CORE CONCEPTS

FUNDAMENTALS OF NURSING

JOSEPH BAHIAN ABANG
AHSE, BSN, RN, MAN
the diagnosis of human responses to actual and
potential problems.
-- American Nurses Association

the act of utilizing the environment of the patient
to assist him in his recovery.
-- Florence Nightingale

to assist the individual sick or well.
-- Virginia Henderson

1. Altruism
2. Body of Knowledge
3. Autonomy
4. Code of Ethics
5. Authority
6. Distinct Identity
7. Accountability

1. Intuitive Nursing (primitive times to 6
th
century)
a. ancient civilizations;
b. during the primitive tribes;
c. belonged to women
d. embedded in superstition and magic
e. 4,000 year-old clay tablet attributed to the Sumerian
civilization
f. slave-nurse was dependent on the master
g. Lasted through the Christian era
h. love thy neighbor as thyself.


2. Apprentice Nursing (6
th
- 18
th
century)
a. on the job training
b. Men engaged in Nursing during the Crusades through:
- Knights Hospitalers or Knights of Saint John of Jerusalem
- Teutonic Knights
- Knights of Saint Lazarus
c. opened a small hospital and training school in Kaisserwerth,
Germany

a. June 1860 when the Florence Nightingale School of Nursing
opened at St. Thomas Hospital in London;

b. The Philosophy of the Nightingales System was based on the
following:
- training of nurses should be considered as important
- training schools for nurses should have close affiliation with
hospitals
- professional nurses should be responsible for the education
- nursing students should be provided with residence

4. Contemporary Nursing
a. Began at the end of World War II; associated with
scientific and technological developments and social
changes since 1945
b. Changing patterns in Nursing education by adding more
clinical content
c. Professionalization of Nursing
d. Globalization: borderless nursing

A. Hospital Real de Manila (1577)
- it was established mainly to care for the Spanish
Kings soldiers but also admitted Spanish civilians.
- founded by Gov. Francisco de Sande.
B. San Lazaro Hospital (1578)
- built exclusively for patients with leprosy.
- founded by Brother Juan Clemente.
C. Hospital de Indio (1586)
- service was in general supported by alms and
contributions from charitable persons.


D. Hospital de Aguas Santas (1590)
- founded by Brother J. Bautista of the Franciscan
Order.
E. San J uan De Dios Hospital (1596)
- founded by Brotherhood of Misericordia and
administered by the Hospitalliers of San Juan de
Dios.

1. J osephine Bracken
- wife of Jose Rizal. Installed a field hospital in an estate
house of Tejeros. Provided nursing care to the wounded
night and day.
2. Rosa Sevilla De Alvero
- converted their house into quarters for the Filipino
soldier during the Philippine-American war that broke out
in 1899.
3. Doa Hilaria de Aguinaldo
-wife of Amelio Aguinaldo; organized the Filipino Red
Cross under the inspiration of Apolinario Mabini.

4. Doa Maria de Aguinaldo
- second wife of Emilio Aguinaldo. Provided nursing care
for the Filipino soldiers during the Revolution. President
of the Filipino Red Cross branch in Batangas.
5. Melchora Aquino (Tandang Sora)
- nurse the wounded Filipino soldiers and gave them
shelter and food.
6. Trinidad Tecson
- Ina ng Biac na Bato, stayed in the hospital at Biac na
Bato to care for the wounded soldiers.

1. Iloilo Mission Hospital School of Nursing
(Iloilo City, 1906)
> It was run by the Baptist Foreign Mission Society of
America.
> Miss Rose Nicolet first superintendent
> Miss Flora Ernst an American nurse, took charge of
the school in 1942
2. St. Pauls Hospital School of Nursing
(Manila, 1907)
>The hospital was established by the Archbishop of
Manila, The Most Reverend Jeremiah Harty, under the
supervision of the Sisters of St. Paul de Chartres.
3. Philippine General Hospital School of Nursing
(Manila, 1907)
> In 1907, with the support of the Gov. Gen. Forbes and
the Director of Health and among others, opened
classes in nursing under the auspices of the Bureau of
Education.
> Anastacia Giron-Tupas, was the first Filipino to
occupy the position of Chief Nurse and Superintendent
in the Philippines.

4. St. Lukes Hospital School of Nursing
(Quezon City, 1907)
> The Hospital is an Episcopalian Institution. It began as a
small dispensary in 1903. In 1907, the school opened with 3
Filipino girls admitted.
> Mrs. Vitiliana Beltran was the first Filipino Director of the
school.
5. Mary J ohnston Hospital and School of Nursing
(Manila, 1907)
> It started as a small dispensary on Calle Cervantes.
> It was called Bethany Dispensary and was founded by the
Methodist Mission.
> Miss Librada Javelera was the first Filipino Director of the
school.


University of Santo Tomas, College of Nursing
> 1946
> Sor Taciana Trinanes First Directress
Manila Central University, College of Nursing
> 1948
> Consuelo Gimeno First Principal
University of the Philippines, College of Nursing
> 1948
> Ms. Julita Sotejo First Dean

NOVICE
ADVANCE BEGINNER
COMPETENT
PROFICIENT
EXPERT
1. Health and Wellness Promotion
- helping people develop resources to maintain or
enhance their well-being.
2. Illness Prevention
- maintain optimal health by preventing disease.
3. Health Restoration
- helping people to improve health following health problems or
illness.
4. Care of the Dying
- comforting and caring for people of all ages while they are
dying.

1. Person
- recipient of the nursing care.
2. Health
- the degree of wellness and well being that a
person experiences.
3. Environment
- pertains to the internal and external surroundings
that affects a person.
4. Nursing
- pertains to attributes, characteristics and actions of
the nurse providing care in behalf of the client or in
conjunction with the client.

Man
Forms the foundation of Nursing

Four Components or Attributes of Man
Capacity to think on an Abstract Level
Establish a family
Establish a territory
Ability to use verbal symbols as language

Concept:
Animals form a family by instinct
Via hormonal scents


1. Florence Nightingale
Environmental Nursing Theory
2. Dorothy Johnson
Behavioral Systems Model
Seven Subsystems
o Attachment and Affiliative
o Dependency
o Ingestive
o Eliminative
o Sexual Achievement
o Aggressive
3. Virginia Henderson
Fourteen (14) Fundamental Needs focusing on
PHYSIOLOGIC SOCIAL RECREATION

4. Faye Abdella
Problem Solving Approach to Twenty-One (21) Nursing
Problems
Focus is on PROPER IDENTIFICATION of the problem
Particularly about the proper nursing diagnosis

5. Imogene King
Goal Attainment Theory
Patient has three (3) interacting systems:
o Individuals / Personal systems
o Group systems / Interpersonal systems fraternity
o Social systems
6. Madeleine Lehninger
Transcultural Nursing Theory / Model
Nursing is a HUMANISTIC and SCIENTIFIC
mode of helping through CULTURE-SPECIFIC
PROCESS

7. Myra Levine
Four (4) Conservation Principles of Nursing
1. Conservation of Energy
o Example: complete bed rest without bathroom privileges
2. Conservation of Structural Integrity
Example: turn patient from side to side every
o two hours to avoid bed sores
3. Conservation of Personal Integrity
o Example: maintain patients privacy
4. Conservation of Social Integrity
o Example: maintenance of patients relationships

8. Betty Neuman
Health Care Systems Model
The concern of nursing is to PREVENT STRESS
INVASION
9. Dorothea Orem
Self-care and Self-care Deficit Theory
Three (3) Nursing Systems based on Art of Care of Patient
Needs
1. Partial Compensatory
o Patient performs some of nursing care needs
2. Wholly Compensatory or Total Compensatory
o For paralyzed patients, for ICU patients
3. Supportive-Educative
o For up and about patient

10. Hildegard Peplau
Interpersonal Model
Four (4) Phases of Nurse-Patient Interaction
1. Orientation
o Nurse and patient test the role each one assumes
o Prepares patient for termination
o Patient identifies areas of difficulty
2. Identification Phase
o Patient identifies with the personnel who can satisfy his needs
3. Exploitation Phase
o Nurse maximizes all the resources to benefit the patient
4. Resolution Phase or Termination Phase
o Occurs when patients needs have been met

Concepts:
Various settings for application of:
o Pre-Interaction Phase
In psychiatric setting, this consists of gathering
data
o Pre-Entry Phase
In community health nursing, this consists of a
courtesy call

11. Martha Rogers
Science of Unitary Human Beings
Man is composed of energy fields, which are in constant
interaction with the environment

Concept:
The most reliable method of identification is the Energy
Field. This is better than the fingerprints as a persons
energy field is absolutely unique!
12. Sister Calista Roy
Adaptation Model
Man is a BIOPSYCHOSOCIAL BEING
Four (4) modes of Adaptation
o Physiologic Mode
Compatible with Hans Selye
o Self Consent
o Role Function
o Interdependence

13. Lydia Hall
CARE, CORE, CURE
Care
o Comfort measures given by the nurse to a patient
o Nurturance aspect of Nursing
Core
o Therapeutic use of self
Cure
o Activities in relation to doctors orders
o Dependent orders
14. Jean Watson
Human Caring Model
Nursing involves the application of ART and HUMAN
SCIENCE through TRANSPERSONAL TRANSACTIONS in
order to help the person achieve mind, body and soul
harmony

15. Joyce Travelbee
Interpersonal Process Theory
Nurse needs to go beyond nursing roles to establish
therapeutic relationship
TRANSPERSONAL COMMUNICATION as the means to
establish therapeutic relationship
This implies that the nurse should not be rigid in the nursing
role


Why do we study this?
In order to prioritize nursing actions

1. Physiologic needs
Food, maintenance of homeostasis
2. Safety and security
3. Love and belongingness
4. Self-Esteem
Feeling good about ones self
Two factors affecting Self-esteem

o Yourself
Sense of adequacy
Accomplishment
o Others
Appreciation
Recognition
Admiration
Belongingness
5. Self-Actualization
Able to fulfill needs and ambitions
Maximizing ones full potential
6. Aesthetics- Beauty

Two Additional Needs by Maslow
Need to know
Need to understand
Richard Kalish
Man needs stimulation
Needs to explore
o Sex
o Activity
o Novelty
Stimulator
Desire to come up with something of your own


Characteristics of Self-Actualized Persons
Judges people correctly
Superior perception
Decisive
o Capable of making decisions
Clear notion as to what is right and wrong
Open to new ideas
o Not adopts new ideas
o Not one track mind
Highly creative and flexible
Does not need fame
Problem-centered rather than self-centered

Concept:
Self-Actualization is very difficult to attain
It is impossible to attain
New needs come after getting one need

HEALTH
> is the fundamental right of every human being. It is
the state of integration of the body and mind.

- is a state of complete physical, mental, and social
well-being, and not merely the absence of disease or
infirmity. (WHO)

- is the ability to maintain the internal milieu. Illness
is the result of failure to maintain the internal
environment. (Claude Bernard)

> is being well and using ones power to the fullest
extent. Health is maintained through the prevention of
diseases via environmental health factors. (Florence
Nightingale)

> is the ability to maintain homeostasis or dynamic
equilibrium. (Walter Cannon)

> is a dynamic state in the life cycle. Illness is an
interference in the life cycle. (Imogene King)

> is a state of a process of being becoming an
integrated and a whole as a person. (Sister Calista Roy)


WELLNESS AND WELL-BEING
> Wellness is a state of well-being.
> Well-Being is a subjective perception of balance, harmony and
vitality.
> Wellness has different dimensions:
1. Physical
2. Emotional
3. Social
4. Intellectual
5. Spiritual
6. Occupational

1. LEAVELL & CLARKS AGENT-HOST-ENVIRONMENT MODEL or
ECOLOGICAL MODEL
This model has three dynamic interactive elements:
1. Agent:
2. Host:
3. Environment:
HEALTH-ILLNESS CONTINUA
DUNNS HIGH-LEVEL WELLNESS GRID

- A health grid in which the health axis and the environment axis
intersect to demonstrate interaction. The health axis extends from
peak wellness to death and the environmental axis extends from very
favorable to very unfavorable. The intersection forms four
health/wellness quadrants:


1. High-level wellness in a favorable environment:
- example is a person who implements healthy lifestyle
behaviors and has economic resources to support this
lifestyle and a family or social environment who also
practices or encourages the practice of healthy lifestyle.
2. Emergent high-level wellness in an unfavorable
environmental
- example is a person who knows the importance of
implementing a healthy lifestyle but could not do so
because of family responsibilities, job demands or lacks the
resources to do so.
3. Protected poor health in a favorable environment
- example is an ill person confined in a hospital and
whose needs are met by the hospital personnel, who can
afford appropriate medication, proper diet and other
treatments needed.
4. Poor health in an unfavorable environment
- example is a starving young child in a refugee camp
in Mindanao.
HEALTH BELIEF MODEL (HBM)
Becker, 1975

> describes the relationship between a persons
belief and behavior.

> individual perceptions and modifying factors may
influence health beliefs and preventive health
behavior.

Individual perceptions includes the ff:
1. Perceived susceptibility to an illness.
2. Perceived seriousness of an illness.
3. Perceived threat of an illness.

Modifying factors include the ff:
1. Demographic variables
2. Sociopsychologic variables
3. Structural variables
4. Cues to action

TRAVIS ILLNESS-WELLNESS CONTINUUM

- The model illustrates that movement to the right of
the neutral point indicates increasing levels of health and
well-being for an individual. This is achieved through
awareness, education and growth. In contrast, movement
to the left of the neutral point indicates a progressively
decreasing state of health.
SMITHS MODEL OF HEALTH
1. Clinical Model
- absence of signs and symptoms of disease.
2. Role Performance Model
- ability to fulfill societal roles.
3. Adaptive Model
- views health as a creative process and disease as a
failure in adaptation or mal-adaptation.
4. Eudaemonistic Model
- health is a condition of actualization or realization of a
persons potential.


Disease
alteration in the body functioning which
results in the reduction of capacities and
shortening of life span.
Illness
a personal state in which the person feels
unhealthy.
In other words:
Disease is an illness with objective facts while
Illness is a subjective perception of not being
well.

Stage 1. Symptoms Experience
- experience some symptoms, persons believes
something is wrong. 3 aspects physical, cognitive and
emotional.
Stage 2. Assumption of the Sick Role
- acceptance of illness, seeks advice.
Stage 3. Medical Care Contact
- seeks advice to professionals for validation of real
illness, explanation of symptoms, reassurance or predict of
outcome.


Stage 4. Dependent Patient Role
- the person becomes a client dependent on the
health professional for help; accepts or rejects health
professionals suggestions; becomes more passive and
accepting.

Stage 5. Recovery/Rehabilitation
- gives up the sick role and returns to former roles
and functions.


1. According to Etiologic Factors:
A. Hereditary due to defect in the genes of one
or other parent which is transmitted to the
offspring.
B. Congenital due to defect in the development,
hereditary factors or prenatal infection
C. Metabolic due to disturbance or abnormality in
the intricate processes of metabolism
D. Deficiency results from inadequate intake or
absorption of essential dietary factor
E. Traumatic due to injury
F. Allergic due to abnormal response of the body
to chemical and protein substances or to
physical stimuli
G. Neoplastic due to abnormal or uncontrolled
growth of cell
H. Idiopathic cause is unknown; self-originated;
of spontaneous origin
I. Degenerative results from the degenerative
changes that occur in the tissues and organs
J. Iatrogenic result from the treatment of the
disease


2. According to Duration or Onset:
A. Acute Illness has short duration and is severe. Signs
and symptoms appear abruptly, intense, and often
subside after a relatively short period.
B. Chronic Illness usually longer than 6 months, and can
also affects functioning in any dimension. Is
characterized by:
> Remission periods during which the disease is
controlled and symptoms are not obvious.
> Exacerbations disease becomes more active given
at a future time, with recurrence of pronounced
symptoms.
C. Sub-Acute symptoms are pronounced but more
prolonged than the acute disease.

3. Disease may also be described as:
A. Organic
B. Functional
C. Occupational
D. Venereal
E. Familial
F. Epidemic
G. Endemic
H. Pandemic
I. Sporadic

Risk Factors of a Disease:
1. Genetic or Physiologic
- genetic predisposition.
2. Age
- increase or decrease clients susceptibility to
acquire disease.
3. Environment
- surroundings that can affect the person.
4. Lifestyle
- habits that increases the chance of acquiring a
disease.
5. Sex
- gender.

1. Primary Prevention
Emphasis on:
o Generalized health promotion and specific
protection
o Recipients are GENERALLY HEALTHY
PEOPLE
When given:
o Before onset of illness or before onset of
disease

Examples:
o Generalized health education
Prevention of accidents
Standards of nutrition
o Immunizations
Specific preventions
o Risk Assessment for specific disease
o Family Planning Services and Marriage
Counseling
o Environmental Sanitation
o Recreation and Housing
2. Secondary Prevention
Emphasis placed on:
o Early detection / diagnosis
o Prompt treatment
o Health maintenance of persons already
having health problems
o Prevention of complications
When given:
o During illness

Examples:
o Screening survey
o Encouraging regular check-ups
o Complying with regular check-ups
o Teaching Breast-self-examination
o Teaching Testicular-self-examination
Concept:
o Most effective method of teaching is
DEMONSTRATION
Additional Examples of Secondary Prevention
o Assessment of growth and development
o General nursing assessment and care at the hospital,
community and the home

3. Tertiary Prevention
Emphasis placed on:
o Support of the client to achieve the following:
Successful re-adaptation
Optimal reconstitution
Regain high-level wellness
Therefore, the purpose is more of
REHABILITATION
When given:
o Begins after the illness or when a defect or disability
is fixed or irreversible

Examples:
o Referring a client to support groups
o Teaching a diabetic client how to inject insulin

1. Caregiver / Care Provider
To convey understanding and support
Activities:
o Support and comfort measures (mothering aspect of nursing /
nurturance aspect of nursing)
2. Counselor
Involves helping patient identify and avoid stressful and
psychological problems
Focuses on:
o Helping client establish capacity for successful interpersonal
relations
o Helping the patient develop new coping skills

Concept:
Do not give advice!
o This is meant to facilitate decision-making on the part
of the client
o This is observed so that the client would not develop
DEPENDENCY

3. Client Advocate
Protects rights of patients
Activity:
o Speaking on behalf of the patient

4. Change Agent
Brings change or adjustments
Nurse only influences a patient
Nurse does not change the patient
5. Teacher
Teaching
Imparting of knowledge
6. Leader
Application of interpersonal influence to bring out desired
behavior (leadership)

. Manager
Decision-making
Planning
Giving directions
Monitoring operations
Facilitating staff development
Therefore, this is done on the supervisory level of
organization
8. Researcher
After graduation, nurse cannot yet be a researcher
He can only be a researcher after he receives his Master
of Arts in Nursing (M.A.N) degree

Basic Guidelines
Develop a well-defined objective
Assess clients readiness to learn
Start with what the client is concerned about
Assess and start with what the client already knows;
proceed from the known to the unknown
Start with the simple proceeding to the complex
Schedule a review of the content
Concept:
Areas of Learning Domain
o Knowledge cognitive
o Skills motor
o Attitude emotional
1. Explanation and Description
Address cognitive aspect of learning
2. One-to-one Discussion
Addresses affective and cognitive learning
3. Answering Questions
Cognitive
4. Demonstration
Motor
5. Discovery
Cognitive and Affective

Concept:
Learning is more effective if the learner discovers
the content for himself. (That is, through
experience!)
6. Group Discussion
Affective and Cognitive
Sharing feelings during group dynamics
7. Practice
Motor
8.Printed and Audiovisual Material
9. Role-playing
For pediatric and psychiatric nursing settings

10. Modeling
What you say is what you do

11. Computer Assisted Learning Programs
Online review

The Nursing Process is a systematic, organized, rational
method of planning and providing individualized,
humanistic nursing care

Purposes of the Nursing Process:
To identify health status
o Actual health problems
o Potential health problems
To establish plans
To deliver specific nursing care

Characteristics of Nursing Process (MEMORIZE THIS!!!)
1. Goal-oriented and client-centered
2. Cyclical (no absolute beginning and end), dynamic
(moving) rather than static
3. Plan of care organized according to client problems
rather than nursing goals
4. Basis of prioritizing nursing activities would be the
problems and not the goals
5. Follows a logical sequence
6. Universally applicable (to any type of patient)
7. Interpersonal and collaborative
8. Adaptation of problem-solving techniques and principles
9. Problem-oriented, flexible, open to new information
10. Allows creativity of nurse and patient

BENEFITS DERIVED FROM THE NURSING PROCESS

Concepts:
Both the nurse and the patient benefit from the nursing
process
Patient obtains greater benefit
Remember:
Nursing process is CLIENT-CENTERED or PATIENT-
CENTERED and NOT NURSE-CENTERED

Benefits from Nursing Process:
1. Improves quality of care
2. Ensures continuity and appropriate level of care
3. Facilitates client participation through planning with patient
4. Enables nurse to maximize resources
5. Feedback allows nurse to evaluate care
6. Serves as a framework for accountability through
documentation
7. Promotes a positive working atmosphere through
collaboration
8. Helps the nurse define roles to those outside the profession
9. For job satisfaction
10. Facilitates professional growth
11. Avoidance of legal action
12. Meeting standards of accredited hospitals

ASSESSMENT PHASE OF THE NURSING PROCESS

Nursing Activities in the Assessment Phase
Data collection
Data Organization
Data Validation
Data Recording

IMPORTANT CONCEPT!
No conclusion is developed in the assessment phase

Purposes of the Assessment Phase
To create a data base of the clients response to health and
illness
To determine the nursing care needs of the patient

Four (4) types of Assessment:

1. Initial Assessment
When performed:
o At specified time after admission
Where done:
o Done at the ward
Where Admitted:
o At the ward
Purpose of Initial Assessment:
o To create a data base for problem identification
o For reference and future comparison

2. Focus Assessment or On-going
Assessment
When performed:
o Integrated throughout the nursing process
Purpose of On-going Assessment:
o To identify problems overlooked earlier
o To determine the status of a health problem (i.e.
hydration status every fifteen minutes)

3. Emergency Assessment
When done:
o During acute physiologic and psychologic crisis
Where done:
o Emergency Room
o Comfort Room
o Anywhere!!!
o On site!!!
Purpose of Emergency Assessment
o To identify life-threatening condition
Framework or Principle in Emergency Assessment
o A Airway
o B Breathing
o C Circulation
o Utilize either Maslows Hierarchy of Needs or ABC principle

4. Time-Lapsed Assessment
When done:
o Several months after initial assessment
Purpose of Time-Lapsed Assessment
o To compare current status of patient with base line
data (initial assessment)

ASSESSMENT PROCESS

Concepts:
Data is equivalent to information

What is the initial output of the Assessment Phase?
Data or Recorded Data
Never validated data!!!

Types of Data:

1. Subjective or Covert Data
Felt by the patient
During the recording of data, this should be stated using
the patients own words
These are the symptoms felt by the patient

2. Objective or Overt Data
Capable of being observed by use of senses sight,
touch, smell, taste, hearing
These are the signs which are observable

Sources of Data:
1. Primary Source
Patient himself except when:
o He is unconscious
o Patient is a baby
o Patient is insane
2. Secondary Source
Patients record
Health care members
Related literature or journals
Significant others (they become primary source when patient
is unconscious
Family or relatives
The person who brought the patient to the hospital

3. Environment of the Patient
Example:
o Patient with diabetes mellitus exhibits acetone breath
Assess for diabetic ketoacidosis

Methods of Data Collection
Observing
Interviewing
Examining

1. Observing
It should be deliberate
Exert effort
Two (2) aspects of observation process:
Noticing the stimuli
Do an interpretation of the stimuli
2. Interviewing
Two (2) types of Interview:
Directive Type of Interview
Structured
Uses closed-ended questions calling for specific data
When used:
o When you need to elicit specific data
o When there is little time available


Concept:
Characteristics of Closed-ended questions:
Yes or No questions
Asks when or asks for the time when event happened
Asks how many
Point with finger when asking to provide clarity
Therefore, they call for highly specific answers

Non-Directive Type or Rapport-Building Interview
Uses more open-ended questions
Advantage is that it allows the patient to volunteer information

Types of Interview Questions:
1. Open-Ended Questions
Questions not answerable by yes or no
Questions that elicit information or explanation

2. Closed-Ended Questions
Questions answerable by yes or no
Leading Questions
Phrasing of question suggests what answer the
interviewer is expecting

3. Neutral Questions
Phrasing allows patient to answer with least pressure
Usually NOT addressed to patient personally (i.e. what is
your opinion about)
Raised as a general topic

Planning the Interview Setting
Concepts:
Before the interview, determine what information you
already know or what information is available
An interview is a planned conversation with a purpose
An interview is a two-way process

When is it done?
o When patient is available
o When patient is comfortable
Recommended distance from the patient is three (3) to
four (4) feet.
Stages of the Interview
1. Opening Stage
Key Concept!!!
This is the most important part of the interview
Rationale
What was said and done during the opening stage sets
the tone all throughout the interview

2. Body of the Interview
Occurs when patient responds to questioning

3. Closing Stage
How to close the interview:
o Summarizing Technique

Validation of Data
Act of double-checking the data
Purposes of Data Validation
o To ensure the:
Correctness
Completeness
Accuracy of the data

Guidelines in Validating Data
Compare subjective and objective data
Be familiar with word usage (particularly if the
patient is a child)
Reassess / double-check data which are
extremely abnormal
Be sure that your data contains CUES and not
INFERENCES
Be sure that your data is FREE OF BIASES
Avoid jumping to conclusions
Data Recording
Concepts:
Data Recording COMPLETES the Assessment Phase
Initial Output of the Assessment Phase is DATA
Final Output of the Assessment Phase is RECORDED
DATA

Activities during the Diagnosing Phase:
This involves sorting, clustering, analyzing and
interpreting data

Concept:
The final output in the Diagnosing Phase is a NURSING
DIAGNOSIS!!!

Different Types of Nursing Diagnoses:
1. Actual Nursing Diagnosis
Problem present at the time the statement was
made

2. High-Risk Nursing Diagnosis
A diagnosis that a patient is more vulnerable or
susceptible compared with others in the same
situation

3. Possible Nursing Diagnosis
There is an evidence of a health problem
but the causes are NOT fully understood

4. Wellness Nursing Diagnosis
A positive statement
Indicates a healthy response


Domains of Nursing Diagnosis
Key Concept!
It only includes health problems that a nurse is capable and
licensed to treat

Parts of a Nursing Diagnosis
1. Problem Statement
Example:
o Fluid Volume Deficit
2. Presumed Etiology
Example:
o related to frequent loss of bowel movement
3. Defining Characteristics
Example:
o as manifested by decreased skin turgor

Advantages of Using Standardized Diagnostic
Terminology
Provides professional accountability and autonomy by
defining and describing the independent areas of
practice
Provides effective vehicle of communication
Provides an organizing principle for meaningful research
Facilitates continuity and individualized care

Concept:
Planning means:
Determining ahead of time
Forecasting a course of action

Key Concept!!!
For your plans to be effective, involve the patient and the
family

IMPORTANT CONCEPT!!!
Final output of the Planning Phase is a NURSING CARE
PLAN or a WRITTEN CARE PLAN

Types of Planning
1. Initial Planning
Done by the nurse
When done:
o At specified time upon or after admission of the
patient
2. On-going Planning
Who are involved:
o Done by all nurses who worked with the patient
o The patient himself
o The family
o But primarily, the NURSE

Purposes of On-going Planning
o To determine if the clients health status has changed
o To decide which problems to focus on during the shift
o To set priorities for client care during the shift
o To coordinate the patient care and activities so that
more than one problem can be addressed at the
same time
3. Discharge Planning
Purpose of Discharge Planning
o To ensure continuity of care

Characteristics or the Planning Process
S Specific
M Measurable
A Attainable
R Realistic
T Time bound
Activities during Planning Process
Set priorities
Set goals
Identify alternatives of nursing care
Select nursing measures
Write nursing orders (supervisors do this)
Write the nursing care plan

Purposes of Goal-setting
To set direction
To provide a time span
To have a criteria for evaluation
To enable the nurse and the patient to determine
whether the problem has been resolved or not
To help motivate the client and the patient by providing a
sense of accomplishment

Key Concept!!!
For your goal to be useful during evaluation, it should be
stated in BEHAVIORAL TERMS

Nursing Goal/Expected Outcome
- declaration of purpose OR intention which directs
interventions.

Types of Goals:
1. Short Term
- can be achieved in a short period of time.
2. Long Term
- requires longer period of time to be accomplished.

Putting the care plan into action
Purpose of Implementation
To carry out planned activities
To help the client
Concept!!!
The implementation phase ends upon recording of the
care given and the response of the patient to that
procedure
Requirements for Implementation
Adequate knowledge
Technical Skills
Communication skills
Therapeutic use of self
Right attitude as a requirement

Nursing Activities during the Implementation Phase
Reassess the patient
o Rationale
To determine if the procedure is still needed
Determine the need for nursing assistance
Implement the nursing strategies
Communicate the procedure performed by documenting
the procedure
Understand orders
o Clarify / verify doctors orders
Encourage patient to participate actively

Guidelines for Implementation of the Nursing
Strategies
Key Concept!!!
It should be based on scientific knowledge, research,
professional standards of practice (care)
o Rationale:
This is done to ensure safe nursing care
It should be adapted to the individual patient
It should always be safe. Do not compromise
It should be holistic
It should be accompanied by support, comfort and
teaching

Intervention Selection
1. Independent
- nurse-initiated.
Example: Health Teaching, Taking Vital Signs, Making NCP
2. Dependent
- physician-initiated.
- performed under the doctors order and
supervision.
Example: Medications, Blood Transfusion, Catheterization
3. Collaborative/Interdependent
- overlapping functions among health care team.
Example: Diet, Laboratory Exams
Nursing Care Plan blueprint of the nursing process
Activities:
1. Reassessing
2. Set priorities
3. Perform nursing intervention
4. Record actions
Composed of 3 Ds:
1. Doing
2. Delegating
3. Documenting

Doing
* Cognitive Skills intellectual skills
* Technical Skills psychomotor skills
* Interpersonal Skills communication skills

Activities:
1. Reassessing the client.
2. Prepare the client physically and psychologically.
3. Prepare the equipment and supplies.
4. Implement the interventions.
5. Communicate the nursing actions.

Delegation
- the transfer of responsibility or task to a subordinate
with commensurate authority while retaining
accountability for the outcome.

5 Rights to Delegation
1. Right Task
2. Right Circumstance
3. Right Person
4. Right Direction/Communication
5. Right Supervision


Activities that cannot be delegated:
1. Initial and ongoing assessment.
2. Planning, nursing diagnosis formulation and evaluation.
3. Education and supervision of the nursing personnel.
4. Special activities like Sterile procedures.
5. Speech and signing of names.

Activities that can be delegated:
1. Routine activities.
- Vital signs taking
- Bed bath
2. Clean procedure.
- Enema
- Ear irrigation

Purpose of the Evaluation Phase
To determine clients progress
To determine the effectiveness of the care plan
To determine as to what extent the nursing goals
have been met
Importance of doing an Evaluation
It determines if the care plan will be:
o Continued
o Modified
o Discontinued

Activities during the Evaluation Phase
Identify the OUTCOME CRITERIA to be used as
measurement
Gather information (data) relevant to the outcome criteria
Compare outcome (data) with the criteria
Assess the reasons for the outcome
Revise the nursing care plan as needed

3 Types of Evaluation:
1. Ongoing
2. Intermittent
3. Terminal
3 Possible J udgments during Evaluation:
1. Goal met
2. Goal partially met
3. Goal not met
4 Types of Outcome Evaluated:
1. Cognitive
2. Psychomotor
3. Affective
4. Physiologic

Types of Evaluation
1. On-going Evaluation
When done:
o During or immediately after the intervention
Importance:
o Allows the nurse to decide and make on-the-
spot modification/s in an intervention

2. Intermittent Evaluation
When done:
o At a specified time
Purpose:
o It shows the extent of progress of the patient
Importance:
o Enables the nurse to correct deficiencies and
modify the nursing care plan

3.Terminal Evaluation
When done:
o At or immediately before discharge
Importance:
States the status of a health problem at
the time of discharge
It determines whether the goals are:
o Met
o Partially met
o Unmet

Quality Assurance

1. Structure Evaluation
- physical settings, condition through which care is
given.

2. Process Evaluation
- pertains to the manner on how the care was given.

3. Outcome Evaluation
- pertains to any changes in the clients health status
as a result of the nursing intervention.

Record
- a formal and legal document that provides
evidence of the clients care.
Purposes:
1. Communication
2. Planning client care
3. Audit and quality assurance
4. Research
5. Education
6. Reimbursement
7. Legal documentation
8. Statistics


Responsible for the disposal of medical records in
government hospital:
- DOH
Criteria for disposal:
- DOH accredited

DOH Records Mgt & Archive Office
Where to get the chart of a pt who has been discharged:
- Medical Records Section

Where to obtain the clients chart during period of
hospitalization :
- Nurse Station

2 Types of Records
1. Problem Oriented Medical Record
- data are arranged based on the clients problem rather
than the source of information.
Basic Components:
A. Database
- primary information about the client.
B. Problem List
- involves all aspects of the persons life that requires
health care.
C. Initial Orders and Health Care Plans
D. Progress Notes
- SOAPIE, Graphic Flow Sheet, Discharge Notes



2. Source Oriented Medical Record
- chart is divided & organized according to the
different sources of data.

Basic Components:
A. Admission Sheet
B. Physicians Order
C. Medical History
D. Nurses Notes
E. Special Records and Reports



REPORTING:
- either oral, taped or written exchanges of
information between nurses or other members of
the health care team.
Purpose: To promote continuity of care.
KINDS:
I. Change of Shift Reports
- exchange of information from the nurse of
the previous shift to the next shift.
A. Oral
B. Audiotape recording
C. Nursing Rounds


II. Telephone Orders & Reports
- reports and orders via telephone.
Physician: capable of ordering the medication
RN: receives the medication order from the doctor
Important:
1. It must be countersigned by the physician
within 24 hrs.
2. If it was not signed within 24 hours, notify the
Head
Nurse.
3. Ideally, 2 nurses must receive the telephone
order.

T e l e p h o n e O r d e r
O N L Y in e x t r e m e e m e r g e n c y
V e r i f y R E P E A T back to physician
W i t h i n 2 4 hr
I n F O C U S
W h o m u s t b e ?
1
s t
Resident physician
2
n d
Post graduate intern
3
r d
Registered nurse

III. Incidence Reports
- record of accidents or unusual events that occurs
in the agency.
Purpose: To prevent future harm/accidents.
Data Included:
1. Clients name and ID number
2. Date, time and place of the incidence
3. Facts of the incidence
4. Clients account of the incident
5. Witnesses of the incident
6. Equipments and medications involved
Facts to Remember:
1. It must be filed within 24 hours.
2. It should be submitted to the Risk Manager.
3. It should not be included in the patients chart.







- is anything written or printed that is relied on as record or proof for
authorized person.
Nursing documentation must be:
Accurate.
Comprehensive.
Flexible
As members of the health care team, nurses need to
communicate
information about clients accurately and in timely manner.
Effective documentation ensures continuity of care, saves time
and
minimizes the risk of error.
Data recorded, reported, or communicated to other health care
professionals are CONFIDENTIAL and must be practiced.
Different Sheets:
1. Nursing Health History and Assessment Worksheet
- completed upon admission.
> Biographic data
> Age, sex and address
> Method of admission
2. Graphic Flowsheet
- it allows the nurse to record specific measurements on a
repeated basis.
> Vital signs
> Intake and Output
3. Medicine & Treatment record
- allows for the repeated recording of medication and treatment
of the patient on a repeated basis.

4. Nursing Kardex
R Readily accessible.
E Ensure continuity of care.
S Series of flips cards kept at a portable index file at the
nurses
station.
T Tool for communication.
2 Parts:
1. Activity and Treatment Section
2. Nursing Care Plan

KARDEX
Is the Kardex a part of the patients record?
No, it is not!!!
It is just a bulletin board

Purpose of the Kardex
To make valuable information readily available
Allergies are written in red ink
It is a reminder
It is not a record

Concept:
A Nursing Care Plan is not a record
5. Discharge Summary
- helps ensure that the clients condition during
discharge is in desirable outcome.
F Final physical assessment.
I Instructions about medications and treatment
regimen.
R Record pertinent data.
A Assess the client support system.
H Health teaching.


Guidelines of Quality Documentation and Reporting:
1. Factual
2. Accurate
3. Complete
4. CurrenT
5. Organized


Exchange of ideas, information, feelings, data between
two communicators
Concept:
Communication is the basic component of Human
Relationships
Elements of Communication
1. Message - Data
2. Sender- Encoder
3. Receiver- Decoder
4. Feedback
5. Context - Setting
Overall environment where the communication takes
place

Modes of Communication
1. Verbal
Oral
Spoken
Written communication
Texted communication
Cable communication
Telex communication
Facsimile communication
2. Non-verbal communication
Facial expression
Grimacing
Posture
Gait
Adornment
Make-up
Gestures

Factors Affecting Communication
Ability of the communicator
Perceptions
Proxemics
o Distances between communicators
Intimate Distance
Actual physical contact to 1.5 feet
Personal Distance
1.5 feet to 4 feet
3 feet to 4 feet for interview
Social Distance
4 feet to 12 feet
Public Distance
12 feet and beyond


Territoriality
o One person believes that the space and all the things
in that space belongs to him
o Do not enter abruptly; this may result in breach of
privacy
Roles and relationships

Circadian Rhythm
A biological rhythm
A biological clock
Regulated from outside the persons body

Types of Sleep
1. Rapid Eye Movement Sleep (REM sleep)
Increased brain metabolism and activity
Also called PARADOXICAL SLEEP
Characterized by:
o Vivid dreams
o Easily recalled upon awakening

Concepts!
REM sleep is NOT AS RESTFUL as NON-REM sleep
However, REM sleep is NEEDED
Dreaming is a psychological outlet of vent up emotions

Nursing Alert!
Deprivation of REM sleep results to:
o Irritability
o Restlessness
o Poor concentration

2. Non-Rapid Eye Movement Sleep (Non-REM Sleep)
Deep restful sleep
Benefit is that it restores the body physically and
psychologically (especially for post-operative patients)

Concept!
Deprivation of Non-REM sleep causes:
o Physical exhaustion
o Decreased resistance against infection

Wellness Teachings to Enhance or Promote Sleep
Establish a regular routine
Have adequate exercise at daytime
o Avoid stimulating activity by bedtime
Avoid all types of stimulants
o Caffeine-containing foods
Coffee
Cocoa
Chocolate
Tea
Cola
o Nicotine
o Alcohol
Prolongs the REM stage of sleep

It excites the patient like an anesthetic
Not a stimulant
Avoid shabu
Use the bed mainly for sleep
If unable to sleep, get up and pursue satisfying
activity
Drink something warm or hot (except stimulants)
o Milk contains L-tryptophan
o L-tryptophan is an amino acid with a natural sedative
effect that induces one to sleep

Do something HOT!
o Twice-a-week masturbation is ideal
o Facilitates release of tension of the day
Side-to-side turning every two hours with back
tapping
Support bedtime rituals
Remove all music in order to sleep

1. Digestion
- the process in which foods are broken down for the body to
use.
2. Absorption
- the process in which digested CHO, CHON, Fats, Water and
Minerals are transported into the blood circulation.
3. Metabolism
- complex chemical process that occurs in a cell in which
nutrients
are utilized for energy source, cell growth and cell repair.




Measures to stimulate appetite:

1. Serve food in a pleasant and attractive manner.
2. Provide comfort.
3. Enhance food with colors.
4. Engage in pleasant conversation.



Proteins
Macromolecules composed of
o Carbon
o Hydrogen
o Oxygen
o Nitrogen
Basic Body Needs:
Carbohydrates
Proteins
Fats
Concepts:
Glucose is a ready source of energy for metabolic
processes

Carbohydrates
When eaten are metabolized to glucose for
energy
Excess carbohydrates are converted to glycogen
and stored in the liver
Other excess carbohydrates go to the fat cells
Key Concept!
During starvation, stored glycogen is converted
to glucose via a process called glycogenolysis
If glycogen is used up, fat resources are
converted to glucose via a process called
gluconeogenesis

Nursing Alert!
Fat conversion to glucose produces waste products
called KETONE BODIES
These give rise to metabolic acidosis as in Diabetic
Ketoacidosis

Additional concepts!
During starvation protein reserves are converted to
glucose via process called gluconeogenesis

Gluconeogenesis
Production of glucose out of non-carbohydrate products
Lipoproteins
Substances composed of fats and proteins
Types of Lipoproteins
1. High Density Lipoproteins (HDL)
High-grade lipoprotein
Good grade lipoprotein
Good cholesterol
Function of HDLs
o Transports the bad cholesterol from systemic circulation to the
liver for metabolism and eventual elimination

2. Low Density Lipoproteins (LDL)
Low-grade lipoprotein
Bad cholesterol
Function of LDLs
They clog the blood vessels
3. Very Low Density Lipoproteins (VLDL)
Very bad cholesterol
Functions of Fats
Insulation
Heat Conservation
Source of Energy

Proteins
Two (2) types in terms of needs of the body:
1. Essential Proteins
Proteins that cannot be produced by the body
itself
To be sourced out from food eaten
Animal protein is complete protein
Plant protein is considered as incomplete protein
2. Non-essential Proteins
Proteins that can be produced by the body

Functions of Protein
Main element of our cells.
o Building blocks of the cells are proteins
Resistance against infection
o Formation of Immunoglobulins (globular proteins)
Maintenance of normal intravascular fluid volume
o Works with glucose and sodium
o Albumin
Main protein of blood
Acts as a colloid
Attracts water around it

Concepts!!!
If protein levels are decreased, sodium and
glucose will not be enough to hold plasma inside
blood vessel resulting into edema
In liver cirrhosis, hypoalbuminemia results to
edema

VITAMINS
Two (2) types of Vitamins
Fat Soluble Vitamins
Water Soluble Vitamins
Fat Soluble Vitamins
1. Vitamin A
Essential for normal vision
For transmission of light stimulus via the optic nerve
2. Vitamin D
Source is food
Precursor is in the skin
Sunlight is needed for Vitamin D to be converted to its active
form
Function:
o Influences calcium metabolism
o To metabolize calcium

Concept!
Without Vitamin D, there would be decreased calcium
levels
Increased levels of Vitamin D leads to increased
calcium levels
Vitamin E
Anti-oxidant
Promotes cell membrane integrity (like Vitamin C)
Vitamin for the heart and skin
Sources are meats and in vegetables
Deficiency results to Vitamin E deficiency hemolytic
anemia

Vitamin K
Synthesis of clotting factors
Synthesis of prothrombin

Concept!
Decreased levels of Vitamin K leads to prothrombin
deficiency
Deficiency in prothrombin leads to bleeding

MICRONUTRIENTS
Ferrous sulfate (FeSO
4
)
Forms:
o Tablet
o Liquid
o Injectable
Oral (tablet and liquid forms)
o Take on an empty stomach
o If there is GI distress (i.e. diarrhea), take with
food

o If GI distress subsides, take on an
empty stomach
Toxic effects:
o Constipation (first option)
Oral Liquid Iron
o Use dropper and apply at the back of
the tongue or use a straw
o Rationale:
To avoid staining the teeth

Health Teaching!!!
o To enhance iron absorption, advice taking
orange juice
o Vitamin C in orange juice enhances iron
absorption
o Do not take milk
o Milk inhibits absorption of iron
o Too much fiber prevents absorption of iron
o Thus, do not take oats when taking iron.

Injectable Iron
o Route is deep I.M.
o Use Z-track technique
o Gauge of Needle is at least 18
o Length of Needle is 1.5 to 2.0
o Site of administration is the GLUTEAL
MUSCLE ONLY!!!
o Rationale:
To avoid staining the skin

Concept:
o Use an airlock
o Place 0.5 ml of air in syringe so that medication would
not leak into the subcutaneous tissues
Nursing Alert!
o Apply firm pressure for at least five (5) minutes after
injection
Do NOT massage

SPECIAL DIETS
1. Light Diet
Given for post-operative patients
Plainly cooked
No spices
Large amounts of FAT omitted
Avoid bran and high fiber

2. Soft Diet
For people with difficulty with swallowing and
chewing
Generally low residue diet
Nursing Alert!
o Avoid the following:
Nuts
Seeds (tomato, guava, berry)
Raw fruits and vegetables
Fried Foods
Whole grains and cereals
3. Pureed Diet
Osteorized diet
4. Full Liquid Diet
Foods that melt or liquefy at body temperature
5. Clear Liquid Diet
Given to surgical patients
Limited to:
o Water
o Coffee
o Tea
o Cola
o Clear stained broth
o Gelatin
o Hard candies
Nursing Alert!
o Dairy products are avoided

6. High Fiber Diet
For patients at risk for constipation
7. Candidiasis Diet
Free of the following:
o Fruits
o Sugar
o Yeast
o Fermented foods
8. Low Residue Diet
Reduced fiber
To decrease GI irritation
For patients with bowel inflammatory diseases:
o Chrons disease AND Ulcerative colitis

Acid-Ash Diet
To alkalinize urine
To soothe an irritated bladder and urethra
Give citrus fruits
Give vegetables
Exceptions are:
o Prune Juice
o Cranberry Juice
o Both produce ACIDIC URINE
Ash-Acid Diet
Given to acidify urine
To minimize or help control Urinary Tract Infections
Give the following:
o Protein
o Meat
o Poultry

ASSESSMENT OF NUTRITIONAL STATUS
Anthropometric Measurements
Skin Fold Test
Derived from reserved fat of the body
Mid-upper arm Circumference Measurement
Obtains the muscle mass of the body
This reflects the protein reserves of the body
Laboratory diagnostic procedure for albumin

SUPPORTING NUTRITION OF PATIENT:
ENTERAL AND PARENTERAL FEEDING
ENTERAL FEEDING
1. NASOGASTRIC TUBE FEEDING (NGT)
Purpose of NGT insertion
o For gastric gavage and lavage
o For administration of food and medication
o To keep the stomach empty
o To prevent aspiration from regurgitation of gastric
contents
o For gastric decompression

How to Insert NGT
o Depth of Insertion
Measure length from the tip of the nose to the ears
to the tip of the xiphoid process
Insertion:
o Position the patient in semi-Fowlers or
Fowlers position
o While inserting to NASOPHARYNX
Position the head in a hyperextended manner

o When glottis, epiglottis are approached
Flex the head
o Rationale:
To prevent entry of the tube into the trachea
Nursing Alert!
o Watch for signs and symptoms of RESPIRATORY
DIFFICULTY
o If there are signs, WITHDRAW TUBE
o While inserting tube, observe for coughing or difficulty
of breathing
After inserting, ascertain proper placement on
the stomach

Concept!
o Most accurate method to test for proper
placement of the NGT is via X-RAY
Other ways to test proper placement:
o 1. Let patient hum
If positive for humming, tube is in the esophagus
and stomach
If negative for humming, tube is in the trachea

Nursing Alert!
o Small-bore tube allows patient to hum
o Therefore, this method is NOT RELIABLE
o 2. Determine the pH of the aspirate
Use litmus paper
Change of color from BLUE to RED indicates that
the aspirate is acidic and, therefore, from stomach
contents
Change of color from RED to BLUE indicates that
the aspirate is basic and, therefore, from lung
contents

IMPORTANT CONCEPTS!!!
o To insure safety of the patient prior to feeding,
CHECK THE FOLLOWING:
Placement of the tube
For patient safety
To prevent LUNG aspiration of food
Patency of the tube
To insure successful introduction or
administration of food
o 3. By auscultating the epigastric region while
insufflating 50 ml of air
Hear gurgling sound

TUBE FEEDING
Never try to submerge the free end of the NGT to water
o This is potentially dangerous
o If in trachea and submerging of free end to water
coincides with inspiration, it will suck the water and lead
to pulmonary aspiration
Position during feeding:
o Fowlers Position
Measure gastric residual volume
o Subtract this from total feeding to introduce
o If aspirate is greater than 50 ml for adult or 10 ml for
infant, then WITHHOLD FEEDING for 2 3 hours.

o Rationale:
Patient is not yet ready for next feeding.
o If same occurs after 2 3 hours, NOTIFY DOCTOR.
There is a problem with gastric emptying
Watch out for COUGHING
o Leakage to trachea
If with DIFFICULTY OF BREATHING
o Stop the procedure
Flush with water after feeding to avoid clogging
of the tube

After the procedure
o Do not place the patient on bed before 30
minutes have lapsed
o Rationale:
To prevent aspiration and regurgitation
Average volume of feeding:
o 300 ml to 400 ml

TOTAL PARENTERAL NUTRITION
Introduced directly to the bloodstream
Tube is inserted via the:
o Subclavian vein
o Internal jugular vein of the neck
o External jugular vein of the neck
Important Concept!!!
o Tube must reach two (2) centimeters before or above
the RIGHT ATRIUM
Nursing Responsibilities:
o Watch out for signs and symptoms of embolism

Care of Insertion Site
o Application of sterile dressing with anti-bacterial
ointment as ordered by doctor (prn)

GASTROSTOMY TUBE FEEDING (Enteral)
No auscultation needed
Assess for the patency of the tube
Use water to do this

DEEP BREATHING
Two (2) types of Deep Breathing:
1. APICAL DEEP BREATHING
Done to expand the upper portion of the lungs
Let the patient place palms on the upper chest
Concentrate on that area
Take a slow deep breath at a count of 1,2,3
Release it slowly through the nose or a pursed
lip at a count of 4,5,6,7

Therefore, expiration is longer than
inspiration
Rationale:
o To prevent respiratory alkalosis
Taught to patients who will undergo:
o Upper abdominal surgery
o Cholecystectomy
Incision site on diaphragm
Patient does not want to breathe
Predisposed to hypostatic pneumonia

2. BASAL DEEP BREATHING
Same procedure
Area of concentration is the lower ribcage
When to teach patient:
o Before surgery
o Before pain is present
Rationale:
o If pain is already present, it would be difficult for
patient to follow
When done:
o Done q2 hours together with turning

COUGHING EXERCISES
Purpose
o To expand the lungs
o To facilitate expectoration of secretions
How often done:
o At least every two (2) hours
Procedure
o Teach the patient to inhale and exhale
o Tell the patient to inhale and exhale a second
time
o Tell the patient to inhale and cough out

NURSING ALERT!!!
o Coughing is contraindicated in the following patients:
With increased intracranial pressure (ICP)
With increased intraoptical pressure (IOP)
With cardiac arrhythmias (but are allowed to do deep
breathing)
Concepts!!!
Deep Breathing and Coughing
o Purpose is to stimulate surfactant production
Yawning and sneezing also stimulate surfactant
production

OXYGEN INHALATION AND ADMINISTRATION
Practical Application Concept!
When administering oxygen, be sure to open the valve of
the oxygen tank first.
Be certain that the valve on the regulator is closed so
that the flow meter would not break!
Concept!
Humidifier moistens the oxygen administered
Purpose
o To avoid drying and irritation of the mucosal lining
o Also traps particulates from the tank
Iron oxide may be present in the tank (iron plus oxygen produces iron oxide
or rust)

Concept!
Fire Precaution
o Place NO SMOKING sign at the door or at the head part of the
patient
Tank and oxygen do not explode
They merely support combustion
Other Concepts!
Do not use volatile substances
Acetone and alcohol can react with oxygen and lead to
toxicity of patient
Do not use oil based or grease on any part of the oxygen
set
Do not allow the patient to use an electric razor as
sparks may trigger combustion

Nursing Alert!
Retrolental Fibroplasia occurs if there is excess oxygen
administration in infants. Excess oxygen leads to
destruction of the retina and blindness

Modes of Administration
1. Low Flow Administration
Utilizes nasal cannula or nasal prongs or nasal catheters
Given to COPD patients

2. High Flow Administration
Uses a venturi mask

NEBULIZATION
With sodium chloride and salbutamol
A physiologic solution
Water liquefies secretions
Sodium chloride stimulates coughing
Salbutamol is a bronchodilator
Purpose:
o For expectoration of secretions
Nursing Pre-therapy Assessment Prior to Nebulization
Have baseline data of patients breath sounds
Assess again after nebulization to assess effectiveness
of the procedure


SPIROMETRY
Purpose is to expand the lungs
Done when inhaling
Instruction to the patient:
o Inhale from the spirometer and NOT blow to the spirometer
Procedure:
o Inhale exhale
o Inhale exhale fully
o Place mouthpiece between teeth
o Hold breath for four (4) seconds
o Then inhale, fully rising the ball
Upon inhalation, the ball rises

CHEST PHYSIOTHERAPY
This is a dependent procedure
There are no absolute contraindications to this
procedure
Contraindicated for the following patients with:
o Pacemakers
o Lung abscess
o Hemoptysis
o Dangerous Arrhythmias
o Active PTB (which goes to the other lobe)
o Lung CA (malignancy goes to other lung)

Three components of Chest Physiotherapy
Vibration
Percussion
Postural Drainage
Vibration
Palms of your hand are placed on chest or back of
patient giving quivering motions
Palms remain in contact with the chest or back
Percussion
Use cupped hands
Hands alternate in rising and coming into contact with
chest or back of patient

Postural Drainage
Drain secretions by gravity
Change positions
IMPORTANT CONCEPT!!!
o Rule out contraindications before performing chest
physiotherapy

Pre-therapy Assessment for Vibration and Percussion
Assess breath sounds to know which lung fields have
secretions
Then assess again after procedure to check
effectiveness of the procedure.

Concepts!!!
Vibration and percussion are done to mechanically
dislodge secretions
Nebulization is done to liquefy secretions
Suctioning is done to clear secretions
Postural Drainage is done to drain secretions using
gravity

Postural Drainage
When done:
o Before meals
o Two (2) hours after meals
Before doing the procedure, the following baseline data are
needed:
o Breath sounds
o Vital signs
o Continuous ECG monitoring
During the procedure:
o Ensure the comfort of the patient
o Provide a kidney basin and tissue paper

Nursing Alert!
o Watch out for signs of symptoms which may
require stopping of the procedure:
Sudden dyspnea
Cyanosis
Extreme diaphoresis
Sudden alteration of blood pressure, respiratory
rate, pulse rate
Appearance of arrhythmias
Hemoptysis
General intolerance of the procedure

Important Concept!
If any of the above occurs, STOP THE PROCEDURE and
inform the physician
Concepts!
After the procedure assess the following:
o Breath sounds
o Vital signs
o Quantity and quality of sputum
o Overall response of the patient to the procedure
Give oral hygiene
o Rationale:
To eliminate phlegm from the mouth
Important Concept!!!
Patients with cystic fibrosis benefit much from postural
drainage

CHEST PHYSIOTHERAPY
- dependent nursing action of using positioning, vibrating, and
percussing to remove tenacious respiratory secretions.
1. Dependent nursing action
- needs doctors order to know if the client can tolerate the
procedure.
2. Correct sequence of CPT
Positioning
Percussion
Vibrating
--- POPE VI


3. Gravitational force: force that drains the secretion
4. Positioning
> Orthopneic: to drain secretions from APEX POSTERIOR
SEGMENT
> Trendelenburg, leaning/lying on abd: to drain secretions from lower
lobe posterior segment
5. Position is around 10 mins.
6. Max. time of CPT: 30 mins.
7. Best time in performing postural drainage: early in the morning upon
waking up before meals
*risk for aspiration (same in general anesthesia)


Percussing:
-- striking of the skin using a cupped hand like
scooping H
2
O to dislodge clients tenacious secretions.
> prevention for reddening: put a layer of cloth
> force come from the wrist
> percuss for 10 mins. (1-2 mins./segment)
> to check if correct: popping/booming sound



Vibration:
-- vigorous quivering of the heel of the hand

> When to start vibrating using the hand?
- take deep breath then exhale

> Post procedure: cough
#1 Consideration: Toleration of patient to the procedure
Contraindication: Inability to tolerate the procedure

* If the RIGHT upper lobe of the lungs is affected:
LEFT side lying with head to 30


SUCTIONING
Purpose is to seek out secretions
Concepts!!!
Question:
o If you have only one (1) suction catheter,
which will you suction first, the nose or the
mouth?
Answer:
o If the patient is an infant or a newborn:
Start on the mouth then proceed to the nose

Rationale:
o If you start on the nose, you will trigger the
sneezing reflex and this would result into
aspiration
Answer:
o If the patient is an adult, suction the mouth
first, then proceed to the nose
Rationale:
o This is done for aesthetic reasons

**suctioning is done as needed (PRN) because it is hassle &
can cause hypoxemia & stimulation of the vagus nerve
> positioning:
conscious: semi-fowlers
unconscious: side-lying
>lubrication:
nose: sterile, water-based
mouth: PNSS

Measurement for Suctioning:
> oropharyngeal:
- mouth to earlobe
> orotracheal:
- mouth to midsternum
> nasopharyngeal:
- nose to earlobe
> nasotracheal:
- nose to earlobe to neck
* hyperventilate the pt. with 100% O
2
before suctioning
* apply suction only during the withdrawal
- to prevent trauma in the mucous membrane.

Pressure of the Suction Gauge:
Wall Portable
1. Infant below 95 mmHg below 5 mmHg
2. Child 95-100 mmHg 5-10 mmHg
3. Adult above 110 mmHg above 10 mmHg

* duration:
- 10-15 seconds
* if repeated, interval is:
- 20 to 30 seconds



Important Concepts!!!
For Endotracheal Suctioning
o NO TUBE IS USED HERE
o This is suctioning of the trachea through the mouth or through
the nose
Two (2) types of Endotracheal Suctioning
o Orotracheal Suctioning
Oral approach
o Nasotracheal Suctioning
Nasal approach

General Conditions for Suctioning
For Endotracheal and Tracheostomy (Naso and Oral and
Tube)
o Before suctioning, HYPEROXYGENATE the patient
o During intervals, HYPEROXYGENATE the patient
For ET, Tracheostomy, ET Tube
o Nursing Alert!
During insertion, if you encounter resistance, withdraw the catheter
about one centimeter (1 cm) before applying suction
o Rationale:
To avoid trauma on the mucous membrane

o Do suctioning intermittently
o Suctioning should not be continuous
o Rotate the catheter (between the thumb and
the index finger) as you withdraw
o Apply suction only when you are ready to
withdraw (i.e. keep finger away from suction
port if you are still not ready)

How to Hyperoxygenate the Patient
Give two (2) to three (3) blows by ambubag
Increase flow rate and concentration of oxygen
Nursing Alert!
o If the patient has thick, tenacious secretions, DO NOT
USE AN AMBUBAG
o Use an OXYGEN INSUFFLATION SUCTION
CATHETER instead!!!
o This is a two-lumen catheter (one lumen brings
oxygen to the patient, the other lumen brings out
secretions from the patient)

In the event of encrustations, PERFORM
TRACHEAL LAVAGE
o Instill 2.5 ml to 5.0 ml Normal Saline Solution for
adults to liquefy the mucous plug
o Instill 2.0 ml Normal Saline Solution for children to
liquefy the mucous plug
Instill 0.5 ml to 1.0 ml Normal Saline Solution for
infants to liquefy the mucous plug

CTT (3 Way Bottle System)
> Drainage Bottle
> Water-seal Bottle
> Suction Control bottle
-- draw fluid & air from the pleura.

*Bottle 1: Drainage: no bubbling
*Bottle 2: Water seal: visible bubbling, intermittent
>if continuous bubbling: theres leakage, dump/ clamp the
tube
>if theres no bubbling: 1. (+) obstruction
to correct: PRESS RELEASE METHOD
if no choice: MILK THE TUBE
2. Lung reexpansion
*Bottle 3: Suction: gentle continuous bubbling
> continuous bubbling






DISCONNECTION OF TUBE:
A. Chest:
> use vaso-occlusive dressing
> if vaso-occlusive dressing is not available -
use VASELINIZED DRESSING
B. Bottle:
> if still intact:
-- re-insert the tube into the bottle
> if broken:
-- immerse tube in PNSS
** If the tube disconnects : re-insert
Nursing Considerations:
1. Maintain aseptic technique.
2. Palpate for crepitus.
Rationale: To determine presence of subcutaneous emphysema.
3. Minimize clamping and opening of the tube.
Rationale: To prevent pneumothorax.
4. Removal of the chest tube is done by the physician.
Position: Upright position
Instruction: Inhale and hold the breath and then do the
Valsalva maneuver.


TEMPERATURE
Oral
Axillary
Rectal
Oral Method
Most convenient
Most accessible
Nursing Alert!
o Applicability is for children aged six (6) years and
above
o Not applicable for children below six (6) years old

Contraindicated in patients with:
o Oral surgery
o Mouth breathers
o History of convulsive seizures
o Unconscious
o Incoherent
o Irrational
o Mentally disrupted
o Insane

Procedure
o Nothing Per Orem for about thirty (30) minutes before
taking temperature
o No food intake
o No drinks
o No smoking
o No chewing gum
o No whistling
o No gargling
Rationale:
o Any of the above would alter the result

Placement:
o Under the tongue, beside the frenulum (right or left)
Total Time:
o Two (2) to three (3) minutes
Axillary Method
Least realiable
Safest method
Nursing Alert!
o During application, be sure that axilla is dry
o Dry using a patting motion
Nursing Alert!
o Do NOT RUB!!!

Rationale:
o This increases heat due to friction
o Rubbing increases blood supply to the area
o Therefore, there will be increase in temperature
reading
o Rubbing provides a false-positive elevation of
temperature reading
Duration:
o In adults nine (9) minutes
o In children five (5) minutes

Rectal Method
Most reliable (except for tympanic thermometer)
Most accurate (except for tympanic
thermometer)
Concept!
o If tympanic method is used using a tympanic
thermometer, the rectal method is only second most
reliable and second most accurate
Disadvantage:
o Placement on a different site yields a different reading
o Therefore, ensure that the bulb of the rectal
thermometer rests on the mucous membrane

Contraindications:
o Hemorrhoids
o Rectal Surgery
o Certain Cardiac ailments due to stimulation of the
vagus nerve; valsalva maneuver leads to arrhythmias
Position of Patient when taking the reading:
o Sims left position
o Sims right position
o For Newborn, lift up ankles to keep buttocks up
o In Toddlers, set on prone position on adults lap
Duration:
o Two (2) minutes

Conversion of Centigrade to Fahrenheit
Centigrade = (5/9)F 32
Centigrade = (F/1.8) 32
Conversion of Fahrenheit to Centigrade
Fahrenheit = (9/5)C + 32
Fahrenheit = (1.8)C + 32
Concepts!!!
Peak body temperature occurs at 12NN to 3PM or
4PM
Lowest body temperature occurs in the early
morning hours of the day

FEVER
Normally, the hypothalamus is able to adjust
body temperatures between 37C to 40C
But due to the presence of pyrogenic materials
like the following:
o Pathogenic microorganisms
o Toxins
o Foreign substances
o Any substance capable of increasing body
temperature
Creates a deficiency of -3C, making a person
enter the FIRST STAGE OF FEVER

First Stage of Fever
Typical signs and symptoms indicate the bodys
compliance mechanism to increase and
conserve heat:
o Chills
o Shivering
o Gooseflesh
Contraction of arectores pilorum or pilo arecti muscles
o Vasoconstriction
Decreases blood supply to the skin
Pallid Skin
o Cyanotic nail beds

Key Concept!!!
o Patient complains of feeling cold
o Sweating will stop because body will minimizes heat loss
Also called:
o Onset Stage
o Chill Stage
o Cold Stage
This stage is characterized by low febrile temperatures
Nursing Management
o Key Concept
Aim is to minimize heat loss
o Key Concept
Do NOT apply TEPID SPONGE BATH because this would make
patient progress to SHOCK

Provide additional clothing as necessary
Provide additional blankets as necessary
Provide something warm to drink
These measures would result to a gradual increase in
body temperature
Question:
o When will you start application of TSB?
Answer:
o If there is a 1C to 2C increase in body temperature

Second Stage of Fever
Also called:
o Coarse Stage of Fever
o Peak Stage of Fever
Key Concept!
o Patient does not feel hot or cold
o Skin is warm to touch
o Skin is flushed
o Fever blisters are present
Herpetic lesions
o Absence of shivering
o Possible dehydration
Important Concept!!!
o For every increase of temperature, there is a corresponding
increase in pulse rate

Rationale:
o Increase in temperature results in an increase in
pulse rate due to increased metabolic rate
o Increased metabolic rate increases oxygen demand
o Due to increased oxygen demand of susceptible brain
cells, CONVULSIVE SEIZURES may occur. These
may also be due to irritation of nerve cells FEBRILE
CONVULSIONS

Increased oxygen demand also leads to an increase in
respiratory rate
Patient complains of:
o Loss of appetite
o Myalgia or muscle pains due to increased catabolism
Nursing Management
o Tepid Sponge Bath
o Cooling Bed Bath

Tepid Sponge Bath
Temperature of water is 32C
o This temperature is maintained throughout the procedure
How to apply:
o Done by patting
Rationale:
o To avoid friction, which increases temperature
Important Concept!
o Do NOT use ALCOHOL when applying TSB
Rationale:
o Alcohol dries the skin and leads to irritation
Key Concept!
o TSB should not be done hurriedly
Rationale:
o When done hurriedly, TSB will stimulate shivering
o Shivering would lead to increased muscle activity
o Increased muscle activity would lead to increased temperature

Cooling Bed Bath
Water temperature will start at 32C
Procedure will go on with gradual decrease in water
temperature until it is maintained at 18C
Therefore, to achieve this drop in temperature, utilize ice
Same procedure of application as in Tepid Sponge Bath
Types of Fever
1. Intermittent Fever
A fever that is alternated at regular intervals by periods
of normal and subnormal temperature

2. Remittent Fever
Fever alternated by wide range of fluctuations in
temperature, all of them are ABOVE NORMAL.
Duration is within a 24-hour period

3. Relapsing Fever
Short periods of febrile episodes alternated by one (1) to
two (2) days of normal temperature

4. Constant Fever
Minimal fluctuations of temperature, all of which are
ABOVE NORMAL

5. Staircase or Spiking Fever
Common in patients with TYPHOID FEVER

PULSE ASSESSMENT
Concepts!
If pulse is regular, count or monitor pulse for thirty (30)
seconds and multiply by two (2). This is legal!
If pulse is irregular, count or monitor the pulse for one (1)
FULL minute
Assessment of the Pulse Deficit
This is the most accurate method
Involves two nurses using one watch
Starts at the same time
Ends at the same time
Comparison of results ensues
Count is done for one (1) full minute

Scale in Pulse Assessment
0 - Absent or cannot be felt
1+ - Weak or thready
2+ - Normal
3+ - Grounding

Pulse pressure:
o Systolic pressure MINUS diastolic pressure
Pulse deficit
o Apical pulse MINUS peripheral pulse
Pulsus paradoxus
o Systolic pressure falls by more than 15 mmHg during INHALATION
Pulsus alternans
o Alternating strong and weak pulses

BLOOD PRESURE

Systolic
Produced by ventricular contraction
Pressure on blood vessels during depolarization or
ventricular contraction

Diastolic
Pressure that remains in the walls of the blood vessels
during relaxation or repolarization or resting

Broadly two (2) types:
Direct
o By insertion of a catheter
Indirect Method
o Auscultatory method
o Palpatory method
o Flush Method
Auscultatory Method
Uses Korotkoff sound
o A popping sound
o NOT the heart beat
o It is a phenomenon an unknown phenomenon!

Determining Amount of Inflation
Using auscultatory method
o Ask patient what is his last BP reading and then add 30 40
mmHg from last systolic reading.
o Deflate gradually rate is approximately 2 3 mmHg per
second
Alternative auscultatory method
o Auscultate for the last sound as you go up. Then add 30 40
mmHg
o Then deflate

Tripartite Blood Pressure
Done if patient is an adult.
Example:
140 mmHg systolic first loudest sound
100 mmHg 1
st
diastolic muffling
70 mmHg 2
nd
diastolic last sound
o Therefore, the tripartite blood pressure is 140 / 100 / 70
If there is no muffling, an example would be:
o 160 / no muffling / 110
Concepts!!!
Take systolic on loudest sound if patient is an adult
If patient is pediatric or up to ten (10) years old, take the
first sound, whether it is faint or loud
If, for example, first sound is at 190 mmHg and there is
silence up to 140 mmHg and then there is a sound at
130 mmHg down to 80 mmHg then
Use the PALPATORY METHOD in combination with the
AUSCULTATORY METHOD because there is an
auscultatory gap

Repeat using:
Auscultatory method
Palpatory method

How to do the Palpatory Method
Inflate
o Determine up to what point to inflate
o Palpate pulse
o If pulse is absent, add 30 40 mmHg
Deflate
o First palpable pulse is true systolic pressure
For diastolic pressure, proceed using the auscultatory
method

Flush Method
Represents the mean blood pressure
Represents the average of the systolic and diastolic
pressures
When done:
o When you have a BP apparatus without a stethoscope
o Used for pediatric patients
How done:
o Inflate up to the point where extremity becomes pale
o Deflate slowly and look for a REBOUND FLUSH when
extremity becomes red again
This is the true reading!!
Note that there is only ONE reading!!!

RESPIRATORY RATE
Normal range: 12 to 21 BPM
Respiratory pattern
o Cheyne-Stokes
o Kussmaul
o Biot
o Agoral

SKIN INTEGRITY
Decubitus ulcers are caused by:
o Unrelieved, sustained pressure
o Localized ischemia
o Shearing force
o Pressure plus friction
Predisposing Factors:
o Unconsciousness
o Incontinence
o Loss of Sensation
o Hypoproteinemia
Decreased lean muscle mass
Increase in fluid shifting leads to edema
Dependent position is the skin attached to or facing the bed
o Emaciation

Stages of Decubitus Ulcer Formation
Stage 1
Involves the epidermis
Manifestation
o Non-blanchable erythema of INTACT SKIN
o This is the first heralding sign of decubitus ulceration
Stage 2
Partial Thickness Skin Loss
Involves epidermis and dermis
Manifestation
o Blister formation
o Shallow craters
o Shallow abrasion and ulceration

Stage 3
Full Thickness Skin Loss Ulceration
There is skin loss already
Involves necrosis of the skin and subcutaneous tissues
EXTENDING TO but NOT THROUGH the underlying
fascia

Stage 4
Formations and manifestations of Stage 3 plus
o Involvement of bones, supporting structures (tendons), joint
capsules
o Massive damage

Tools to Assess Risk of Ulceration
Nortons Pressure Area Risk Assessment Form
Shannons Scoring System
Branden Scale of Predicting Ulceration
Waterlow Risk Assessment Cards
o Most important tool
o Most common tool
o Most often used tool

EDEMA
Caused by shifting of fluid into the interstitial tissues

Management of Edema
1. Elevation of the edematous part
Nursing Alert!
If edema is due to Congestive Heart Failure (Right Sided),
NEVER ELEVATE THE LOWER EXTREMITIES
Rationale:
This increases the workload of the right side of the heart

Concept!
If edema is due to prolonged standing, DO THE ELEVATION

2. Wear elastic stockings
3. Use warm compress alternated with cold compress
Rationale:
Vasoconstriction and vasodilation causes re-circulation of
fluid
Concept!
This is contraindicated if there is inflammation
Assessment of Edema
Induration
1+ - 1 cm induration
2+ - 2 cm induration
3+ - 3 cm induration
4+ - 4 cm induration
5+ - 5 cm induration

PAIN MANAGEMENT
Pain
A noxious stimulation of actual or threatened / potential
tissue damage
Categories of Pain according to Origin
Cutaneous
o Skin
Deep Somatic
o Tendons, ligaments
o Bones
o Blood Vessels
Visceral Pain
o Organs of the body

Categories of Pain based on Cause
Acute
o Due to trauma or surgery
o Persists for less than six (6) months
Chronic Malignant Pain
o Related to cancer
o On and off
o Persists for more than six (6) months
Chronic Non-malignant Pain
o Persists for more than six (6) months

Categories of Pain according to Where It Is
Experienced
Radiating Pain
o Felt on the source and is extending to nearby tissues
Referred Pain
o Felt on other parts detached from the source
o Example:
o Pain on a lacerated liver may be felt on the right shoulder and
not on the right upper quadrant
Intractable Pain
o Highly resistant to pain-relief methods
Phantom Pain
o Pain that is felt on a MISSING BODY PART or a PART THAT IS
PARALYZED by SPINAL CORD INJURY.

Pain Threshold
Amount of pain stimulation that is required in order to
feel pain

Pain Tolerance
Maximum amount of pain and duration that a person is
willing to endure

Gate Control Theory
Concept!
This is the most widely used theory in pain management
Concepts!
At the dorsal horn of the spinal cord is a gate.

This gate is called the SUBSTANCIA GELATINOSA
A series of nerves pass through this gate
Small diameter nerve fibers pass through the substancia
gelatinosa
o Pain signals are carried to the spinal cord by the small diameter
nerve fibers
Large diameter nerve fibers also pass through the
substancia gelatinosa
o Large diameter nerve fibers close the gate prevents the
transmission of impulses through the spinal cord
o Therefore, when LARGE DIAMETER NERVE FIBERS ARE
STIMULATED, THE GATE IS CLOSED
o Pain management operates on the principle of how to stimulate
the Large Diameter Nerve Fibers to close the gate.


Pain Management Strategies
Pharmacologic Methods
Narcotics
NSAIDs
Adjuvants or Co-analgesics
Non-Pharmacologic Methods
Physical Interventions
Cognitive / Behavioral Interventions
Non-Pharmacologic Physical Interventions
1. Cutaneous Stimulation
Massage
o Effleurage
o Soft massage
o Gentle stroking
Petrissage
o Hard massage
o Large and quick pinches
o Also done by striking

Application of Counter-Irritant
o Bengay
o Menthol
o Omega Pain Killer
o Flax Seeds
o Poultices
Heat and Cold Application
o Nursing Alert!
o Rebound Phenomenon
When you apply heat (usually done for 20 minutes), vasodilation is
produced
If heat is applied for more than 20 minutes, there is vasoconstriction
This is an inherent defense mechanism from burning of tissues

Cold Application
o Maximum vasoconstriction is reached when skin reaches 15C
o If there is further drom in temperature, there is vasodilation (skin
becomes reddish)
o This is the inherent defense mechanism from being frozen
Accupressure
o Pressure on certain points of the body
o Stimulates release of endorphins, which have natural analgesic
effects
o This started in Ancient China

Accupuncture
o Insertion of long slender needles on certain chemical pathways
o Origin is also Ancient china
Contralateral Stimulation
o Example: Injury on left side and massage is done on the right
side
o Useful when patient cannot be accessed:
For patients in a cast
For patients with burns
For patients with phantom pain

2. Immobilization
Application of splints
3.Transcutaneous Electrical Nerve Stimulation
Composed of electrodes
Operated by battery
Electrodes are applied on painful site or over the spinal cord
4.Administration of a Placebo
Relieves pain because of its intent and not because of
physical or chemical properties
Cognitive or Behavioral Non-Pharmacologic Interventions
Purpose:
o To alter pain perception
o To alter pain behavior
o To provide client with a greater sense of control over the pain

Specific Interventions
1.Distraction
Purpose is to divert attention from pain
Slow Rhythmic Breathing
o Stare at a certain object
o Take deep breath slowly
o Release or exhale slowly
o Concentrate on breathing
o Picture a peaceful scene
o Establish a rhythmic pattern
2.Massage and Slow Rhythmic Breathing

3.Rhythmic Singing and Tapping
Key Concept!
o Faster beat music is more preferable
4.Guided Imagery
Imagine that you are walking along a peaceful shore
Eyes are closed and suggestions are given
5.Hypnosis
The success of hypnosis depends on the ability of the
patient to concentrate and the capacity of the hypnotist
to suggest
Based on suggestion
Progressive relaxation

Oliguria
Renal output of less than 500 ml per day
Anuria
Renal output of less than 100 ml per day
Retention
Positive for distended bladder
May also occur in the absence of bladder distention
Altered Urinary Elimination
Enuresis
Common among pediatric patients
Age 4 5 years old child has adequate bladder control
Primary Enuresis
o Never had a dry period
Secondary Enuresis
o Acquired enuresis
o At age 7, bladder control is present for at least one year
o Then, enuresis comes back
o Urinating could NOT be controlled again

Incontinence
Involuntary passage of urine
Types of Incontinence
1.Functional Incontinence
Involuntary passage
Unpredictable time
2.Reflex Incontinence
Occurs at somewhat predictable times when specific
bladder volume is reached
No awareness of bladder filling
No urge to void
It may be related to neurologic impairment

3.Stress Incontinence
Loss of urine is less than 50 ml occurring with increased intra-
abdominal pressure
o Occurs when laughing
o Occurs when sneezing
o Occurs when smiling
4.Total Incontinence
Continuous flow of urine
No bladder distention
No bladder spasm
No awareness of bladder filling
5.Urge Incontinence
Urine flows as soon as a strong sense of feeling to void
occurs
Strong bladder spasm
Management of Incontinence
1.Kegels Exercises
Also called:
o Pubococcygeal Muscle Exercises
o Pelvic Floor Muscle Exercises
Applicable for:
o Functional Incontinence
o Stress Incontinence
How done:
o Advise patient to stand with legs slightly apart
o Concentrate on perineum
o Draw perineum upward slowly

Alternative way:
o When urinating, try to stop in the middle of flow or try to stop
diarrhea from flowing
o Advantage of Kegels Exercises
o Increases muscle tone of the pelvis
o Increases muscle control

2.Clean Intermittent Self Catheterization
Applicable for Reflex Incontinence
How done:
o Use a mirror for:
Obese male patients
Female patients
Concept!
o Possible Board Question:
Is your Clean Intermittent Self Catheterization procedure a sterile
procedure?
o Answer:
No, it is just a clean procedure. Therefore, you can just wash the
catheter for the next use.

3.Credes Maneuver
Application of a steady but gentle pressure on the supra-
pubic region to force urine out of the bladder
Nursing Alert!
o Do not use if there is OBSTRUCTION (i.e. renal obstruction in
the form of renal stones)
o This is done only for patients who are no longer expected to
regain control (Reflex incontinence and retention)

4.Prompted Voiding or Scheduled Toileting
For Reflex Incontinence

5.Application of Adult Catheter and External Condom
Catheter
For elderly with Total Incontinence

6.Catheterization

MIDSTREAM CLEAN CATCH URINE SPECIMEN
How is this done?
If patient is a Male
o Clean the penis
o Do this from the meatus down to the shaft
o Let the patient urinate
o Discard the first or the initial urine
o Collect midstream urine
o Purpose is to attain sterile specimen for urine culture and
sensitivity testing
If patient is a Female
o Let patient wash genitals
o Dry the genitals
o Get to bed

Place patient in semi-Fowlers position when she is ready to void
Clean and spread labia with two fingers
Remain holding labia
Then let patient urinate
Let go of first flow
Collect next flow

CATHETERIZATION
Coude Catheter
o Elbowed catheter for Benign Prostatic Hypertrophy patients
Robinson Catheter
o Straight catheter
Multi-Lumen Retention Catheter
o Foley catheter

Concepts!!!
See to it that penis is perpendicular to body to straighten up
the urethra to bladder
While inserting the catheter, ask the patient to breathe
through the mouth
Cleanse the penis before insertion
Grasp penis firmly to avoid stimulating erections
Where to tape catheter
o Tape it upward on the abdomen
Rationale:
o To avoid scrotal excoriation
o Tape on the inner thigh (with penis sideways either on left or right
and follow the normal contour of the penis

Length of Catheter
o 40 centimeters
Depth of Insertion
o While inserting, the point at which urine starts to flow, insert
further by five (5) centimeters and then inflate the balloon
KOZIER
o Insert up to a the Y-point, retract after inflating (this method is
more prone to infection

For females
o Insert at female Urethra
Length of Catheter
o 22 centimeters
Depth of Insertion
o Point at which urine starts to flow, insert further by five (5)
centimeter before inflating balloon

GIT FECAL ELIMINATION
Wellness Teachings
Fluid intake of at least 2,000 ml per day
Regular exercise
High fiber diet
Avoid ignoring the urge to defecate
Do not abuse laxatives
Concepts!
For Flatulence
o Avoid carbonated drinks
o Do not use straw
o Avoid chewing gum
o Avoid gas-forming foods:
Camote
Cabbage
Cauliflower
Onions

For Constipation:
Increase fluid intake
Prune juice
Papaya
Increase fiber in the diet
Use METAMUCIL (natural fiber) instead of laxatives
Special Laboratory Procedures
1.Guiac Test
To determine the presence of occult blood
Concepts!!!
o Have a meat-less diet three (3) days before examination
o Withhold oral iron supplements
o Injectible iron is allowed
o Avoid any food that discolors the stool.
2.GI SERIES
Upper GI Series Barium Swallow
Nursing Considerations:
o Elimination of contrast medium
How:
o Increase fluid intake
o Increase fiber in the diet
Rationale:
o To offset the risk of constipation
o Inform patient that the color of the stool will be WHITE
Lower GI Series Barium Enema
Done at the radiology department
Nursing Concern:
o Elimination of Barium
How:
o Cleansing enema may be needed after barium enema

Different Types of Enema

1. Cleansing Enema
Soap suds enema
Alkaline solution
Nursing Alert!
o Contraindicated in patients with liver cirrhosis and with increased
ammonia in the blood
Rationale:
o Alkaline solution facilitates transfer of ammonia from the GI tract
to the bloodstream

Therefore, use lemon juice or dilute vinegar instead!!!
Nursing Alert!
o Also contraindicated in possible appendicitis or appendicitis
patients
Rationale:
o Can lead to rupture of the appendix
2. Carminative Enema
Used to expel out flatus
Burned sugar
Now commercially available
3. Oil Retention Enema
Purpose:
o To lubricate the colon and to soften the feces
o Retention time is one (1) to three (3) hours

4. Retention Flow Enema
Also called Harish Flush Enema
Solution is continually administered until what comes out
of the body is clear.

Positions in Enema
Cleansing Enema
High Cleansing Enema
o Clean as much of the colon as possible
o On introduction, Sims Left position facilitates flow of enema to
sigmoid colon

o Then, assume Dorsal Recumbent position to facilitate flow of
enema to transverse colon
o Then, Right Side-Lying position to facilitate flow of enema to the
descending colon
Low Cleansing Enema
For cleaning of rectum and colon only
Human Sexual Response
Excitement / Physical Stimulation
Erotic stimuli causes sexual stimulation
Lasts for a few minutes to several hours
Types of Stimulation
Physical Stimulation
Oral stimulation
o Fellatio
Oral stimulation of the penis using the mouth
o Cunningulus
Oral stimulation of the vagina
o Anningulus
Oral stimulation of the anus
In homosexual male, typhoid fever may be obtained from anningulus
Male and Female oral sex is called SOIXANTE NEUF

Physiological Sexual Stimulation
Stimulation by:
o Smell
o Sight
o Hearing
o Fantasy
o Spoken words
o Mental imagery

During stimulation or Period of Excitement
Males
o Erection of the penis
Females
o Redness near the ear
o Nipples, breasts move up
o Fourchette retracts
o Clitoris becomes visible
o Increased vaginal secretion
o If female is unaroused, there is backpain as penis hits the cervix
If the female is well-stimulated, the cervix rises

Plateau Stage
Lasts thirty (30) seconds to three (3) minutes
In males:
o Scrotum rises upward
o Shaft of penis increases in length and width
In females:
o Cervix rises
In both sexes:
o There is increased muscle tone
Myotonia
Orgasmic Phase or Orgasmic Stage
Climax of sexual tension
Peak of sexual experience
Lasts three (3) to ten (10) seconds

Resolution Stage
Key Concepts!
o Females have longer resolution phase
o Males have shorter resolution phase

Stages of Perioperative Nursing
Pre-operative Phase
Intra-operative Phase
Post-operative Phase

Pre-operative Phase
Begins upon decision of patient to undergo the operation
Ends when patient is placed on the operating table

Intra-operative Phase
Begins when patient is placed on the operating table
Ends when client is admitted to the Post-Anesthesia
Care Unit or PACU

Post-operative Phase
Begins upon admission to the PACU
Ends upon the discharge of the patient
Skin Preparation
Purpose:
o To reduce post-operative infection by:
Removing soil and transient microbes
Reducing microbial count to subpathological level
in a short period of time with minimal skin irritation.

Concepts!
Hair on the skin should not be shaved if it does not
interfere with the procedure
If hair needs to be removed, the best method would be
through the use of:
o Clippers
o Depilatory cream
Shaving is NOT ADVISED. This is the last choice
Where is shaving done?
o Not at the Operating Room!

TYPES OF WOUNDS

1. Clean Wound
Uninfected
No inflammation
Respiratory, Alimentary and Urinary tracts are not
entered

2. Clean Contaminated Wound
A surgical wound
No evidence of infection
Respiratory, GI, Urinary tracts are entered

3. Contaminated Wound
Involves large spillage of content from the GI, Urinary
and Respiratory tracts
Positive for inflammation
Positive for infection
Dirty Infected Wound
Old wounds
Necrotic, gangrenous wound

Modes of Applying Gauze Dressing

1. Dry to Dry
A wide mesh of cotton applied to the surface of the
wound
A second layer is applied over it

2. Wet to Dry
Inner layer is saturated with NSS or anti-microbial agent
On top is a moist absorbent material

3. Wet to Damp
A variation of wet to dry
It is removed before it is completely dried

4. Wet to Wet
Inner layer is saturated with NSS or anti-microbial
solution
Second layer is a wide mesh
It is kept moist with a wetting agent