STRENGTHS
secondary to immobility (/)
● DETERMINING PROBLEMS AND RISKS ○ Impaired spirituality r/t strict rules necessitating church
○
Impaired nutritional status: decreased caloric intake attendance (X)
○
Alteration in fluid volume ● MAKE SURE THAT BOTH ELEMENTS OF THE STATEMENT DO
○
Impaired sleep NOT SAY THE SAME THING
○
Altered respiratory status ○ Potential for altered skin integrity r/t immobility (/)
● DETERMINING STRENGTHS ○ Potential for altered skin integrity r/t ulceration of sacral
○ Normal weight for age and height (cope better with surgery) area (X)
○ Absence of allergies, nonsmoker
● BE SURE THAT CAUSE AND EFFECT ARE CORRECtLY STATED
FORMULATE DIAGNOSTIC STATEMENTS ○ Pain: Severe headache r/t avoidance of narcotics due to fear
● THREE PART STATEMENTS of addiction (/)

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 7
 FUNDAMENTALS
WEEK 2 LECTURE: DIAGNOSING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○ Pain related to headache (X)

● WORD THE DIAGNOSIS SPECIFICALLY AND PRECISELY TO
PROVIDE DIRECTION FOR PLANNING NURSING INTERVENTION
○ Alteration in mucous membrane integrity r/t decreased
salivation secondary to radiation of neck (/)
○ Alteration in mucous membrane integrity r/t noxious agent
(X)
● USE NURSING TERMINOLOGY RATHER THAN MEDICAL
TERMINOLOGY TO DESCRIBE THE CLIENT’S RESPONSE
○ Potential for altered respiratory status r/t accumulation of
secretions in lungs(/)
○ Potential for pneumonia (X)
● USE NURSING TERMINOLOGY RATHER THAN MEDICAL
TERMINOLOGY TO DESCRIBE THE PROBABLE CAUSE OF THE
CLIENT’S RESPONSE
○ Potential for altered respiratory status r/t emphysema (/)
○ Potential for altered respiratory status r/t emphysema (X)

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 8
 FUNDAMENTALS
WEEK 2 LECTURE: PLANNING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○Nurses’ uses this for predictable, commonly occurring

PLANNING problems
● INDIVIDUALIZED CARE PLAN
● The process of designing nursing activities required to prevent, ○ Tailored to meet the unique needs of a specific client
reduce, or eliminate a client’s health problems (needs that are not addressed by the standardized plan)
● Is an intentional, systematic phase of the nursing process that ○ Individual plan for unusual problems or problems needing
involves decision making and problem solving special attention
● The nurse refers to the client’s assessment data and diagnostic
statements for direction in formulating client goals and GUIDELINES FOR WRITING NURSING CARE PLAN
designing the nursing interventions
● END PRODUCT OF PLANNING PHASE IS CLIENT CARE PLAN ● DATE AND SIGN THE PLAN
○ DATE - essential for evaluation, review, and future planning
TYPES OF PLANNING (IOD) ○ SIGNATURE - demonstrate accountability
● USE CATEGORY HEADINGS
● INITIAL PLANNING ● USE STANDARDIZED, APPROVED MEDICAL OR ENGLISH
SYMBOLS RATHER THAN COMPLETE SENTENCES
○ The nurse who performs the admission assessment usually
develops the initial comprehensive plan of care ○ Turn and reposition q2h
○ Should be initiated as soon as possible after initial ● BE SPECIFIC
assessment ○ Nurses are working shifts of different lengths (12hr shift
and 8hr shifts)
● ONGOING PLANNING
○ Occurs at the beginning of a shift as the nurse plans the ○ It is important to be specific about expected timing of an
care to be given that day intervention
○ Using ongoing assessment data, the nurse carries out daily ● REFER TO PROCEDURE BOOK RATHER THAN INCLUDING ALL
planning for the following purposes: THE STEPS ON A WRITTEN PLAN
■ Client’s health status has changed ○ Write “See unit procedure book for tracheostomy care”
■ Set priorities for the client’s care during the shift ● TAILOR THE PLAN TO THE UNIQUE CHARACTERISTICS OF THE
CLIENT BY ENSURING THAT THE CLIENT’S CHOICES ARE
■ Decide which problems to focus on during the shift
INCLUDED
■ Coordinate the nurse’s activities so that more than
one problem can be addressed at each client contact ○ This reinforce the client’s individuality and sense of control
● DISCHARGE PLANNING ○ Example:
○ Planning for needs after discharge ■ Provide prune juice at breakfast rather than other
juice
○ Crucial part of a comprehensive healthcare plan and should
be addressed in each client’s care plan ● ENSURE THAT THE NURSING PLAN INCORPORATES
PREVENTIVE AND HEALTH MAINTENANCE ASPECTS AS WELL
○ Effective discharge planning begins at first client contact
AS RESTORATIVE ONES
○ “Provide active assistance ROM exercises to affected limbs
NURSING CARE PLAN
q2h”
○ Prevents joint contractures and maintains muscle strength
● INFORMAL NURSING CARE PLAN and joint mobility
○ Strategy for action that exists in the nurse’s mind ● ENSURE THAT THE PLAN CONTAINS ONGOING ASSESSMENT
○ Example: OF THE CLIENT
■ Mrs. Phan is very tired. I will need to reinforce her ○ Inspect incision q8h
teaching after she is rested ● INCLUDE COLLABORATIVE AND COORDINATION ACTIVITIES IN
● FORMAL NURSING CARE PLAN THE PLAN
○ Is a written or computerized guide that organizes ○ Write interventions to ask a nutritionist or physical
information about the client’s care therapist about specific aspects of the client’s care
○ Provides for continuity of care ● INCLUDE PLANS FOR THE CLIENT’s DISCHARGE AND HOME
● STANDARDIZED CARE PLAN CARE NEEDS
○ A formal plan that specifies the nursing care for groups of
client’s with common needs
○ Example: All clients with myocardial infarction

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 9
 FUNDAMENTALS
WEEK 2 LECTURE: PLANNING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

●Client will raise right arm to shoulder height by

PLANNING PROCESS friday
■ LONG TERM GOAL (weeks or months)
● SETTING PRIORITIES ● Client will regain full use of right arm in 6
weeks
● ESTABLISHING CLIENT GOALS AND OUTCOMES
● SELECTING NURSING INTERVENTIONS AND ACTIVITIES ○ Example:
● WRITING INDIVIDUALIZED NURSING INTERVENTIONS ON ■ Improved nutritional status
CARE PLANS ● DESIRED OUTCOMES
○ More specific
○ Example:
SETTING PRORITIES
■ Gain 5 lbs by April 25

● HIGH PRIORITY
SELECTING NURSING INTERVENTIONS AND ACTIVITIES
○ Life threatening problems
○ Impaired respiratory or cardiac function
● MEDIUM PRIORITY ● INDEPENDENT INTERVENTIONS
○ Health threatening problems ○ Are those activities that nurses are licensed to initiate on
the basis of their knowledge and skills
○ Acute illness and decreased coping ability
● LOW PRIORITY ○ These are tasks that nurses can begin independently, using
their knowledge and skills.
○ Arises from normal developmental needs or requires
minimal nursing support ○ Examples:
● USE MASLOW’s HIERARCHY OF NEEDS WHEN SETTING ■ Physical care
PRIORITIES ■ Emotional support and comfort
■ Teaching
■ Environmental management
■ Referrals to healthcare professionals
● DEPENDENT INTERVENTIONS
○ Activities carried out under the orders of licensed
physicians
○ Examples:
■ Medications
■ Intravenous therapy
■ Diagnostic test
■ Treatments
■ Diet
■ Activity
● COLLABORATIVE INTERVENTIONS
○ Actions the nurse carries out in collaboration with other
health care team members (physical therapists, social
ESTABLISHING GOALS OR DESIRED OUTCOME
workers, dietitians)
○ Examples:
● SHOULD BE SMART ■ The nurse and dietitian make a meal plan that fits the
● CLIENT, any part of the client, attribute of the client (pulse or patient's needs, especially if they have trouble
urinary output) + Verb (action the client is to perform) + swallowing. The nurse makes sure the patient eats
Modifiers/ condition (They explain what, where, when, or the right foods and gets enough nutrients.
how) + Desired performance (These criteria may specify time,
speed, accuracy, distance, and quality)
WRITING INDIVIDUALIZED NURSING INTERVENTIONS
● EXAMPLE:
○ Client performs breathing exercise twice daily
● GOALS ● The Format of written interventions
○ Broad statements ○ VERB, CONDITIONS/MODIFIERS, TIME ELEMENT
○ 2 TYPES ■ Measure and record ankle circumference daily at
■ SHORT TERM GOAL (hours or days) 0900

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 10
 FUNDAMENTALS
WEEK 2 LECTURE: PLANNING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

■ Apply spiral bandage firmly to left lower leg daily at

1000]

DELEGATING IMPLEMENTATION (PERAV B)

● While choosing and writing nursing interventions on the client’s

care plan, determine who should actually perform the activity
● CNA - Certified Nursing Assistant
● UAP - Unlicensed Assistive Personnel
● CAN BE DELEGATED
○ Positioning
○ Eating
○ Recording I and O
○ Ambulating
○ Vital signs, Bathing
● A licensed nurse must stay responsible for a client even when
tasks are assigned to a licensed practical or vocational nurse, or
to a certified nursing assistant or medication aid.

NEVER DELEGATE (UEAT)

● Unstable clients
○ New admission
○ Returning to floor after procedure
○ Post operative
○ Unstable VS
○ Blood sugar
○ Neuro status
● Evaluation
○ Interpreting data
○ Lab values
○ Pain
○ Vital signs
● Assessment IFP Assessment
● Teaching IFP Education

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 11
 FUNDAMENTALS
WEEK 2 LECTURE: IMPLEMENTING AND EVALUATING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

■ Encourage to make own decisions

IMPLEMENTING ● ENCOURAGE client’s to actively participate
○ Examples
● The action phase in which the nurse performs the nursing ■ Enhance sense of independence and control
interventions ■ The amount of desired involvement is related to the
severity of the illness, culture, fear, understanding of
● This includes:
illness and intervention
○ Reassessing the client
○ Determining the nurse’s need for assistance ● Be HOLISTIC
○ Implementing the nursing interventions ○ Example:
○ Supervising the assigned care ■ The nurse honor’s the client’s expressed preference
○ Documenting nursing activities ● IMPLEMENT safe care
● PROVIDE teaching, support,and comfort
○ Explain the purpose of interventions, what the client will
REASSESSING THE CLIENT
experience and how the client can participate

● To make sure the intervention is still needed

SUPERVISING DELEGATED OR ASSIGNED CARE
● Even though an order is written on the care plan, the client’s
condition may have changed
● If other healthcare workers are assigned to provide care, the
nurse in charge of the client's overall care must ensure that the
DETERMINING THE NURSE’S NEED FOR ASSISTANCE
activities have been implemented according to the care plan
● The nurse is accountable for any delegation of care and for
● The nurse is unable to implement the nursing activity safely or evaluation of the care that has been implemented
efficiently alone
○ Example: Ambulating an unsteady obese client
DOCUMENTING NURSING ACTIVITIES
● Assistance would reduce stress on the client
○ Example: Turning a client with acute pain when moved
● The nurse lacks the knowledge or skills to implement a nursing ● The nurse completes the implementing phase by recording the
activity interventions and client responses in the nursing progress
notes
○ Example: A nurse who is not familiar with traction
equipment ● It is important to record a nursing intervention immediately
after it is implemented
● Nursing care MUST NOT be recorded in advance
IMPLEMENTING THE NURSING INTERVENTION (ABCDE HIP)

● ADAPT activities to the individual client

EVALUATING
○ Examples:
■ Beliefs, values, age, health status and environment
are factors that can affect the success of the nursing ● Conclusions drawn whether the nursing interventions should
action
● BASE nursing interventions on scientific knowledge, research
and professional standards of care
○ Examples:
■ Know scientific rationale. Side effects, and
complication
● CLEARLY understand the interventions and question any that
are not understood
○ Examples:
■ Responsible for intelligent implementation of medical
and nursing plans of care
● Respect DIGNITY of the client and enhance self esteem
○ Examples:
■ Providing privacy be terminated, continued, or changed

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 12
 FUNDAMENTALS
WEEK 2 LECTURE: IMPLEMENTING AND EVALUATING OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

5 COMPONENTS OF EVALUATION PHASE

● COLLECTING DATA
○ Some data may require interpretation
■ “My pain is worse now that it was after breakfast”
■ (+) restlessness, pulse rate and respiratory rate
increased
● COMPARING DATA WITH DESIRED OUTCOMES
○ The goal was met
○ The goal was partially met
■ Short term outcome achieved but the long term goal
was not
○ The goal was not met
○ EVALUATION STATEMENT
■ Goal met: Oral intake 300 mL more than output; Skin
turgor resilient; mucous membranes moist
● RELATING NURSING ACTIVITIES TO OUTCOMES
○ Determining whether the nursing activities had any
relation to the outcome
● DRAWING CONCLUSIONS
○ GOAL MET
■ Actual problem resolved + potential problem
prevented and risk factors no longer exist =
DISCONTINUE CARE
■ Potential problem prevented + risk factors are
present = KEEP PROBLEM NCP
■ Actual problem still exist + some goals met =
NURSING INTERVENTIONS CONTINUED
○ GOAL PARTIALLY MET, GOAL NOT MET
■ NCP may need to be revised, since problem is only
partially resolved
■ NCP does not need revision, the client needs more
time to achieve previously established goals
● CONTINUING, MODIFYING,or TERMINATING NCP
○ Depending on the agency, modifications may be made by
drawing a line through portions of the care plan, making
portions using a highlighting pen, or indicating revision as
appropriate for Electronic charting system
○ The nurse may also write
■ “discontinued” (“dc’d”)
■ “Problem resolved”
■ And the date

FUNDAMENTALS OF NURSING NURSING PROCESS, ASSESSMENT, DIAGNOSIS, PLANNING, INTERVENTIONS, AND EVALUATION 13
 FUNDAMENTALS
WEEK 3 LABORATORY: ADMINISTERING MEDICATION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

MEDICATION ADMINISTRATION ADMINISTERING ORAL DRUGS (SOLID)

● Most common task performed by a nurse ● Assess pt.’s ability to swallow (to prevent aspiration)
● Requires systematic, organized, and accurate drug preparation, ● Help the client to a sitting position
and documentation that are needed to ensure client’s safety ● Offer one tablets at a time
and possible resolution of his health problems ● Teach him or her about the drug you administered
● MEDICATION ○ Name
○ A substance administered for the diagnosis, cure, ○ Indication
treatment, or relief of a symptoms or for prevention of ○ Side effects
disease
THERAPEUTIC ACTIONS OF DRUGS (CSS CPR) ADMINISTERING ORAL DRUGS (LIQUID)

● Curative ● For infant, child, or patient who has trouble in swallowing pills
● Supportive ● MATERIALS:
● Substitutive ○ Measuring cup
● Chemotherapeutic ○ Damp paper towel
● Palliative ○ Prescribed medication
● Restorative ● Assess ability of the pt’s to swallow (to prevent aspiration)
ROUTES OF DRUG ADMINISTRATION ● Help the patient to a sitting position
● Give proper assistance
● Oral
○ Solid: Tablets, Caplets, Capsule, Lozenges ADMINISTERING ORAL DRUGS (LIQUID TO AN INFANT)
○ Liquid: Syrup, suspension, elixir, emulsion, drops, extract
● Sublingual ● Place bib under infant’s chin
● Buccal ● Hold infant securely in the crook of your hand and raise his
● Topical head about 45 degree angle
○ skin ● Place the dropper at the corner of the infant’s mouth so the
● Parenteral drug will run into the pocket between his cheek and gum
○ IV, ID, IM, SQ (keeps him from spitting out the drug and reduces the risk of
● Ophthalmic aspiration)
○ Through eyes ● Wash the dropper thoroughly before returning it to the bottle
● Otic
○ Through ears
● Nasal
○ Through nostrils

TYPES OF TABLETS

● SCORED TABLETS
○ Tablets that have intended dosage
○ There’s a presence of mark that implies that the tablet can
be split
○ For example: there is a 100g full tablet but it has 1 score
(split) in the middle, then it can be split into 50 g
● NON SCORED TABLETS
○ Tablets that doesn’t have a score or line and it is not
recommended to break

FUNDAMENTALS OF NURSING ADMINISTERING MEDICATION, MEDICATION ORDER, DRUG COMPUTATION 1

 FUNDAMENTALS
WEEK 3 LABORATORY: MEDICATION ORDERS OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

MEDICATION ORDERS MEDICAL ABBREVIATION

● Medication orders can be given orally or via phone rather than ● OD - once a day (8am) WHITE CARD
in writing ● BID - twice a day (9am & 6 pm) YELLOW CARD
● Follow these steps to help ensure its accuracy ● TID - three times a day (8-1-6 ) PINK CARD
○ Have another nurse listen on the call to confirm that she ● QID - Four times a day BLUE CARD
heard the same order you did ● Prn - as needed or as necessary GREEN CARD
○ Repeat the name of the ordered drug to the doctor to ● q - every
verify that you heard it correctly ● q4 - every 4 hours BLUE CARD
■ Have the prescriber spell the drug name if necessary ● q6 - every 6 hours YELLOW CARD
○ Write out the order, noting that it was a verified telephone ● q8 - every 8 hours ORANGE CARD
order, then sign and date it ● q12 - every 12 hours
○ Administer the medication as ordered ● po - by mouth
○ The prescriber MUST co sign your written order within the ● SL - sublingual
time allotted by your facility or before 24hr ● ID - Intradermal
● Subq - Subcutaneous
IMPORTANT PARTS OF MEDICATION ORDERS ● IM - Intramuscular
● IV - intravenous
● Client’s full name ● IO - Intraosseous
● Date and Time the order is written ● HS - Hours of sleep / before bed time
● Name of the drug ● mg - milligrams
● Dosage of the drug ● gm or g - grams
● Frequency of administration ● gr - grains
● Route ● ml - milliliters
● Name and Signature of the doctor ● cc - cubic centimeter
● L - liter
● Neb - nebule
● Amp - Ampule
● Tsp - teaspoon
● Tbsp - tablespoon
● ODBB - Once a day before breakfast
● R - refused
● NA - Not available
● P -prescribed
● Syr - syrup
● Susp - Suspension
● Elix - Elixir
TYPES OF DRUGS / MEDICATION ORDER ● Supp - Suppository
● Pess - Vaginal Suppository
● STANDING ORDER ● gtt/gtts - Drop/Drops
○ Drug that must be carried out as specified by the doctor
until it is canceled or changed by the doctor NURSING PRACTICE GUIDELINES
● SINGLE ORDER
○ Drug order that must be carried only once
● Nurses who administer medications are responsible for their
○ One time order only
own actions
● STAT ORDER
○ Question any order that is illegible or that you consider
○ Carried out at once but IMMEDIATELY
incorrect
● PRN ORDER
○ Call the person who prescribed the medication for
○ As needed or when necessary
clarification
○ Allows the nurse to administer drug if based on his
● Be knowledgeable about the medications you administer
knowledge and assessment

FUNDAMENTALS OF NURSING ADMINISTERING MEDICATION, MEDICATION ORDER, DRUG COMPUTATION 2

 FUNDAMENTALS
WEEK 3 LABORATORY: MEDICATION ORDERS OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○ You need to know why the client is receiving the medication

○ Look up the necessary information if you are not familiar
with the medication
● Use only medications that are in a clearly labeled container
● DO NOT use liquid medication that are cloudy or have changed
color
● Calculate drug doses ACCURATELY
○ If you are uncertain, ask another nurse to double check
your calculation
● Before administering the medication, identify the client
correctly using the appropriate means of identification
● DO NOT leave medications at the bedside
● If a client vomits after taking an oral medication
○ Report this to the nurse in charge or primary care provider
● When a medication error is made, report it immediately to the
nurse in charge, the primary care provider or both
● ALWAYS check a medication’s expiration date

CHECK THREE TIMES FOR SAFE MEDICATION ADMINISTRATION

● FIRST CHECK
○ Read the MAR / CHART / MEDICATION CARD and remove
the medication from the client’s drawer
○ Verify that the client’s name and room number MATCH the
MAR
○ Check the expiration date of the medication
● SECOND CHECK
○ While preparing the medication (e.g., pouring, drawing up,
or placing unopened package in a medication cup) look at
the medication label and check against the MAR
● THIRD CHECK
○ Before giving the medication to the client

10 RIGHTS THE NURSE MUST OBSERVE IN ADMINISTERING

MEDICATION

● RIGHT CLIENT
● RIGHT MEDICATION
● RIGHT DOSAGE
● RIGHT TIME OR FREQUENCY
● RIGHT ROUTE
● RIGHT PATIENT EDUCATION
● RIGHT TO REFUSE
● RIGHT DOCUMENTATION
● RIGHT TO ASSESS
● RIGHT EVALUATION

FUNDAMENTALS OF NURSING ADMINISTERING MEDICATION, MEDICATION ORDER, DRUG COMPUTATION 3

 FUNDAMENTALS
WEEK 3 LECTURE: DRUG COMPUTATION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

DRUG COMPUTATION

● g -> mg : (g) (1000) = mg

● mg -> g : mg/1000 = g

1 mL = 15 minims = 15 gtts.
5 mL = 1 fluid dram = 1 tsp.
15 mL = 3 fluid drams = 1 tbsp.

DRUG COMPUTATION (SOLID)

● D/S = Number of Tablets required

○ D - Doctor’s order / Strength reuired
○ S - Stock dose / dosage strength

DRUG COMPUTATION (ORAL)

● D/S * Q = Volume dose required

○ D - Doctor’s order / Strength required
○ S or H - Stock dose / dosage strength
○ Q or V - Stock Volume

DRUG COMPUTATION (PARENTERAL)

● D/S * Q = Volume dose required

○ D - Doctor’s order / Strength required
○ S or H - Stock dose / dosage strength
○ Q or V - Stock Volume

FUNDAMENTALS OF NURSING ADMINISTERING MEDICATION, MEDICATION ORDER, DRUG COMPUTATION 4

 FUNDAMENTALS
WEEK 2 LABORATORY: HOT AND COLD APPLICATION, DRUG PREPARATION, MEDICATION CARD OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○Lower tolerance: Very young children and older adults

HOT AND COLD APPLICATION ○Varied tolerance: People with nerve issues might not feel
temperature changes as much but are at higher risk of
getting hurt
● Heat and cold applied to the body for local and systemic effects
● Safe heat and cold application will be provided to patients as ● LENGTH OF EXPOSURE
part of pain management programs wherever the applications ○ At first, heat or cold feels more intense
are appropriate and effective ○ Overtime, our tolerance increases, and it doesn’t feel as
extreme
● SKIN CONDITION
HOT APPLICATION
○ Injured or damaged skin is more sensitive to temperature
changes
● Is the application of hot agent, warmer than skin
○ Heat causes VASODILATION
SELECTED INDICATIONS OF HEAT AND COLD
○ It increases blood flow to the affected area
○ It can be moist or dry
○ To relieve pain and congestion ● MUSCLE SPASM
○ To promote suppuration – wound with pus discharge ○ HEAT
○ To provide warmth ■ Relieves muscles and increases contractility
○ To promote healing ■ Relaxes muscles and makes them more flexible
○ To decrease muscle tone ○ COLD
○ To soften exudates ■ Relaxes muscles and decrease muscle contractility
○ It increases cellular metabolism ■ Relaxes muscles but reduces flexibility
○ It increases inflammation ● INFLAMMATION
○ It increases capillary permeability ○ HEAT
○ Sedative effect ■ Increase blood flow
■ Soften Exudates
○ COLD
COLD APPLICATION
■ Vasoconstriction decreases capillary permeability
■ Decreases blood flow
● Is the application of a cold agent cooler than the skin either in a ■ Slows cellular metabolism
moist or dry ● PAIN
● Causes vasoconstriction ○ HEAT
● Prolonged exposure could result in impaired circulation ■ Relieves Pain possibly by promoting muscle relaxation
○ To reduce pain and body temperature and increasing circulation
○ To anesthetize an area ■ Promoting psychological relaxation and a feeling of
○ To control hemorrhage comfort
○ To control the growth of bacteria ○ COLD
○ To prevent gangrene ■ Decrease pain by showing nerve conduction rate and
○ To prevent edema blocking nerve impulses
○ To reduce inflammation ■ Produces numbness
● CONTRACTURE
VARIABLES AFFECTING PHYSIOLOGICAL TOLERANCE TO HEAT ○ HEAT
AND COLD ■ Reduces contracture and increases joint ROM by
allowing greater distention of muscles and connective
● BODY PART tissue
○ Less sensitive: The back of the hand and foot ○ COLD
○ More sensitive: Inner wrist, forearm, neck, and perineal ■ Not typically used for contracture
area ● JOINT STIFFNESS
● SIZE OF THE EXPOSED AREA ○ HEAT
○ The larger exposed areas feel heat and cold more intensely ■ Reduces joint stiffness by decreasing viscosity of
than smaller areas synovial fluid and increasing tissue distensibility
● INDIVIDUAL TOLERANCE ○ COLD

FUNDAMENTALS OF NURSING HOT AND COLD APPLICATION, DRUG PREPARATION, MEDICATION CARD 1
 FUNDAMENTALS
WEEK 2 LABORATORY: HOT AND COLD APPLICATION, DRUG PREPARATION, MEDICATION CARD OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

■ Not typically used

● TRAUMATIC INJURY
○ HEAT
■ Not typically recommended
○ COLD
■ Decreases bleeding by constricting blood vessels
■ Decreases edema by reducing capillary permeability

GUIDELINES

● Determine the client’s ability to tolerate

● Identify the conditions that might contraindicate the
treatment
● Explain the application to the client
● Assess the skin area to which the heat or cold will be applied
● Ask the client to report any discomfort
● Return to the client 15 mins after starting the therapy and
observe the local skin area for any untoward signs
● Remove the equipment at the designated time and dispose of
it properly
● Examine the area to which the heat or cold was applied and
record the clients response

FUNDAMENTALS OF NURSING HOT AND COLD APPLICATION, DRUG PREPARATION, MEDICATION CARD 2
 FUNDAMENTALS
WEEK 3 LABORATORY: PARENTERAL MEDICATION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

ADMINISTERING PARENTERAL MEDICATIONS INTRAMUSCULAR INJECTION SITE

● Administration of medication by injection ● VENTROGLUTEAL SITE

● Invasive procedure that must be performed with aseptic ○ Recommended Uses:
technique ■ Adults and children over 7 months
● After a needle pierces the skin, the patient is at risk of infection ○ Needle:
● Each type of injection requires the application of specific skills ■ 1-1.5 in., 21-22g
to ensure the medication reaches the proper location ○ Volume:
● The effects of parenterally administered medication DEVELOP ■ 4mL (SAH) refer to agency policy
RAPIDLY, depending on the rate of medication absorption ○ Landmarks:
● Always closely observe the patient’s response ■ In side lying position c upper leg flexed
■ Heel of opposite hand on head of greater trochanter
■ Thumb in groin
COMMON PARENTERAL ROUTES ■ Index finger on anterior superior iliac spine
■ Third finger spread laterally along crest to form V
● INTRAMUSCULAR - 90 degree, 1-3 mL syringe, 18g - 27 g ■ Palpate for well developed muscle in site
● SUBCUTANEOUS - 45 degree, 1-3 mL syringe ● DORSOGLUTEAL SITE
● INTRAVENOUS - 25 degree ○ High risk – hitting sciatic nerve, blood vessel, or bone
● INTRADERMAL - 10 - 15 degrees ○ NON RECOMMENDED
○ Uses:
■ Adults and Children
○ Needle
INTRAMUSCULAR INJECTION
■ 1 - 1.5 in
○ Volume
● DELEGATION CONSIDERATION ■ 4 mL refer to agency policy
○ The administration of injections cannot be delegated into ○ Landmarks:
an Unregulated Care Provider (UCP) ■ Prone position c toes pointed inward
○ Instruct UCPs to report the occurrence of potential ● DELTOID SITE
medication side effects or any changes in the patient's ○ High Risk – small muscle, close to radial nerve and artery
vital signs or level of consciousness (e.g sedation) ○ Recommended Uses:
immediately ■ Adults and Immunization
● EQUIPMENT ○ Needle:
○ Proper size syringe and needle: ■ 1 - 1.5 in, 21-22g
■ Syringe: ○ Volume:
● 2-3 mL for ADULT ■ 1 mL
● 0.5 - 1 mL for INFANTS and SMALL CHILDREN ○ Landmarks:
■ Needle: ■ Place two fingers side by side below the acromium
● Corresponds to the site of injection and the age process
of the patient ■ The side of your distal fingers determines the top of
● 1.6 - 3.2 cm (depending on the site of the child) the triangle
– ANY SITE FOR CHILDREN ■ The tip of the triangle is in the same plane as the
● 2.5 - 3.8 cm DELTOID ADULTS axillary fold
● 3.8 cm VENTROGLUTEAL ADULTS
■ Small gauze pad or alcohol swab, or both cotton balls
NEEDLE
with & w/o alcohol
■ Vial or ampule of medication
■ Clean gloves ● Needle diameter is measured by gauge – needle opening or
needle circumference
■ Medication Administration Record (MAR)
■ Computer printout ● As the gauge becomes smaller, the diameter becomes larger
● INTRAMUSCULAR INJECTION – 18 to 27g needle (depending
on the viscosity of the medication)

FUNDAMENTALS OF NURSING INTRAMUSCULAR INJECTION, INTRADERMAL INJECTION, SUBCUTANEOUS INJECTION 1

 FUNDAMENTALS
WEEK 3 LABORATORY: PARENTERAL MEDICATION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

● Chart the medication dose, route, site, time and date of

SYRINGES infection on the MAR immediately after giving the medication,
as per agency policy
● Syringes come in numerous sizes, from 0.5 mL to 60 mL ● Document if the scheduled medication is withheld and record
the reason as per agency policy
● SUBCUTANEOUS & INTRAMUSCULAR INJECTION - 1 to 3 mL
(adequate) ● Report any undesirable effects from the medication to the
prescriber
● The use of syringe larger than 5 mL is unusual for injection
● The larger volume creates discomfort ● Record the patient’s response to medications in the nurses’
notes and report to prescriber if required

CRITICAL DECISION POINTS

● Factors that interfere with blood flow to muscles will impair

the medications absorption
○ Atrophied muscles absorb medication poorly
● Because intramuscular injections can have harmful side effects,
other ways of giving medicine are safer. Check if an
intramuscular injection is really needed and consider other
methods if possible.
● Taking the medication according to schedule ensures the
patient receives the effect of the medication at the right time
● Unless contraindication exist for this site, the VENTROGLUTEAL
site is the preferred injection site for adults and children but
for infants VASTUS LATERALIS site should be used
● Ensure the patient's position is not contraindicated by a
medical condition
● If blood appears in the syringe, remove the needle and dispose
of the medication and syringe properly
○ Prepare another dose of medication for injection

UNEXPECTED OUTCOMES

● Complaints of localized pain, numbness, tingling, or burning

sensation at injection site, indicating possible injury to nerve
or tissue
○ RELATED INTERVENTIONS
■ Assess the injection site
■ Document your findings
■ Notify the patient’s health care provider
● Signs and symptoms of allergy or side effects
○ RELATED INTERVENTIONS
■ Follow institutional policy or guidelines for
appropriate response to adverse drug reactions
■ Notify the patient’s health care provider immediately
■ Add allergy information to the patient’s medical
record

RECORDING AND REPORTING

FUNDAMENTALS OF NURSING INTRAMUSCULAR INJECTION, INTRADERMAL INJECTION, SUBCUTANEOUS INJECTION 2

 FUNDAMENTALS
WEEK 3 LABORATORY: PARENTERAL MEDICATION OF NURSING

SUMMER TERM | 2023 - 2024 | BY: XENO, tmb <3

○ Syringe used for tuberculin is 1 mL because of a very small

SUBCUTANEOUS INJECTION amount drug needed
○ Needle used:
● Administered in the loose connective tissue, the layer of skin ■ short (¼ to ⅝ inch)
directly below the dermis and epidermis ■ Fine gauge (g25-27)
● May be abbreviated as SC, SQ, Sub-cu, SUb-q, SubQ or subcut
● Subcutaneous tissue has few blood vessels INTRADERMAL INJECTION SITES
○ Drugs injected by SC are for slow, sustained rates of
absorption ● Inner surface of the forearm
● SC - lower than IM; faster than ID ● Subscapular region of the back
● MEDICATION IS ADMINISTERED SLOWLY ABOUT 10 SEC/MIL ● Deltoid region

SUBCUTANEOUS INJECTION SITES PREPARING INTRADERMAL

● Outer area of upper arm ● Mixture of drug and water for skin testing
● The abdomen ○ 0.9 cc of distilled water or sterile water and 0.1 cc of the
○ From rib margin to iliac crest drug
○ Avoiding a 2 inch circle around the navel ● Inject the solution intradermally and just enough to form a
○ HAS THE FASTEST RATE OF ABSORPTION AMONG THE wheal
SITES ● Encircle the site correctly and write the time when to check the
● Front of the thigh, midway to the outer side injection site to determine reaction to the drug
○ 4 inches above the knee ● Check the site after 30 minutes for signs of reaction
○ Has slower rate of absorption than the upper arm ● If negative = ANST (-)
● Upper back ● If positive = ANST (+)
● Upper area of the buttocks ○ Manifestations:
○ Behind the hip bone ■ Reddening of the site accompanied with marked
○ HAS THE SLOWEST RATE OF ABSORPTION AMONG THE elevation
SITES ■ Increase in circumference of the wheal
■ Presence of itchiness on the site
EQUIPMENT

● 25 - 31g thick
● ⅜” to 1” long needle can be used
○ The size is determined by the amount of SC tissue present,
which is based on patient build
● ⅜” and ⅝” needles are most commonly used
● Suitable for small volume (0.5 - 1 mL); water soluble

INTRADERMAL INJECTION

● Introduction via needle of tiny amounts of fluid into layers of

skin
● Means “between the skin layer”
● Under the epidermis
● Provides local rather than systemic effect
● For diagnostic purposes
○ Allergies
○ Sensitivities to drugs
● For administering tuberculin testing

FUNDAMENTALS OF NURSING INTRAMUSCULAR INJECTION, INTRADERMAL INJECTION, SUBCUTANEOUS INJECTION 3