Emillie Grace D. Tombucon, RN, MSNc

 Is the diagnosis and treatment of human

responses to actual or potential health problems (ANA, 1980)
 Is an interpersonal process whereby professional

nitse practitioner assists an individyal, family or community to prevent or to cope with experience of illness and suffering and if necessary to find meaning in these experiences (Joyce Travelbee)  RA 9173, Philippine Nursing Act of 2002

Roles and responsibilities of Nurses
 Caregiver

 Communicator
 Educator  Counselor  Manager  Change Agent  Leader  Clinician  Advocate

first top notcher with 93. nurses week .Written by Lystra Grette of        Farrand Nursing School Ilo ilo Mission Hospital Training school for nurses.5% Act 2493-first law affecting the nursing practice Act of 2808-the first nursing law Miss Anastacia Giron Tupas.FNA was founded with 150 nurses Proclamation 539.Dean and pioneer of Philippine Nursing September 2. 1909 Anna Dahlgen.Nursing Hx  Nightingale Pledge. 1922.Pres Carlos P Garcia.

Components of Nursing Process  Assessment  Diagnosis  Planning  Implementation  Evaluation .

NANDA  Actual Nursing Diagnosis.Based on clinical judgment of the client‟s degree of vulnerability  Wellness Nursing Diagnosis.focuses on clinical judgment about trasitioning from s specific level to a ahigher level of wellness  Syndrome Nursing Diagnosis.based on clinical judgment of the nurse on review of validated data  Risk Nursing Diagnosis.cluster of actual or high-rsik diagnosis that are predicted to be present because of certain situation .

 a formulated hypothesis or.Theory  a set of related statements that describes or explains phenomena in a systematic way.  the doctrine or the principles underlying an art as distinguished from the practice of that particular art. .  a provisional statement or set of explanatory propositions that purports to account for or characterize some phenomenon. any hypothesis or opinion not based upon actual knowledge. loosely speaking.

and /or prescribing. predicting. systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing.Nursing theory  A nursing theory is a set of concepts. . definitions. explaining. relationships. and assumptions or propositions derived from nursing models or from other disciplines and project a purposive.

characteristics and attributes of person giving care. and sociocultural components. and influences affecting the person  Health. family. .All internal and external conditions. spiritual. including physical.Degree of wellness or illness experienced by the person  Nursing. circumstances. psychological.Individual.Actions.Recipient of care.METAPARADIGMS IN NURSING  Person. or community  Environment.

Derived a definition of nursing .Patients require help towards achieving independence. Florence Nightingale’s Legacy of caring- Focuses on nursing and the patient environment relationship  Ernestine Wiedenbach: The helping art of clinical nursing  Virginia Henderson’s Definition of Nursing .Identified 14 basic human needs on which nursing care is based. . .

Cure. social phenomenon that is only effective when practiced interpersonally considering humanistic aspects and caring.Abedellah’s Typology of twenty one Nursing problems -Patient‟s problems determine nursing care  Lydia E.Caring is a universal.  Patricia Benner’s Novice to Expert . Hall :Care.  Jean Watson’s Philosophy and Science of caring. Faye G. Core model-Nursing care is person directed towards self love.

 Dorothea E. Orem’s Self care deficit theory in

nursing-Self–care maintains wholeness.
 Three Theories:  Theory of Self-Care  Theory of Self-Care Deficit  Theory of Nursing Systems  Nursing Care:  Wholly compensatory (doing for the patient)  Partly compensatory (helping the patient do for himself or herself)  Supportive- educative (Helping patient to learn

self care and emphasizing on the importance of nurses‟ role

 Myra Estrin Levine’s: The conservation model  Martha E.Roger’s: Science of unitary human

beings  Dorothy E.Johnson’s Behavioural system modelIndividual as a behavioural system is composed of seven subsystems: the subsystems of attachment, or the affiliative, dependency, achievement, aggressive, ingestive-eliminative and sexual.  Sister Callista: Roy‘s Adaptation model- The individual is a biopsychosocial adaptive system within an environment.The individual and the environment provide three classes of stimuli-the focal, residual and contextual.

 Betty Neuman’s : Health care systems model-

Neuman‟s model includes intrapersonal, interpersonal and extrapersonal stressors. Nursing is concerned with the whole person. Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on the variables affecting the client‟s response to stressors.  Imogene King’s Goal attainment theory-

Exploitations  4. Peplau: Psychodynamic Nursing Theory-nterpersonal process is maturing force for personality.  The four phases of nurse-patient relationships are:  1.  Stressed the importance of nurses’ ability to understand own behaviour to help others identify perceived difficulties. Resolution . Identification  3. Hildegard E. Orientation  2.

Surrogate  6. . Stranger  2. Leader  5. Teacher  4. Resource person  3. Counselor  Interpersonal process alleviates distress. The six nursing roles are:  1.

. Ida Jean Orlando’s Nursing Process Theory- Elements of nursing situation:  Patient  Nurse reactions  Nursing actions  Joyce Travelbee’s Human To Human Relationship Model. Nursing is accomplished through human to human relationships that began with the original encounter and then progressed through stages of emerging identities.Therapeutic human relationships.

culture-care theory. . Major concepts include care. mutual and in constant interaction with environment. cultural values and cultural variations  Rosemarie Rizzo Parse’s :Theory of human becoming.Caring is universal and varies transculturally. culture.Clients are open. Madeleine Leininger’s Transcultural nursing. caring.

Health  Is the extent to which an individual or group is able to relize aspirations and satisfy needs and change or cope with environment. It is the complete physical. mental and social well being and not merely the absence of disease or infirmity .

Prevention  Primary Prevention  Secondary  Tertiary Assuming the Sick Role  Experience of symptom  Assumption of dependent role  Recovery and rehabilitation .

Exercise  Isotonic-dynamic  Isometric-Static  Isokinetic.Resistive .

or RLR. Left Lateral Recumbent. Fowler's Position -A person in the Fowler's position is sitting straight up or leaning slightly back. Trendelenberg Position. Prone. A „low fowlers‟ position is someone whose head is only slightly elevated. A „high fowlers‟ position is somewhat who is sitting upright. or LLR.Someone in the prone position is lying face down.Positioning  Supine. This position is often used for rectal examination and treatments and enemas. means that the patient is lying on their right side.A person in the Trendelenberg position is lying supine with their head slightly lower than their feet.The left lateral recumbent. Right Lateral Recumbent. left leg extended and right leg flexed.The Right lateral recumbent. Their legs may either be straight or bent. SIM'S POSITION -This position is a variation of lateral position with the patient on the left side.Someone in the supine position is lying on his or her       back. . means that the patient is lying on their left side.


Supine position .

Prone Position  This prone position can be used to prevent contractures in knees and hips. .  Prone position counter indicated with spinal cord clients.

 Reposition HOB. arms folded across chest  Nurses tightens abdominal girdles. . chin to chest.  HOB down---don‟t move up hill. bed in low position.  Nurses shift weight.  Position height of bed for nurses‟ comfort.  Have patient flex knees. moving patient.Positioning/Moving a Client Up in Bed  Allow patient to move himself if he can. flex knees.

. find assistance if     it is needed.Turning a Patient  Determine what patient can do. Position patient supine on far side of bed. Patient arms across chest. Position height of bed for nurses‟ comfort. Tighten girdles. flex knees. far leg over near one.

Turning Patient (con‟t)
 Place one hand on patient shoulder, other on hip.
 Roll patient toward you.  Position patient for comfort, support with pillows if

need be.  Raise side rails, lower bed.

Passive ROM

 The patient is unable

to move independently and someone else manipulates body parts.

Active-Assistive ROM

The nurse provides minimal support as the patient moves through ROM.

.Active ROM The patient moves independently through a full ROM for each joint.

mass. strength and improves cardiac and pulmonary functioning.Only active ROM increases muscle tone. .

temperature fluctuates and is nonnormal Relapsing-short febrile periods of a few days Intermittent.2-3 minutes very accurate CI wih MI. perforation Axillary.Hyperythermia is temperature 38-41 C Hyperpyrexia.6) Oral-3-5 minutes Rectal.careful fo rinjury.temperature fluctuates and normal on fluctuation Constant fever.temperature that fluctuates minimally .Vital signs  Temperature – 37 C (98. hemorrhoids Tympanic. safe and none invasive Pyrexia.41 C Remittent fever.6-9 minutes.

Thyroxine Output 4. Basal metabolic rate 2. Muscle Activity 3. Vaporization . Symathetic Stimulation 5. Fever Factors Affecting Heat Loss 1. Radiation 2.Factors affecting Heat production 1. Conduction 3. Convection 4.

8 + 32  C=(Temp in F-32)/1.Celsius to Fahrenheit  F= (Temp in C) X1.8 Conversion: 41 C= ___ F .

Factors Affecting Body Temperature  Circadian Rhythms  Age  Exercise  Sex  Hormone levels  Stress  Environment .

.  Skin temperature rises & falls in response to environmental conditions & depends on bld flow to skin & amt.Body Temperature  Core temperature – temperature of the body tissues. of heat lost to external environment  The body‟s tissues & cells function best between the range from 36 deg C to 38 deg C  Temperature is lowest in the morning. is controlled by the hypothalamus (control center in the brain) – maintained within a narrow range. highest during the evening.

.  Infrared Tympanic (Ear) – sensor probe shaped like an otoscope in external opening of ear canal. (reads in seconds) there is a probe for oral/axillary use (red) & a probe for rectal use (blue). Relies on battery power – return to charging unit after use. Ear canal must be sealed & probe sensor aimed at tympanic membrane – ret‟n to charging unit after use. (just recently non mercury)  Electronic – heat sensitive probe.Thermometers – 3 types  Glass mercury – mercury expands or contracts in response to heat. There are disposable plastic cover for each use.

5 C higher than oral When unsafe or inaccurate by mouth (unconscious. Measures 0.Sites Oral Posterior sublingual pocket – under tongue (close to carotid artery) Axillary Bulb in center of axilla Lower arm position across chest Rectal Side lying with upper leg flexed. Must be awake & alert. Less accurate (no major bld vessels nearby) Leave in place 3 min Leave in place 5-10 min. Measures 0. disoriented or irrational) Side lying position – leg flexed Rapid measurement Easy assessibility Cerumen impaction distorts reading Otitis media can distort reading 2-3 seconds . Not for small children (bite down) Non invasive – good for children. insert lubricated bulb (1-11/2 inch adult) (1/2 inch infant) Ear Close to hypothalmus – sensitive to core temp. Leave in place 2-3 min.Pull pinna up & back Child – pull pinna down & back No hot or cold drinks or smoking 20 min prior to temp.5 C lower than oral temp. changes Adult .

Pulse  Number of pulsations/minute over a peripheral artery  Rate: Beats per minute  60-100 Beat per minute  Bradycardia  Tachycardia  Rhythm: regular or irregular (dysrhythmia)  Amplitude  0 to 4+ .

popliteal. Felt by palpating artery lightly against underlying bone or the difference between the systolic an diastolic pressure  Pulse deficit – the difference between the radial pulse and the apical pulse – indicates a decrease in peripheral perfusion from some heart conditions ie. brachial. . posterior tibial. rhythm.Assessing Radial Pulse  Left ventricle contracts causing a wave of bld to surge through arteries – called a pulse. Atrial fibrillation. femoral. radial.  Carotid. strength – can assess by using palpation & auscultation.  Pulse Pressure. dorsalis pedis  Assess: rate.

if irregular – count radial for 1 min. midclavicular line. 3rd & 4th fingers lightly on skin where an artery passes over an underlying bone. just below lt. and then apically for full minute. Do not use your thumb (feel pulsations of your own radial artery). Count 30 seconds X 2. nipple – listen for a full minute “Lub-Dub”  Lub – close of atrioventricular (AV) values – tricuspid & mitral valves  Dub – close of semilunar valves – aortic & pulmonic valves .Procedure for Assessing Pulses  Peripheral – place 2nd.  Apical – beat of the heart at it‟s apex or PMI (point of maximum impulse) – 5th intercostal space.

average 80 bpm  Tachycardia – greater than 100 bpm  Bradycardia – less than 60 bpm Rhythm – the pattern of the beats (regular or irregular) Strength or size – or amplitude.Assess: rate.1+ -----------------2+--------------. the volume of bld pushed against the wall of an artery during the ventricular contraction  weak or thready (lacks fullness)  Full.3+ ----------------4+ Absent Weak NORMAL Full Bounding . strength & tension  Rate – N – 60-100. bounding (volume higher than normal)  Imperceptible (cannot be felt or heard)   0----------------. rhythm.

Normal Heart Rate Age Infants Toddlers Preschoolers School agers Adolescent Adult Heart Rate (Beats/min) 120-160 90-140 80-110 75-100 60-90 60-100 .

is pulse obliterated by slight pressure (low tension or soft)  Stethoscope  Diaphragm – high pitched sounds.)  Tension – or elasticity. lung & heart sounds – tight seal  Bell – low pitched sounds. the compressibility of the arterial wall. bowel.Assess (cont. heart & vascular sounds. apply bell lightly (hint think of Bell with the “L” for Low) .

Apical Pulse  Site: PMI at 5th ICS at left MCL  A/R rate correspond usually  Pulse Deficit is the difference between the A/R rate .

Peripheral Sites  Temporal  Carotid  Brachial  Radial  Femoral  Popliteal  Posterior tibial  Dorsalis pedis .

Dorsalis Pedis .Common Pulse Points  Central Pulses  Carotid  Femoral  Peripheral Pulses  Radial  Brachial (children under 1)  Posterior Tibial.

Pulse Assessment  Stethoscope for apical pulse using bell side to hear low frequency sounds of heart and blood  Doppler Ultrasound  Cardiac Monitor  Palpation of peripheral arterial pulse .

Factors Influencing Pulse Rates  Exercise  Temperature  Emotional States  Drugs  Hemorrhage  Postual Changes  Pulmonary Conditions .

Respirations  Passive process regulated by brain stem  Ventilation regulated most importantly by high arterial CO2 (hypercarbia)  COPD regulation is by hypoxemia (low 02 levels) via chemoreceptors in carotid artery and aorta  Respiratory Rate  Eupnea: 12 to 20 breaths/min  Tachypnea  Bradypnea .

Factors influencing Respirations  Exercise  Acute pain  Anxiety  Smoking  Body Position  Medications  Neurological Injury  Hemoglobin Levels .

while still holding hand.Respirations  Assess by observing rate. while men & young children breathe diaphramatically ***usually  Asses after taking pulse. rhythm & depth  Inspiration – inhalation (breathing in)  Expiration – exhalation (breathing out)  I&E is automatic & controlled by the medulla oblongata (respiratory center of brain)  Normal breathing is active & passive  Women breathe thoracically. so pt is unaware you are counting respiratons .

.Assessing Respiration Rate # of breathing cycles/minute (inhale/exhale-1cycle) N – 12-20 breaths/min – adult . with period of apnea at the end of each cycle. of air inhaled/exhaled normal (deep & even movements of chest) shallow (rise & fall of chest is minimal) SOB shortness of breath (shallow & rapid) Regularity of inhalation/exhalation Normal (very little variation in length of pauses b/w I&E Depth Rhythm Character Digressions from normal effortless breathing Dyspnea – difficult or labored breathing Cheyne-Stokes – alternating periods of apnea and hyperventilation. gradual increase & decrease in rate & depth of resp.Eupnea – normal rate & depth breathing Abnormal increase – tachypnea Abnormal decrease – bradypnea Absence of breathing – apnea Amt.

Pulse Oximetry Spo2  Spo2 acceptable ranges: 90%-100%  Sp02 85%-89% acceptable for chronic diseases  Spo2 less than 85% is unacceptable .

Factors influencing Respirations  Exercise  Acute pain  Anxiety  Smoking  Body Position  Medications  Neurological Injury  Hemoglobin Levels .

pressure exerted on vessel wall. ventricle contracts & pumps bld into the aorta – max. ventricle contracts – bld is forced out into the aorta to the lg arteries. Pressure of bld within the arteries of the body – lt. when the heart is filling. smaller arteries & capillaries  Systolic.force exerted against the arterial wall as lt.medications  . minimum pressure in arteries.  Factors affecting B/P lower during sleep  Lower with bld loss  Position changes B/P  Anything causing vessels to dilate or constrict .Blood Pressure  Force exerted by the bld against vessel walls.  Diastolic – arterial pressure during ventricular relaxation.

B/P (cont.>160.more reliable – read at eye level. stethoscope  3 types of sphygmomanometers o Aneroid – glass enclosed circular gauge with needle that registers the B/P as it descends the calibrations on the dial. o Electronic – cuff with built in pressure transducer reads systolic & diastolic B/P . o Mercury – mercury in glass tube . >90  Hypotensive <90  Non invasive method of B/P measurement  Sphygmomanometer.) P&P p. 240 see table 9-3  Measured in mmHg – millimeters of mercury  Normal range  syst 110-140 dias 60-90  Hypertensive .

rt arm . tube connects to the manometer.  Do not take B/P in  Arm with cast  Arm with arteriovenous (AV) fistula  Arm on the side of a mastectomy i. another to the bulb.B/P (cont.)  Cuff – inflatable rubber bladder. important to have correct cuff size (judge by circumference of the arm not age)  Support arm at heart level. P&P p. palm turned upward .e. rt mastectomy. 240.above heart causes false low reading  Cuff too wide – false low reading  Cuff too narrow – false high reading  Cuff too loose – false high reading  Listen for Korotkoff sounds – series of sounds created as bld flows through an artery after it has been occluded with a cuff then cuff pressure is gradually released.

brain and kidneys .Hypertension  Asymptomatic  Diastolic 80-89 mm Hg on 2 subsequent visits  Systolic 120-139 mm Hg on 2 subsequent visits  HTN greater than 140/90  Greater peripheral vascular resistance with decrease in blood flow to heart.

Hypotension          Systolic B/P falls below 90 mm Hg Hemorrhage Pump failure of heart Pallor Mottling of skin Clamminess Confusion Increase in HR Decrease in urinary output .

Hypotension  Orthostatic (Postual)  Risk Factors  Dehydration  Anemia  Prolonged bedrest  Recent blood loss .

5-8 Liters average .Blood Pressure  Variations in B/P  Peripheral resistance and compliance  Wall elasticity  Neural and humoral mechanisms  Renin-angiotensin-aldosterone  Increase per vascular resitance  Increase Na and H2O retention  Cardiac Output  3.

Blood Pressure Assessment Non-invasive Monitoring  Equipment: stethoscope and sphygmomanometer  Select appropriate cuff size  Sites  Brachial artery  Popliteal if brachial artery inaccessible .

What factors may influence accuracy of B/P measurement?  Exercise  Caffeine  Smoking  Cuff size  Too rapid or too slow release of valve  Release so descent is 2-3mm Hg .

Korotkoff Sounds  Phase I = 1st thump sound  Phase II = whooshing sound  Phase III = softer thump than Phase I  Phase IV = soft blowing that fades  Phase V = silence .

B/P Variation Factors  Age  Diurnal Rhythms  Stress  Ethnicity  Weight  Gender  Body Position  Exercise  Medications [anti-HTN. contraceptives] . cardiac. opiod analgesics.

Physical Assessment  Inspection  Palpation  Percussion  Auscultation Skin  Pallor  Cyanosis  Jaundice  Erythema .

2 cm deeper than papule  Tumor.larger 1-2 cm  Wheal. petichiae  Patch-vitiligo Palpable elevated solid mass  Papule. non palpable change in skin color  Macule-freckles. flat.Circumscribed.localized skin edeme (hive) .elevated nevus  Plaque-psoriasis  Nodule.

impetigo  Scale. Eroison.dandruff  Scar  Keloisd-hypertrophied scar  Excoriation-scratch mark  Lichenification-rough thickened (dermatitis) .scratch mark chicken pox  Ulcer-pressure sores  Fissure.athlete foor  Crust.

Eyes and Vision  PERRLA  Anisocoria  N pupil size 3-7 mm in diameter  Snellen‟s Chart.20/20 Myopia Hyperopia Presbyopia Astigmatism .

Tonometry PerimetryOpthalmoscopy Gonioscopy .

auricle pinna.3 ossicles (incus malleus stapes. external canal and tympanic membrane  Middle.Cochlea. vestibule and semicircular canal . Eustachian tube)  Inner.Ears and Hearing  Outer.

lateralization test that compares right and left ear  Rinne. Tuning fork  Weber.compares air conduction with bone conduction  Schwabach-compares client hearing with examiner .

Nose and paranasal sinuses  Nasal speculum  Penlight .

wharton duct  Sublingual .stensen‟s duct  Submandibular.Mouth and pharynx  Central lower incisor 5-8 mos  20 temporary teeth  32 permanent teeth  Parotid.

when the AP diameter is wider than the transverse diameter  Pigeon Chestpermanent deformity with narrow transverse diamter. protruding sternum  Funnel Cheststernum is depressed with narrowing  Kyphosis .Thorax and Lungs  Barrel Chest.

They are heard over the periphery of the lung field. As stated earlier.  Vesicular breath sounds consist of a quiet.consist of a full inspiratory and expiratory phase with the inspiratory phase usually being louder. They are normally heard over the hilar region in most resting animals and should be quieter than the tracheal breath sounds. They are normally heard over the trachea and larynx  Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer expiratory phase. wispy inspiratory phase followed by a short. .Normal breath sound  Bronchial Sounds. almost silent expiratory phase. these sounds are NOT produced by air moving through the terminal bronchioles and alveoli but rather are the result of attenuation of breath sounds produced in the bronchi at the hilar region of the lungs.

emphysema Tactile Fremitus .Abnormal Breath Sounds  Crackles  Wheezes  Rhonchi  Friction Rub Dull.Pneumonia Hyper-resonance.

Cardiovascular system  Systole  Diastole  Tricuspid Valve  Mitral  Pulmonic Valve  Aortic Valve .


use warm hands and stethoscope. supine         position.Abdomen  Empty bladder. slow approach Skin Umbilicus Contour Symmetry Enlarged Organs Masses Peristalsis Pulsation .

 Bowel sounds. 4-5 cm in depth .5 to 34 per minute  Borborygmi  Bruits  Light palpation-note for tenderness or superficial pain  Deep palpation-note masses and structure of underlying content.

atrophy  Contractures.abnormal contraction  Tremor-involuntary trembling of a limb or body part.Musculoskeletal  Muscle size. intentional and resting .shortening of tendons  Muscle tone Muscle strength  Fasculation.

Joint movement .



Inflammatory Response .

Abnormal Spinal Curvature .

Nervous System .

 Confusion  Disorientation  Lethargy  Obtundation  Stupor  Coma DysarthriaDysphonia.abnormal Aphasia Agnosia .

Reflexes .




Crisis  Maturational or Developmental  Situational Crisis  Coping mechanisms      Primary appraisal Secondary appraisal Pre crisis Impact Crisis Resolution Post Crisis .