You are on page 1of 45


History of Nursing Pre Nightingale Era: > Nursing the sick was designated to the woman of the tribes > Illnesses were attributed to evil spirits within the body of the person who was ill > The ancient practitioner used both black and white magic to cure ills > The priest physician, whose practice had a strange mixture of superstition and fact, replaced the medicine man. Early Civilization : > Egyptian temples had housing for the sick > Deborah, the nurse companion of a child, was the first nurse noted in history > India, was the first country to record the use of a nurse in the care of the sick 300 AD : > Women entered the nursing profession 1100 1200 AD: > St. Anthonys Brothers Hospital was formed > Brothers of Misericordia. Italy were formed > Alexian Brothers was formed 1633 : > Sisters of Charity was founded 1809 : > Mother Elizabeth Seton, introduced the sisters of Charity in America, later known as the Daughters of Charity 1836 : > Deaconess Institute of Kaiserwerth, Germany was founded 1860 : > The Nightingale Training School for Nurses at St. Thomas Hospital in London, England was established > Florence Nightingale published the Notes on Nursing : What it is and What it is Not Prevailing Themes in Nursing History: ROLE OF WOMEN Rooted in the traditional role of women as nurturing, comforting, supporting being mothers, sisters or daughters RELIGION Benevolence Values of self-denial, spiritual calling, devotion to duty and hardwork Parable of the Good Samaritan Emergence of Knights and Deaconess groups WAR Crimean War (1854-56) Florence Nightingale tended to the sick and wounded, and espoused hand washing and clothes-washing Result: mortality rate in Barrack Hospital fell from 42% - 2% WAR

American Civil War Harriet Tubman and Sojourner Truth helped injured slaves Clara Barton pressured the US government to adapt the principles of the Red Cross World War II Shortage of care for wounded and dying soldiers Rise of auxiliary health workers, nursing aides and technicians under the supervision of nurses Societal Attitudes 1800s - So-called nurses did not have education, organization or societal status 1900s - Image was as doctors handmaiden; negative image as sex objects or tyrannical surrogate mother Reversed by Florence Nightingales work in the Crimean War Led to rise in nurse organizations The Nature of Nursing What is Nursing? Florence Nightingale the act of utilizing the environment of the patient to assist him in his recovery Virginia Henderson = one of the first modern nurse to define nursing the unique function of the nurse is to assist the individual, sick or well in the performance of those activities contributing to health or its recovery American Nurses Association (ANA) Nursing is direct, goal oriented and adoptable to the needs of the individual, the family, and community during health and illness The diagnosis and treatment of human response to actual or potential health problems Scope of Nursing Involves four areas: 1. promoting health and wellness = engaging in attitudes and behavior that enhances the quality of life and maximize personal potentials Acts Like: = enhance healthy lifestyle = preventing drugs and alcohol misuse 2. Preventing Illness = the goal is to maintain optimal health by preventing disease Acts Like: = immunization = pre natal and infant care = prevention of STD 3. Restoring Health = focus is on the ill client and extend from early detection of disease through helping the client during the recovery period Acts Like: = providing direct care to the ill = performing diagnostic and assessment procedures = consulting other health professionals about the clients problem

4. Care of the Dying = involves comforting and caring for people of all ages who are dying Nurse Leaders in History Florence Nightingale Said to be the 1st political nurse 1st nurse scientist-theorist Notes on Nursing: What It Is and What It Is Not Received training in Kaiserswerth, Germany Studied in Paris, France with the Sisters of Charity Developed Nightingale Training School for Nurses (1860) Clara Barton Schoolteacher by profession Nurse volunteer during the American Civil War nursing services Pressured her government to adapt the principles of the International Red Cross movement Credited for establishing the American Red Cross Lillian Wald Founder of Public Health Nursing First offered trained nursing services to the poor of New York slums Founded the Henry Street Settlement and Visiting Nurse Service Lavinia Dock Participated in protest movements for womens rights which resulted in the 1920 passage of the 19th Amendment to the US Constitution Campaigned to allow nurses to regulate their own profession (instead of physicians). Margaret Higgins Sanger Founder of Planned Parenthood Imprisoned for opening the 1st Birth Control Information Clinic in America Served as president of the International Planned Parenthood Federation; at this time it was the largest private international family planning organization Mary Breckinridge Introduced a model rural health care system into the United States in 1925 Established the Frontier Nursing Service and created a decentralized system of nurse-midwives, district nursing centers, and hospital facilities The system lowered the rate of death in childbirth as nurse-midwives were no more than six miles away from any patients First Registered Nurse in the World (1887) - Ellen Dougherty Americas First Trained Nurse - Linda Anne Richards First President of the American Nurses Association - Isabel Hampton Robb First Nurse to be Appointed to University Professorship - Mary Adelaide Nutting First Black Nurse - Mary Mahoney

Black Florence Nightingale - Mary Seacole Nursing as a Profession Qualifications : > Graduate of Bachelor of Science in Nursing > A licensed nurse Profession > is a calling that requires special knowledge, skill, and preparation. > requires prolonged, specialized training to acquire a body of knowledge pertinent to the role to be performed > requires an orientation of the individual towards service, either to a community or to an organization. Characteristics of a Profession 1. Specialized Education > education for those preparing to become nurses should take place in institutions of higher education. (ANA) 2. Body of Knowledge > establish a well-defined body of knowledge and expertise as supported by a number of theoretical frameworks that give direction to nursing practice. 3. Ethics > requires integrity of its members who are expected to do what is considered right regardless of the personal cost. 4. Autonomy > regulates itself and sets standards for its members There are many definitions and descriptions of nursing, but the essence of nursing is CARING for and CARING about people as holistic beings in matters related to health. Nursing is a humanistic, caring, nurturing, comforting, and supporting profession thats has evolved through the course of history. Although most people have a clear idea of what nursing is, its uniqueness needs to be clearly stated to other health care workers and the public. Nursing Theories offer ways of looking at nursing practice in clear, explicit terms that can be communicated to others. Nursing Theories provide direction and guidance for a) structuring professional nursing practice, education and research; and b) differentiating the focus of nursing from other professions. Florence Nightingale Environmental Theory Health is maintained through prevention of disease via the manipulation of the environment. Major concepts of health are ventilation, warmth, light, diet, cleanliness, and absence of noise. Madeleine Leininger Transcultural Nursing Use nursing knowledge to provide cultural specific or culturally congruent nursing care to people because care and culture are inextricably linked. Nola J. Pender

Health Promotion Model Prior behavior and inherited and acquired characteristics influence beliefs and the enactment of health-promoting behaviors. People commit to behaviors from which they anticipate personally valued benefits. Rosemarie Rizzo Parse Theory of Human Becoming Quality of Life from each person's own perspective as the goal of nursing practice Faye Glenn Abdellah 21 unique nursing problems related to human needs 21 problems are actually a model describing the "arenas" or concerns of nursing, rather than a theory describing relationships among phenomena. Lydia Eloise Hall Core, Care and Cure Direct professional nurse-to-patient relationship is itself therapeutic and that nursing care is the chief therapy for the chronically ill patient. Virginia Avenel Henderson Independence in the satisfaction of human beings 14 fundamental needs The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery or to peaceful death, that he would perform unaided if he had the necessary strength, will or knowledge. Dorothy Johnson Behavioral Systems Model Nurses should use the behavioral system as their knowledge base; comparable to the biological system that physicians use as their base of knowledge. 7 subsystems: achievement, aggressive, dependence, attachment, elimination, ingestion and sexual. Patricia Benner 5 stages of skills acquisition: 1. Novice 2. Advanced Beginner 3. Competent 4. Proficient 5. Expert Area of concern was not how to do nursing but, rather, How do nurses learn to do nursing?" Imogene King Open Systems Model Theory of Goal Attainment Three interacting systems with each system having its own distinct group of concepts and characteristics. These systems include personal systems, interpersonal systems, and social systems

Attainment, maintenance, or restoration of health to allow client to achieve maximum potential for daily living. Myra Levine Conservation Model Focused on conserving an individuals wholeness Four Conservation Principles: energy, structural integrity, personal integrity, and social integrity. Betty M. Neuman Neuman Health Care Systems Model Views the client as an open system Based on the individuals relationship to stress, the reaction to it, and the reconstruction factors that are dynamic in nature Ida Jean Orlando The Nursing Process Theory The purpose of the nursing process is to meet a patient's immediate needs. The role of the nurse is to find out and meet the patient's immediate need for help. The process helps the nurse find out the nature of the distress and what help the patient needs. Dorothea E. Orem Self-Care Deficit Theory 3 systems within professional nursing practice: 1. Compensatory system - nurse provides total care 2. Partially compensatory system - nurse & patient share responsibility for care 3. Educative - development system - client has primary responsibility for personal health, with nurse acting as a consultant Self Care Requisites: = are measures or actions taken to provide self care 3 Categories of Self Care Requisites: 1. Universal requisites are common to all people 2. Developmental requisites 3. Health deviation requisites Hildegard Peplau Psychodynamic Nursing Understanding ones own behavior to help others identify felt difficulties and applying principles of human relations to problems arising during the experience. Peplaus Interpersonal Relations Model = the use of therapeutic relationship between the nurse and the client Four Phases of the Nurse Client Relationship 1. Orientation = client seeks help and the nurse assist the client to understand the problem and the extent of the need for help 2. Identification = the client assumes a posture of dependence, and interdependence = nurse assures the person that the nurse understands the interpersonal meaning of clients situation

3. Exploitation = client derives full value from what the nurse offers through the relationship (power shifts from nurse to patient) 4. Resolution = final phase = new goals are adopted Sister Callista Roy Adaptation Model Goal is to enhance life processes through adaptation. Both individual and environment are sources of stimuli that require modification to promote adaptation an ongoing purposive response. Dr. Jean Watson Theory of Human Caring Geared toward subjective inner healing processes called "carative factors" , which complemented conventional medicine, but stood in stark contrast to "curative factors. Martha Elizabeth Rogers Science of Unitary Human Beings Nursing is a science and art to facilitate and promote symphonic interaction between human beings and their environment Unitary Man: 1. is an irreducible, four dimensional energy field identified by pattern 2. manifest characteristics different from the sum of the parts 3. interacts continuously and creatively with the environment 4. behaves as a totality FIRST training school for nurses in the Philippines Iloilo Mission Hospital Training School for Nurses First examination given by the Board of Examiners for Nurses Manila, June 1920 First board topnotcher Anna Dahlgen, rating 93.5% First law affecting the practice of nursing in the Philippines Act 2493 of 1915 First Nursing Law Act no. 2808, signed on March 1919 First board examination held outside of Manila Iloilo in 1946 First president of the Filipino Nurses Association Miss Francisca Delgado Pioneer of Philippine Nursing Anastasia Giron-Tupas Dean of Philippine Nursing Loreto Tupaz Proclaimed as Nurses week (Proc. No. 539)

Every last week of October PNA Founded 1922 as Filipino Nurses Association by Anastacia Giron Tupas Francisca Delgado was elected 1st President Primary purpose: To promote the standards of Nursing Board of Nursing created 1919 Member of the ICN since 1929 Renamed in 1962 Role of Nurses > To protect the health of the people by establishing minimum standards, which should be met by qualified practitioners > Conscientious in actions, knowledgeable on the subject, and responsible to self and others > Supervises, teaches, and directs all those involved in nursing care > Focuses on service to the client > Pursues education to attain professional growth and autonomy Health Care Delivery System the totality of services offered by all health disciplines Recipients of Nursing Care Consumer Patient Client a person who engages the advice or services of another who is qualified to provide this service. They are collaborators in the care, that is, as persons who are responsible for their health. Health Is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. Is not a condition; it is an adjustment. It is not a state but a process. The process adapts the individual not only to our physical, but also our social environment. Scope of Nursing 1. Promoting Health and Wellness Directed toward maintaining and improving the general health of individuals, families and communities. Helping people develop resources to maintain or enhance their health and well being. 2. Health Maintenance Doing actions that help clients maintain their health status. 3. Health Restoration Helping people to improve health following illness or health problems 4. Care of the Dying Comforting and caring for people of all ages while they are dying Levels of Health Care

Preventive and Primary Care Services Preventive care focuses on reducing and controlling risk factors for disease through activities such as immunization and occupational health programs Illness prevention programs involves providing immunization, identifying risk factors for illness, and helping people take measures to prevent this illness from occurring Primary Care aims to provide integrated accessible health services and majority of personal health services; develop a sustained partnership with clients; and render care to the family and community Service Institutions for Preventive and Primary Care Services > School health services > Occupational health services > Physicians offices > Clinics > Nursing centers > Volunteer agencies > Primary health care in the community Secondary and Tertiary Care Diagnostic and treatment are generally the most commonly used services of health. Accommodate health problems which are more complicated and require medical specialist Service Institutions for Secondary and Tertiary Care > Hospitals > Intensive Care > Sub acute care > Psychiatric facilities > Rural hospitals Restorative and Continuing Care Assist the individual in regaining maximal functional status, enhancing the individuals quality of life while promoting clients independence and self care Continuing Care > Long term care offers services over a prolonged period of time to people who have lost or never acquired functional capacity > May be provided in institutional settings, communities, or at home Service Institutions for Restorative Care > Home health Care > Rehabilitation > Extended Care facilities > Nursing Facilities > Adult day care centers > Hospice Examples of levels of prevention: Eating nutritious foods Primary level of prevention Performing self-examination for breast or testicular cancer Secondary level of prevention Obtaining tuberculosis skin tests

Secondary level of prevention Obtaining treatment for a streptococcal infection Secondary level of prevention Obeying seatbelt laws Primary level of prevention Work training program after hip dislocation Tertiary level of prevention Active ROM exercises for stroke victim Tertiary level of prevention Obtaining immunization for Hepatitis B Primary level of prevention Quitting smoking and limiting alcohol intake Primary level of prevention Wearing a helmet while working at a construction site Primary level of prevention Taking mefenamic acid for a headache Secondary level of prevention A diabetic patient asking a nurse to teach him how to inject insulin Secondary level of prevention Models for Delivery of Nursing 1. Case Method = referred to as total care = one of the earliest nursing model developed = client centered method, the nurse is assigned to and is responsible for the comprehensive care of a group of client during an 8 or 12 hrs shift 2. Functional Method = focuses on the jobs to be completed eg. Bed making, temp. = task oriented approach 3. Team Nursing = the delivery of individualized nursing care to clients by a nursing team led by a professional nurse 4. Primary Nursing = is a system in which one nurse is responsible for the total care of a number of clients 24 hrs a day and 7 days a week = the nurse uses technical knowledge and management skills Types of Health Promotion Programs 1. information dissemination 2. health appraisal and wellness assessment 3. lifestyle and behavior change programs 4. environmental control programs Wellness & Well-Being Nightingale state of being well and using every power the individual possesses to the fullest extent

WHO a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity ANA a dynamic state of being in which the developmental and behavioral potential of an individual is realized to the fullest extent possible Wellness is a state of well-being means engaging in attitudes and behaviors that enhance quality of life and maximize personal potential Well Being a subjective perception of vitality and feeling well a state that can be discussed objectively, occurs in levels, and can be plotted on a continuum Basic concepts of wellness 1. self responsibility 2. an ultimate goal 3. dynamic growing process 4. daily decision making in the areas of nutrition 5. stress management 6. physical fitness Travis and Ryan = state of wellness is a choice = a way of life = a process = integration of body mind and spirit = loving acceptance of the self Healthy Living Eating 3 balanced meals a day. Eating moderately to maintain a healthy weight. Exercising moderately, following a regular routine. Sleeping 7-8 hours a day. Limiting alcohol consumption to a moderate amount. Eliminating smoking. Keeping sun exposure to a minimum. Illness is a highly personal and subjective state in which the persons physical, emotional, intellectual, social, development, or spiritual functioning is thought to be diminished Agent Host Environment Model ( Leavell and Clark) Disease non-subjective state can be described as an alteration in body function resulting in a reduction of capacities or shortening of normal life span

Classification Acute Chronic

Definition Rapid onset, short period of time, self-limiting 1) Permanent; 2) Leaves permanent disability; 3) Causes non-reversible disability; 4) requires special training for rehab; 5) requires long period of care Can spread from one person to another Exists before birth Tends to become worse and cause death Results from deterioration of organs and tissues Affects function or performance but does not have manifestations of organic illness Psychologic disease manifested by physiologic symptoms Has unknown cause Caused by medical therapy

Communicable Congenital Malignant Degenerative Functional Psychosomatic Idiopathic Iatrogenic

How people behave when they are ill are highly individualized and affected by variables: Age Socioeconomic status Education Sex Religion Modes of coping Occupation Ethnic origin Psychological stability Illness Behavior a coping mechanism involves ways individuals describe, monitor, and interpret their symptoms The Sick Role (Talcott Parson) Four Aspects: 1. Clients are not held responsible for their condition 2. Clients are excused from certain social roles and tasks 3. Clients are obliged to try to get well as quickly as possible 4. Clients or their families are obliged to seek competent help Five Stages of Illness (Edward Suchman) 1. Symptom experience 3 aspects:

a. the physical experience of the symptom b. the cognitive aspect c. the emotional response *At this stage the sick person may try some remedies 2. Assumption of Sick Role acceptance of illness the client is excused from normal duties and role expectations * If symptoms of illness persist, medical help may be sought. 3. Medical care contact the client seeks advice of health professional 3 types of information sought: a. validation of real illness b. explanation of symptoms in understandable terms c. reassurance that they will be alright or prediction of what will be the outcome * Person may accept or deny 4. Dependent client role after acceptance of illness and seeking treatment the client becomes dependent on the professional help 5. Recovery or Rehabilitation the client is expected to relinquish the dependent role and resumes former role and responsibilities Factors Affecting Health and Illness A. Internal Variables Developmental stages Intellectual background Perception of functioning Emotional factors Spiritual factors B. External Variables Family practices Socio economic factors Cultural background Variables Influencing Illness Behavior A. Internal Variables Perception Nature of illness Coping Skills B. External Variables Visibility of Symptoms Social group Cultural Background

Economic variable Accessibility of Health Care System TRANSCULTURAL NURSING CHARACTERISTICS: CULTURE IS LEARNED IT IS TAUGHT SOCIAL INTETRACTIONS ADAPTIVE BARRIERS- ETHNOCENTRISM, PREJUDICE, STEREOTYPING, DISCRIMINATION AND RACISM. Factors that affect Culture and Care Cultural background of the nurse: differences and similarities Folk medicine practices Attitudes toward health and illness, healthcare, etc. Modesty and concepts of the human body Language differences Religious practices: specific prohibitions Jewish Dietary practices: KOSHER Diet - NO pork, shellfish, milk and meat products eaten together - fruits as alternative (no bugs) - Sealed foods do not touch their food - Plastic utensils - individually wrapped Prayer with Rabbi for comfort observe Sabbath and holidays Circumcision of male infants - generally a religious ceremony Death: - body should be handled as little as possible by non-Jews - cover body with clean white sheet, feet pointing towards doorway Islam Dietary practices: HALAL Diet - NO pork, blood, alcohol, lard, gelatin, shortening - Fasting during Ramadan Prayer is most important 5 times a day - Ambulatory: assist to bathroom to wash up - Bedridden: provide pitcher of water and basin Respect modesty provide privacy Severe illness or death: read the Quran, allow to face Mecca Wear disposable gloves if non-Muslim (do not wash the body, cut hair or nails) Wrap the body in a white sheet without religious emblem Cremation is forbidden Mormons Dietary practices: - Word of Wisdom health code - NO tea, coffee, alcohol, tobacco, chocolate

- may avoid hot drinks - eat meat sparingly - avoid products that contain a lot of blood Respect wearing of sacred undergarment - removed only for hygiene purposes, laundering, or surgery Dying: - contact with spiritual leaders; observe last rites - burial is preferred, but cremation not forbidden - post-mortem, organ transplant depends on family Jehovahs Witnesses Dietary practices: - no blood or blood products Smoking is prohibited NO to blood transfusion - Absolute: packed RBC, plasma, white cells and platelets - Ask individual: albumin, IMGs or clotting factors. Blood samples allowed (dispose any unused blood and do not reuse) Dialysis allowed - no other source of blood must be used Do not usually celebrate birthdays or Christmas Observe modesty and privacy Buddhism Dietary practices: - mostly vegetarian - meat and fish are not forbidden NO to abortion and active euthanasia Holy days: all full moons and Vesak full moon in May Blood transfusion, organ transplant, post- mortem personal choice Allow peace and quiet for meditation Allow visit from monks Cremation is preferred Most believe in reincarnation Christian Dietary practices: - no dietary restrictions - may wish to fast on Fridays, Lent, or before Communion Respect Sacraments such as Baptism, Holy Communion, and Last Rites Lay person may baptize During illness: - offer to see chaplain, visit chapel, Communion, or a Bible Blood transfusion, post-mortem care, organ transplant are allowed Cultural Values Refers to the individuals desirable or preferred way of acting or knowing something, that is sustained over a period of time and which governs actions or decisions. ABCDs in Transcultural Nursing:

Administration of medications must take into consideration some of the patients beliefs and practices. Examples: -Catholics usually will fast on Ash Wednesday and Good Friday except for sick patients -Muslims will fast during Ramadan -Jehovahs witnesses - medications are acceptable to the extent necessary Be familiar with some diseases which are common in a specific race. Examples: Africans - sickle cell anemia, hypertension Asians osteoporosis Blacks cervical cancer (female) prostate cancer (male) Jewish breast cancer Whites testicular cancer Communicate properly and be familiar with common communication practices across cultures. Examples: Asians rarely communicate their need for analgesics since they were taught self restraint. Hispanic women- discussions pertaining to the reproductive organs with male relatives or health care providers are considered impolite Muslim women prefer to talk to female doctors on matters related to reproductive problems Dietary modifications must be considered when planning nursing care. Examples: Chinese cold desserts (YIN) are served after surgery Europeans main meal is served by midday and is usually followed by coffee Jewish Kosher diet ( no meat and dairy products at the same time) Muslim Halal diet (no pork) The F I L I P I N O F - aithful; Fiesta oriented I - mitative L - oving and tender (malambing) I - ngenius P - liant I - nadequate initiative N - o discipline O - riented to: Kapalaran, kabuuan, kapayapaan 5 Categories of Caring Behaviors 1. "Authentic Presence" 2. "Competence" 3. "Emotional Support"

4. "Physical comforting" 5. "Positive consequences" There are four (4) standard statements which describe a nurses accountabilities in the nurse-client relationship. Nurses use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish and terminate the nurseclient relationship. Nurses work with the client to ensure that all professional behaviors and actions meet the therapeutic needs of the client. Nurses are responsible for effectively establishing and maintaining the limits or boundaries in the therapeutic nurse-client relationship. Nurses protect the client from harm by ensuring that abuse is prevented, or stopped and reported. Verbal and emotional abuse Includes, but is not limited to: sarcasm; retaliation or revenge; intimidation, including threatening gestures/actions; teasing or taunting; insensitivity to the clients preferences; swearing; cultural/racial slurs; and an inappropriate tone of voice, such as one expressing impatience. Neglect Includes, but is not limited to: non-therapeutic confining or isolation; denying care; non-therapeutic denying of privileges; ignoring; and withholding: clothing, food, fluid, needed aids or equipment, medication, and/or communication. Sexual abuse Includes, but is not limited to, consensual and non-consensual: sexually demeaning, seductive, suggestive, exploitative, derogatory or humiliating behaviour, comments or language toward a client; touching of a sexual nature or touching that may be perceived by the client or others to be sexual; sexual intercourse or other forms of sexual contact with a client; sexual relationships with a clients significant other; and non-physical sexual activity such as viewing pornographic websites with a client. Financial Abuse

Includes, but is not limited to: borrowing money or property from a client; soliciting gifts from a client; withholding finances through trickery or theft; using influence, pressure or coercion to obtain the clients money or property; having financial trusteeship, power of attorney or guardianship; abusing a clients bank accounts and credit cards; and assisting with the financial affairs of a client without the health care teams knowledge. Admission and Discharge ETHICAL CARE CONCEPTS Once the patient has entered the ER, it is implied that YOU (RN) are in direct care of the patient. SAFETY top priority Self-esteem safe and warm Types of Admission: Voluntary Involuntary Emergency - Patient - needs certification - 24-72 hours only AUTONOMY Patient has freedom of choice Know your pt.s rights Provide privacy Encourage self-care BENEFICENCE Done for the pt.s benefit despite pain NON-MALEFICENCE Do no harm (ex. Proper disposal of sharps) JUSTICE Triage and prioritizing CLINICAL ISSUES An urgent situation arises as a patient was brought in needing restraints. You tried to get an order for restraints from the MD, who has so far not responded. What would you do? Answer: Implement your INDEPENDENT nursing functions > Stay with the patient. > Put side railings up. > Bring patient near the nurses station. *In using restraints, always document: a. reason b. time c. duration *Check distal pulses every 3 hours! The nurse receives an order from the ROD of 2mgs. of Lithium for Lola Chayong, 78 years old. After questioning the order of the doctor, what is the nurses most appropriate action following the inappropriate order of the ROD? Answer: Document the incident. Remember:

Except for emergencies, the nurse should always do independent nursing actions first before dependent nursing actions. DELEGATION Issues Dont Delegate: Sterile technique sterile dressing change, catheterization Client Education Assessment Tasks needing specialized therapy or care Evaluation Creation of NCP Triage Telephone Advice Medications preparation, administration, teaching, documentation Monitoring special cases Interpretation of data Delegate: ADLS Routine procedures with predictable results Standard and chronic procedures colostomy care Bathing Post mortem care Feeding Weighing Simple dressing changes Patient transfers and ambulation DELEGATE only if: The client is medically stable, in a chronic condition and not fragile. Task is considered routine for the client. Task does not require a substantial amount of scientific knowledge or technical skill. Task has a predictable outcome. It conforms to agencys procedures and policies on delegation. Admission Factors that contribute to stress upon confinement: Fear of the unknown Admission procedure Personality of the admitting nurse Financial constraints Qualities of a good admitting nurse: Keen observer Good communicator Sound judgment Sensitive Creative Warm Professionally competent

Committed to service Benefits of Discharge Teaching Prevents the patients unnecessary confinement Promotes an early return to health Makes patient more cooperative Reduces upset behavior Reduces post-operative complications TEACHING: 3 Basic Elements CONTENT what to teach STRATEGIES how to teach LEARNER at whom the learning is aimed Most Important Factor: The need of the learner Teaching Methods: Listening Conference Demonstration / Return Demonstration Question and Answer Visual Aids Goal of Teaching: LEARNING Principles of Learning Learners learn best when they perceive a need to learn Interest and motivation when there is relevance Anxiety = attention, retention and ability Feedback promotes improved performance Simple complex = understanding Repetition = learning Active participation makes learning more meaningful Environment affects rate, amount, and quality of learning Common causes of Discharge Anxiety Fear of the unknown Fear of not having enough money to cover hospital bills Fear of not being able to carry out treatment at home Therapeutic Relationship The core of Nursing Who establishes and maintains this key-relationship? The Nurse What does the nurse use to maintain a therapeutic relationship? > Knowledge > Skills > Attitudes > Caring behaviors Five components to the nurse-client relationship:

1) TRUST is critical in the nurse-client relationship because the client is in a vulnerable position. Initially, trust in a relationship is fragile, so its especially important that a nurse keep promises to a client. If trust is breached, it becomes difficult to re-establish. 2) RESPECT is the recognition of the inherent dignity, worth and uniqueness of every individual, regardless of socio-economic status, personal attributes and the nature of the health problem. 3) PROFESSIONAL INTIMACY is inherent in the type of care and services that nurses provide.Professional intimacy can involve psychological, spiritual and social elements that are identified in the plan of care. Access to the clients personal information also contributes to professional intimacy 4) EMPATHY is the expression of understanding, validating and resonating with the meaning that the health care experience holds for the client. In nursing, empathy includes appropriate emotional distance from the client to ensure objectivity and an appropriate professional response. 5) THE NURSE-CLIENT RELATIONSHIP The appropriate use of power, in a caring manner, enables the nurse to partner with the client to meet the clients needs. Phases: 1. The PREINTERACTION Phase 2. The ORIENTATION (Introductory) Phase 3. The WORKING Phase 4. The TERMINATION Phase COMMUNICATION Therapeutic communication involves the use of techniques such as using silence, offering self, restating, reflecting, and seeking clarification to name a few. Involves displaying a genuine interest in the person communicating that is demonstrated through the use of a relaxed and comfortable body posture. Therapeutic communication requires the components of empathy, positive regard, and a positive sense of self Use of techniques Therapeutic Use of Self Genuine interest in the client Use of a relaxed and comfortable body posture. Components of empathy, positive regard, and a positive sense of self Exchange of Meaning essence of communication Maintain Eye contact Give full attention Eliminate barriers Appropriate response Provide evidence of listening to client Use all senses to assess verbal and non-verbal communication Active listening the basis of all nurse-client interactions. Barriers to Active Listening Lack of privacy Noise Seating arrangements

Use of jargon Perceptual and sensory distortions in clients Counter-transference Anxiety in the nurse Pain in the client Stereotyping Interventions: A nswer needs E ncourage expression and participation I nsight oriented , focussed on feelings O ffer support and encouragement U nconditional and non-judgemental TRY EXPRESSION RAPPORT UNCONDITIONAL POSITIVE REGARD SETTING LIMITS THERAPEUTIC COMMUNICATION Providing general leads - Perhaps you would like to talk about - Where would you like to begin? Being specific and tentative - Rate your pain on a scale from 0-10. (Are you in pain?) - You seem unconcerned about diabetes. (You dont care about your diabetes and you never will.) Using open-ended questions - How have u been feeling lately? Using touch - Placing your hand over the clients hand appropriately. Seeking clarification - Im not sure I understand that Offering self - We can sit here quietly for a while; we dont have to talk unless you want to. Giving Information - I do not know the answer to that, but I will ask the charge nurse for the exact information. Acknowledging - You combed your hair and trimmed your beard. Presenting reality - Your magazine is here in the drawer. It has not been stolen. Reflecting - What do you think would be helpful? - You seem unsure about telling your husband. Summarizing - During the past hour, we talked about - So far, youve told me that

Using silence Restating or paraphrasing BARRIERS Stereotyping - Men dont cry. - Most people dont have any pain after this surgery. Agreeing and disagreeing - No, Dr. Dela Cruz is a the head of the Department of Surgery and is an excellent surgeon. Being defensive - We do the best that we can here at the hospital. You are not the only client here, you know. Challenging - How can u say your dying when your pulse is 60? - You cant say your husband doesnt love you since he visits you everyday. Probing - Why do you always lie? - Why do you look at me like that? False reassurance - Dont worry - Im sure everything will turn out fine. Passing judgment - Thats good. - What you did was wrong. Key Points for Therapeutic Communication: 1. Dont ask Why? 2. Avoid passing the buck 3. Dont give false reassurance 4. Avoid nurse-centered responses 5. Recognize the patients feelings Prioritization: - use Maslows Hierarchy of Needs (prioritize physiologic) - use ABCs (airway, breathing, circulation, disability, exposure) - actual diagnosis over potential or risk diagnosis Important to client : ex. PAIN Unstable conditions Amount of time, materials, equipment required for care Actual problems Client before equipment Triage System of evaluation to establish priorities Emergency: greatest risk receives priority Major Disaster:

classification based on principles to benefit the largest number; those requiring highly specialized care may be given minimal or no care First Aid Remove client from immediate danger Maintain or establish airway /breathing Control bleeding Avoid unnecessary movement of spinal column or extremities Control pain Monitor level of consciousness NURSING PROCESS A systematic, rational method of planning and providing nursing care. Its goal is to identify a clients actual or potential health care needs, to establish plans to meet the identified needs, and to deliver and evaluate specific nursing interventions to meet those needs. Cyclic and dynamic in nature Client-centered Focus on problem-solving and decision making Interpersonal and collaborative Uses critical thinking Universally applicable Goal: is to identify a clients healthcare status, and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions Assessment: Collecting, organizing, validating, and documenting client data Is a continuous process carried out during all phases of the nursing process Focuses on a clients responses to a health problem where data collected should be relevant to the particular health problem. STEPS Initiate contact Demonstrate caring attitudes Develop mutual trust and confidence Provide comfort - comfortable room - minimize distractions - ensure privacy - adequate lighting - normalize room temperature Purpose: To establish a database about the clients response to health concerns or illness and the ability to manage health care needs Activities: 1. Establish DATA base a. Obtain a nursing health history b. Conduct a physical assessment c. Review client records

d. Consult resource persons e. Consult health professionals 2. Update data as needed 3. Organize data 4. Validate data 5. Document data Type Initial Time Performed Performed within specified time after admission Purpose Establish complete database for problem identification



Ongoing process integrated Determine status of a with nursing care specific problem identified in a earlier assessment / Identify new or overlooked problems During any physiologic or Identify life-threatening psychologic crisis of a client problems Several months after initial assessment Compare clients current status to baseline data previously obtained

Time-lapsed Reassessment

Components of a Nursing History Biographic Data Chief Complaint or Reason for Visit History of Present Illness Past History Family History of Illness Lifestyle Social Data Psychologic Data Patterns of Health Care DIAGNOSIS A clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. - NANDA Components of a Nursing Diagnosis Diagnostic Label name of nursing diagnosis listed in taxonomy, describes essence of problem Example: Stress Incontinence; Anxiety; Feeding Self-Care Deficit Qualifiers

add additional meaning to a nursing diagnosis, changes in condition, etc. Example: Altered; Impaired; Ineffective; etc. Related Factors Conditions, circumstances, etiologies that contribute to the problem not direct, causal relationship but some relationship can be described as related to. Actual Diagnosis a statement about a health problem that the client has and the benefit from nursing care. Ineffective airway clearance related to decreased energy as manifested by an ineffective cough. Risk Diagnosis a statement about health problems that a client doesn't have yet, but is at a higher than normal risk of developing in the near future. Risk for injury related to altered mobility and disorientation. Possible Dx Possible fluid volume deficit related to frequent vomiting for 3 days as manifested by increased pulse Syndrome Dx rate. Wellness Dx Rape-trauma syndrome related to anxiety about potential health problems as manifested by anger, genitourinary discomfort, and sleep pattern disturbance. Potential for enhanced organized infant behaviour, related to prematurity and as manifested by response to visual and auditory stimuli. Differentiating Nursing Diagnosis from Medical Diagnosis ND: is a statement of nursing judgment and refers to a condition that nurses are licensed to treat MD: are made by physicians and refers to a condition that only a physician can treat ND: describes a clients physical, sociocultural, psychologic, and spiritual responses to an illness or health problem MD: refers to a disease process Three steps in the diagnostic process 1. Analyzing data > involves the following steps a. compare data against standards b. cluster the cues ( generate hypothesis) c. identifying gaps and inconsistencies 2. identifying health problems, risks, and strength 3. formulate diagnostic strength PLANNING

Determine how to prevent, reduce, or resolve the identified client problems and how to implement nursing interventions in an organized, individualized, and goaldirected manner. Purpose: Develop an individualized care plan that specifies client goals and related nursing interventions IMPLEMENTATION A single nursing action - treatment, procedure or activity - designed to achieve an outcome to a diagnosis - nursing or medical - for which the nurse is accountable. Translation of care plan into action STEPS Put nursing plan to action Coordinate care / services Utilize community resources Delegate and supervise Monitor health services provided Provide health education and training Document responses to nursing action 1. Assess/Monitor: Collect and analyze data on the health status 2. Care/Perform: Provide a therapeutic action 3. Teach/Instruct: Provide Information, knowledge and/or skill 4. Manage/Refer: Coordinate, administrate, and/or refer EVALUATION Measuring the degree to which goals and outcomes have been achieved and identifying factors that positively or negatively influence goal achievement Purpose: Determine the extent to which client goals and outcomes have been achieved and to determine whether to continue, modify, or terminate plan of care Process of making judgments as to the extent the objectives are met STEPS Nursing audit Care outcomes Performance appraisal Estimate cost benefit ratio Assessment problems Identify needed alterations Revise plans as necessary Triage System of evaluation to establish priorities and assign appropriate treatment or personnel Emergency: greatest risk receives priority

Major Disaster: classification based on principles to benefit the largest number; those requiring highly specialized care may be given minimal or no care First Aid 1. Remove client from immediate danger 2. Maintain or establish airway /breathing 3. Control bleeding 4. Avoid unnecessary movement of spinal column or extremities 5. Control pain 6. Monitor level of consciousness Vital Signs Independent nursing action Nurse has ultimate responsibility for accuracy Temperature, Pulse, Respirations, Blood Pressure are assessed and interpreted together. Nurse must consider patient's normal pattern in relation to standard values/range. Assessment is determined by routine, physicians orders and nurses clinical judgment May be taken on admission as baseline data, beginning of each shift, change in patient's status, before/after invasive procedures, before/after certain medications, before/after nursing interventions Body Temperature Definition: Heat of body measured in degrees; indicates relationship between heat production and heat loss. Physiology Heat Production: metabolism, muscle activity, hormones, pyrexia Heat Loss: radiation, conduction, convection, evaporation Regulation: Skin & Central Nervous System (Hypothalamus) Factors Affecting Temperature: age, circadian rhythm, stress, gender, environmental extremes Temperature regulation and heat production are affected by : Basal metabolic rate Sympathetic stimulation Muscle activity Thyroxine output Fever Heat is lost from the body through: 1. Radiation : transfer of heat from one object to another object without contact between them 2. Conduction: transfer of heat from the body to another surface 3. Convection : dispersion of heat by air current 4. Evaporation : when water vaporizes heat energy is used to change it from liquid to a gas Normal: The generally accepted value of 98.6 F (37.0 Celsius) orally. Rectal: (+1 degree C); Axillary (-1 degree C) PHYSIOLOGICAL VARIATIONS IN NORMAL BODY TEMPERATURE Digestion of food - rise 0. 5 to 1.0 F

Exercise (Vigorous) - rise to 102-104 F (return to normal within thirty minutes with rest or shower) Diurnal Variation - low point early a.m.; peak in late afternoon, early evening. Variation varies - rarely up to three degrees, usually 1 to 2 F or may be reversed with changes in work habits. Menstrual Cycle - rise of 0.5-0.75 F rectally at time of ovulation with drop back at menstruation. Absent with amenorrhea. Pregnancy - continuation of above rise for about the first four months of pregnancy. Emotion - slight temporary rise with emotion Convert Celsius to Fahrenheit: multiply by 9/5 + 32 C Convert Fahrenheit to Celsius: subtract 32 C x 5/9 ORAL Most accessible and convenient RECTAL Most reliable measurement AXILLARY Safest and most noninvasive TYMPANIC MEMBRANE High-tech Contraindicated for confused and with convulsive disorders, trauma, chills, epilepsy; the very young, unconscious, uncooperative Inaccurate with very hot or cold food or fluid or smoked Contraindicated following nasal surgery or oral surgery Risk of exposure to body fluids Inconvenient and unpleasant Contraindicated following rectal surgery, with diarrhea In newborns, it can result in rectal perforations May be source of embarrassment / anxiety Placement at different sites within the rectum yields different temperatures Presence of stool may interfere with temperature placement Risk of exposure to body fluids Can be used in newborns and unconscious patients Thermometer must be left a long time to obtain an accurate measurement

Equipment is expensive Can be uncomfortable and involves risk of injuring the membrane if probe is inserted too far Usually used in ultra-modern settings

PULSE Definition: Wave of blood that can be palpated at major arteries. Produced by contraction of left ventricle. Cardiac Output: Amount of blood pumped per minute. Stroke Volume: Amount of blood pumped into aorta with each ventricular contraction, approx. 70cc.

Regulation of Pulse: Involuntary Autonomic Nervous System (ANS) = Sympathetic & Parasympathetic SinoAtrial node (SA): Pacemaker Factors Affecting Pulse: age, gender, exercise, fever, medications, hemorrhage, stress, pain, position change Assessing Pulse Rate (beats/min): Bradycardia,Tachycardia Rhythm (pattern of beats): Sinus Rhythm versus Dysrhythmia Volume/strength/amplitude: scale 0 - +4 Alternative assessment techniques: Doppler Stethoscope for apical pulse at apex of heart (AHR) Nursing Interventions for Taking the Pulse: 1. Site temporal = used when radial is not accessible Carotid = in infants, cardiac arrest Apical = used for cardiac disease Brachial = to measure BP, cradiac arrest in infants Radial = most commonly used site Femoral = in cardiac arrest, for infants and children Popliteal = to determine circulation to LE Posterior tibial = circulation to the foot RESPIRATION Definition: Process through which oxygen is inhaled and carbon dioxide is exhaled. Physiology: CNS control: Cerebral Cortex (voluntary) Brainstem (involuntary) Mechanical and Chemical Factors: Muscle activity and Blood gas levels Critical Factor: Level of carbon dioxide in arterial blood Factors Affecting Respirations: age, exercise, stress, fever, medications, pulmonary diseases Assessing Respirations Rate: apnea, bradypnea, tachypnea Depth: deep, shallow Rhythm/pattern: regular, irregular Quality: quiet, labored Normal Range : 12 -18 breaths per min adults Nursing Interventions for Taking Respiration 1. choose a time when the client is ralaxed 2. grasp the clients wrist and place it across the chest 3. administer medications for respiratory conditions 4. Inspect Chest movement 5. Palpate and count the respiratory rate 6. Assess a. depth, rhythm, and character of respiration

b. skin and mucous membrane color c. position assumed for breathing d. signs of cerebral anoxia (restlessness, drowsiness) e. activity tolerance f. associated symptoms such as chest pain and dyspnea g. medications affecting respiratory rate h. Cough (productive, nonproductive) i. Respirations following administration of respiratory depressants such as morphine BLOOD PRESSURE Definition: Measure of pressure/force exerted by the blood as it moves through the arteries; moves in waves consistent with the pumping action of the heart. Terms: Korotkoff sounds, systolic, diastolic, pulse pressure, hypertension, hypotension, orthostatic hypotension Physiology: Hemodynamic factors: Circulating blood volume, Cardiac output, Peripheral resistance, Blood viscosity Factors that affect blood pressure: Age, sex, race, obesity, exercise, stress, pain, circadian rhythm, cardiovascular/renal disease Assessing Blood Pressure Cuff size Too small: False high reading (pressure not transmitted evenly to artery). Too large: False low reading (pressure directed to a large surface area) Auscultatory Gap Pain An unpleasant sensory and emotional experience associated with the actual or potential tissue damage, or described in terms of such damage or both. (The International Association for the Study of Pain) The fifth vital sign Pain management focuses on lessening the sense of suffering experienced by a person with chronic pain. Bradykinin and histamine Pain syndromes, pain threshold and pain tolerance Types of Pain Acute : sudden or slow onset; varies from mild to severe : may last up to 6 months : subsides as healing takes place Chronic : exists beyond an expected time for healing. : lasts 6 months or longer : pain behavior is absent Radiating : perceived at the source and extends to nearby tissues

Referred : pain felt in a part of the body that is considerably removed from the tissues causing pain Intractable : pain that is highly resistant to relief Phantom : painful sensation perceived in a missing body part Pain Nociceptive Neuropathic Source Description This is the typical pain that we have all experienced. It is the signal of tissue irritation, impending injury, or actual injury. The result of a malfunction somewhere in the nervous system. The site of the nervous system injury or malfunction can be either in the peripheral or in the central nervous system. The pain is often triggered by an injury, but this injury may not clearly involve the nervous system, and the pain may persist for months or years beyond the apparent healing of any damaged tissues. The use of this category should be reserved for those rare situations where it is clear that no somatic disorder is present. It is universal that psychological factors play a role in the perception and complaint of pain. Some conditions the pain appears to be caused by a complex mixture of nociceptive and neuropathic factors.


Mixed Category

General Strategies for Pain Acknowledge the Clients Pain Verbal Acknowledgment Listening attentively Conveyance of assessment of the clients pain experience Prompt and competent care Pharmacologic Management Opioid analgesics Non-opioid / NSAIDs Non pharmacologic Pain management 1. Cutaneous stimulation 2. Application of Heat or Cold 3. Acupressure 4. Contralateral stimulation 5. Distractions 6. Hypnosis Physiologic Effects of Heat and Cold Heat Cold

> vasodilation > inc. capillar permeability > inc. cellular metab. > relax muscle > inc. inflam. > dec. pain by relaxing mm

> vasoconstriction > dec. capillary permeability > dec. cellular metab. > relax muscle > dec. inflam. > dec. pain by numbing the area

Methods of Examination: Inspection Auscultation Palpation Percussion Nutritional Status Assessment 1. Anthropometric Measurements 2. Biochemical data 3. Clinical signs of nutritional status 4. Dietary history Carbohydrates simple and complex Adenosine Triphosphate (ATP) is a compound with high energy bonds that stores energy for later use in cellular functions. Proteins composed of amino acids Anabolism - building tissue Catabolism - breaking down tissue Lipids insoluble in water but soluble in alcohol and ether Water Soluble Vitamins Names Vitamin C Ascorbic Acid Vitamin B1 Thiamine Vitamin B2 Riboflavin Physiologic Functions / Deficiency Sources

Collagen formation, increases iron Citrus fruits, cauliflower, absorption, antioxidant broccoli, spinach, (SCURVY) tomatoes Healthy nervous system, carbohydrate metabolism (BERI-BERI) Pork, beef, liver, nuts, legumes, grains and cereals

Healthy skin esp. around the eyes, Milk and its products, nose, mouth eggs, organ meats, (CHEILOSIS; GLOSSITIS) legumes,

Water Soluble Vitamins

Vitamin B3 Niacin or Nicotinic Acid Vitamin B6 Pyridoxine

Healthy nervous system, skin and Meat, poultry, fish, digestion, lowers cholesterol peanuts, beans, peas, milk (PELLAGRA) and its products Healthy nervous system (Scaly Dermatitis; Peripheral Nervous system toxicity unsteady gait, numb feet and hands, clumsiness, perioral numbness; Peripheral neuritis) Meats, esp. liver and kidney, cereal grains, yeast, soybeans, peanuts, chicken, salmon, tuna

Vitamin B9 Folic Acid

Formation of red blood cells (Bone marrow depression; macrocytic anemia)

Green leafy vegetables, asparagus, bananas, liver

Water Soluble Vitamins Vitamin B12 Cyano-cobalamine Healthy Formation of red blood Meat, poultry, fish, cells shellfish, milk, eggs, (Pernicious Anemia) cheese Interrealated with functions of other B-complex vitamins; coenzyme in metabolism (Alopecia) Coenzyme in metabolism; synthesis of amino acids Liver and kidneys, nuts, egg yolk, tomatoes


Pantothenic Acid

Vegetables, liver, eggs, legumes, and whole grains

Fat Soluble Vitamins Names Vitamin A Retinol Physiologic Functions / Deficiency Sources

Production of visual purple (Night Liver, kidney, fish oils, Blindess; Xeropthalmia) carrots, squash, spinach, broccoli

Vitamin D Calciferol Vitamin E Tocopherol Vitamin K

Normal growth of bones and teeth Direct sunlight, milk, fish (Ricketts; Bone Diseases) Muscle development, slows the aging process (Anemia) Blood clotting factors and prothrombin production and synthesis (Hemorrhage) Vegetable oils

Pork, liver, green leafy vegetables, tomatoes, egg yolk, cheese

Clear Liquid Diet transparent to light clear liquid at room temperature water, bouillon, clear broth, carbonated beverages, gelatin, popsicles, hard candy To relieve thirst / dehydration patients with nausea and vomiting post-op Full Liquid Diet offers more calories both clear and opaque liquids All liquids served at room or body temperature Custard, creamed soup, milk, plain ice cream, sherbet, strained soup, strained vegetable juices Given before solid food are introduced patients with more calorie needs Soft Diet Chopped, pureed, or regular foods with soft consistency Food seasoning are permitted No foods that contain nuts or seeds that can easily be trapped within the mouth and cause discomfort No raw fruits and vegetables, fried foods and whole grains Given for dental problems, difficulty of swallowing Oral problems, plastic surgery of jaw and neck Elderly Bland Diet No to gas-forming foods, irritating to the gastric mucosa, and stimulate gastric acid secretions Avoid caffeine, cocoa, colas, tea, fried foods, pepper and spicy foods Ulcers, Gastritis, Reflux Esophagitis High-Protein Diet

Help build tissue and muscle, and lose fat Excellent sources are meat, fish, poultry, dairy products Malnutrition, Burns, Liver disease, Nephrotic Syndrome High-fiber Diet Adds volume and weight to stool to speed elimination of undigested materials through the intestines Fruits and vegetables Constipation, Hyperlipidemia helps regulate blood glucose in DM helps control blood cholesterol in heart disease Positions for Assessment Dorsal recumbent back lying position with knees flexed and hips externally rotated; small pillow the head; soles of feet on the surface Supine or Horizontal recumbent - Back-lying position with legs extended; with or without pillow under the head Sitting - Back unsupported with legs hanging freely Lithotomy - back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table. Sims - Side-lying position with lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow. Prone - Lies on abdomen with head turned to the side, with or without small pillow HEENT Assessment: Head: shape and symmetry; condition of the hair and scalp Eyes: conjunctiva and sclera, pupils; reactivity to light and able to follow a finger or light Ears: hearing aids, pain, hears whispers, comprehension Nose: drainage, congestion, difficulty breathing or with sense of smell Throat and mouth: mucous membranes, any lesions, teeth or dentures, odor, swallowing, trachea, lymph Skin 1.Function = protect the body = regulate temperature = act as sensory organ 2. In older adults, skin loses its elasticity. It appears thin and translucent because of the loss of the dermis and subcutaneous fat. Dry and flaky 3. Procedure & technique = inspection and palpation 4. Color varies among individual but usually uniform over the body a. pallor reduced tissue circulation and oxygenation

b. cyanosis bluish tinge, most easily seen in the nail beds, lips and buccal mucosa c. jaundice yellowish tinge, first seen in the sclerae d. erythema redness e. vitiligo patches of hypopigmented skin f. moisture palpate for wetness and oiliness g. temperature reflects circulatory adequacy h. texture for smoothness or roughness i. Turgor gently pinch the skin on back of the hand and release j. edema buildup of fluid in the tissue k. vascularity look for localized pressure spots, superficial blood vessels and petechiae Lesions inspect, palpate and describe ( size, shape, texture, color; distribution and configuration) a. vesicle or bulla circumscribed, round or oval, lesion filled with serous fluid or blood vesicles are smaller than 0.5 cm; bullae are larger b. pustules vesicle or bulla filled with pus ( acne ) c. macule flat unelevated change in color (freckle) d. papule, plaque circumscribed elevation of the skin (warts), papules < 1 cm, plaque > 1 cm e. nodule elevated solid hard mass that extends deeper into the dermis than a papule f. tumors larger than 2 cm and may have an irregular border g. cyst 1 cm or larger, elevated, encapsulated, fluid-filled or semi-solid mass h. wheal a reddened, localized collections of edema fluid, irregular in shape ( hives, mosquito bites) i.. furuncle deep inflamed pustular area usually surrounding a hair follicle Thoracic region. Assess lung sounds and cardiac sounds. Front and back: assess for character and quality as well as the presence or absence of appropriate sounds. Palpate the chest wall and breasts for any tenderness, lumps. Vesicular > soft, low-pitched, normal sounds of air moving through small airways Bronchovesicular > moderate intensity blowing sounds of air moving through larger airways Adventitious Lung Sounds Abnormal extra or additional sounds that are heard over normal breath sounds. Crackles or RalesFrom fluid in small airways; common on inspiration; discontinuous; non-musical; popping; brief Ex. ARDS Wheezes Narrowing of airways; inspiration and expiration; Continuous; musical; high-pitched Ex. Asthma

Stridor Ronchi Stertor Friction Rub

Type of wheeze; inspiration; harsh, high-pitched Ex. Obstruction of trachea or larynx Obstructed larger airways; continuous; musical; Ex. COPD Inspiration; sonorous snoring; Low-pitched; grating sound

Lub-dub distinct normal heart tones that occur in sequence in one normal heart beat Murmurs - produced as a result of turbulent flow of blood, turbulence sufficient to produce audible noise; change with the severity of the cardiac disease Abdomen: Listen to bowel sounds throughout the four quadrants. Palpate for tenderness or lumps. Palpate the bladder. Ask about intake and appetite, and output both urinary and bowels Genitalia: assess for tenderness, lumps or lesions Mental and Emotional Status Assessment a. level of consciousness b. orientation to time place and person c. ability to follow simple command d. behavior and appearance e. language (indicator of cerebral function) f. memory (have client repeat a series of 5 or 6 numbers) g. knowledge h. abstract thinking Sensory functions Motor function includes coordination, balance and reflexes CRANIAL NERVE FUNCTION I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Auditory IX Glossopharyngeal X Vagus smell vision eyelid and eyeball movement turns eye downward and laterally chewing face & mouth touch & pain turns eye laterally facial expressions, secretion of tears & saliva taste hearing equillibrium sensation taste slows heart rate, stimulates digestive organs, taste

XI Accessory XII Hypoglossal

controls shoulder movements, controls swallowing movements controls tongue movements

Some say marry money but my brother says bad business marry money BODY MECHANICS Is the efficient, coordinated and safe use of the body to produce motion and maintain balance during activity MAJOR PURPOSE to facilitate safe and efficient use of appropriate muscles The line of gravity should pass through the base of support The wider the base of support, the greater the stability Objects that are close to the center of gravity are moved with the least effort Synchronized use of many large muscles increases overall strength Pulling creates less friction than pushing Continuous muscle exertion can result in muscle strain and injury Pressure Ulcers Stage Ulcer Characteristics Interventions I. INTACT SKIN non blanchable erythema CLEAN WOUND BASE partial thickness skin loss (epi/dermis or both) No dressing. Monitor frequently. Use moist dressing but keep surrounding skin dry.



ESCHAR and NECROSIS fullSame as StageII plus debride thickness skin loss involving damage eschar and necrotic tissue. Use or necrosis of subcutaneous tissue. wet-to-dry dressings. Do not use topical antiseptics.


EXTENSIVE TISSUE DAMAGE full-thickness skin loss. Damage to muscle, bone, etc.

Same as StageIII plus remove all dead tissue. Use clean dry, dressings debridement

Braden Scale Used to evaluate risk for developing pressure ulcers Based on the evaluation of 6 Factors, namely: Nutrition Activity Moisture

Mobility Sensory Perception Friction and Shear Remember: The lower the score, the higher the risk! Rest implies calmness, relaxation without emotional stress and freedom from anxiety Most people are able to rest when they: Feel that things are under control Feel accepted Feel that they understand what is going on Are free from irritation and discomfort Have a satisfying amount of purposeful activity Know they will receive help when it is needed SLEEP basic need universal process common to all people a state of consciousness in which the individuals perception and reaction to the environment are decreased Characterized by: 1. Minimal physical activity 2. Variable levels of consciousness 3. Changes in the bodys physiologic processes 4. Decreased responsiveness to stimuli Principles & Practices of Surgical Asepsis 1. All objects used in sterile field must be sterile 2. Sterile objects become unsterile when touched by unsterile objects 3. sterile objects that are out of vision or below the waist level of the nurse are considered unsterile 4. sterile objects can become unsterile by prolonged exposure to airborne microorganisms 5. fluids flow in the direction of gravity 6. moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action 7. the edges of sterile fields are considered unsterile 8. the skin cannot be sterilized and is unsterile 9. conscientiousness, alertness, and honesty are essential qualities in maintaining surgical asepsis Drug or medication Desired effect Therapeutic effect or action

Adverse effect

Undesirable action differing from planned effect

Side effect Toxic effect Cumulation

Often predictable outcome that is unrelated to the primary action of the drug Pathologic extension of the primary action of the drug Elevation of circulating levels of a drug consequent to slowing of metabolic pathways or excretory mechanisms

Drug dependence

Driving need for continued use of a drug that leads to abuse (psychic or physical)


Unpredictable, highly-individualized response; genetic interference with metabolic degradation of a drug

Paradoxical effect

A response to a drug that contrasts sharply with the usual therapeutic effect


Lowering of effect from an established dosage

Drug allergy

Induction of allergen-antibody reactions such as anaphylaxis, urticaria, angioedema, serum-sickness, etc.

> absorption = process by which a drug gets from its site of entry into the blood stream > distribution = the movement of the drug, via the blood stream, to the specific tissues for its actions where it accumulates

> metabolism (biotransformation) = the breakdown of the drug into its inactive form > excretion = occurs after the drug is metabolized Parts of Medication Order 1. clients name 2. date and time order is written 3. name of the drug to be given 4. dosage of the drug 5. route of administration 6. frequency of administration 7. signature of the person writing the order Safety Measures for preparing and administering Drugs : 1. check the label of the medication container 2. return the medication to the pharmacy if the label is missing or illegible 3. notify nurse manager if there is tampering with any medications 4. Never administer medications prepared by another nurse 5. Observe the five rights a. Right medication b. Right client c. Right dosage d. Right route e. Right time 6. to identify the client, check his/her identification bracelet and ask to state his/her name 7. Recheck medications if the client questions their appearance or time of administration 8. monitor the effects of the medications Drug Computation Formula : Dose ordered Dose on hand X amount on hand = Amount to administer Care for the Elderly Categorizing the Aging Population: 55 64 = the older population 65 74 = the elderly 75 84 = the aged 85 and older = the extreme aged Or 60 74 = the young-old 75 84 = the middle-old 85 and older = the old-old 6.08% of population = 60 years old and above Average lifespan: 67.5 years Living arrangements: 61.8% with grandchild Leading cause of morbidity: INFLUENZA Leading cause of mortality: Cardiovascular Diseases

Expanded Senior Citizens Act 2003: RA 9257 Focus of Nursing Care: Promotion of Optimum Level of Functioning Many physical changes occur with aging and involve all body systems The older adult has to adjust to possible psychosocial changes. Intellectual abilities of the healthy elderly person undergo minimal change. Of the four types of memory, secondary memory is the most affected by the aging process. Moral concerns of elderly people tend to be interpersonal rather than social or legalistic. Sensory Changes > Hearing have trouble hearing high-pitched tones > Vision reduced peripheral vision, degeneration of eye muscles, clouding of lenses with cholesterol deposits (arcus senilis), color vision changes (can see red, orange and yellow better), focusing problems, cataracts, glaucoma and blindness > Taste and Smell some loss in taste sensation, minimal olfactory sensory loss, chewing problems > Touch reduced sensitivity, decreased sweat gland activity, poorer circulation, wrinkling, drying, scaling of skin, Musculo-skeletal changes > fragility of bones, stiffening of joints, loss of elasticity in connective tissues, prone to injuries and falls, less subcutaneous fat making them prone to cold Digestive Changes > loss of teeth and gum problems, more sensitive to emotions, lesser bowel movements, dehydration due to decreased sense of thirst, immobility, lifestyle risk factors Circulation changes > heart slows down leading to decreased cardiac output, blood vessels lose elasticity and harden, prone to pressure ulcers Sexuality Changes > loss of sexual desire can be due to emotional problems, disease, or drug use, some loss of physical sexual function Crutch-Walking Ensure proper fit of crutches length is from anterior fold of axilla to lateral of heel axillary bars should be padded padded handle bars should allow complete extension of the arms and flexion of elbows make sure crutches are rubber-tipped Assist in proper technique 1. Only 1 leg can bear weight: a. Swing-to gait b. Swing through gait c. Three-point gait (ex. fractured hip) 2. Both legs can move separately and bear some weight a. Four-point crutch gait (ex. polio, arthritis, cerebral palsy)

b. Two-point gait (ex. bilateral amputee) 3. Tripod Gait Observe incorrect use of crutches - using the body in poor mechanical fashion - lifting crutches while still bearing down on them - walking on ball of foot, with foot turned outward and flexion at hip or knee level - hunching shoulders or stooping with shoulders - looking downward while ambulating - bearing weight under arms; should be avoided to prevent injury 3 types of Canes: 1. Standard cane 2. Tripod or Crab cane 3. Quad cane Most Popular Types of Walkers: 1. Standard walker 2. Four-wheeled walker 3. Two-wheeled walker Concepts on Death and Dying A childs concept of death depends to a considerable extent on his age, intellect, life experience and cultural background Children under the age of 3 have no awareness or understanding of death Children 3 to 5 years denies death and do not consider it as permanent Children 6 years of age and above seem to accommodate the fact that death is final Children 9 to 10 years old achieve a realistic concept of death as a permanent biologic process Elizabeth Kubler-Ross Stages of Grieving/Dying DENIAL No, not me. ANGER Why me? BARGAINING If only DEPRESSION Stage of silence ACCEPTANCE Yes, its me. Be physically present Encourage verbalization of feelings Allow the patient to cry Recognize your own thoughts about death and dying Nursing Diagnoses Anticipatory grieving Ineffective individual coping Dysfunctional grieving

Twenty years from now you will be more disappointed by the things that you didn't do than by the ones you did so. So throw off the bowlines. Sail away from the safe harbor. Catch the trade winds in your sails. Explore. Dream. Discover. God be with you always.