FUNDAMENTALS IN

NURSING

BY: NURSE_JHEN
1. What vitamin is necessary for a patient suffering from pellagra?
a. vitamin B1 c. vitamin B3
b. vitamin B2 d. vitamin B6
2. According to the intentional torts, which of the following describes
the intentional touching of a person or something that person is
holding or wearing, which is wrong in some way.
a. assault c. domestic violence
b. battery d. false imprisonment
3. What stage of illness will the person belong if the client is
expectedly to gradually become independent and resume former
roles and duties?
a. symptom experience c. assumption of sick role
b. dependent role d. recovery period
4. This is considered to be the 4th stage of grief and loss according
to Kubler-Ross.
a. denial c. bargaining
b. anger d. depression
5. According to Jean Piaget, in his theory of cognitive development,
OBJECT PERMANENCE belongs to what level?
a. Preoperational c. concrete
b. Sensorimotor d. formal
METAPARADIGMS IN
NURSING
THEORIES OF
NURSING
 FLORENCE NIGHTINGALE
12 May 1820 – 13 August 1910
• "The Lady with the
Lamp“
• Bplace: Florence, Italy
• Raised: England
• Educated:
Kaiserswerth,
Germany – founded by
Theodore Fleidner
• At 17 – entered the
covenant
• Crimean war
• St. Thomas Hospital School of Nursing,
London – June 15, 1860
• Works: notes on nursing (1860) and
notes on hospital
• 1st theory of nursing
• Environmental Model

• “Changing or manipulating the

environment”
• “The body can repair itself in a
nurturing environment”
FAYE GLENN
ABDELLAH
• born March 13,
1919
• nursing research
• “ nursing as an art and a science”
• Identified 21 nursing problems
• “nursing is a society”
• Works: Better Nursing Care
Through Nursing Research and
Patient-Centered Approaches to
Nursing
Abdellah's Typology of 21 Nursing Problems:
• To promote good hygiene and physical comfort
• To promote optimal activity, exercise, rest, and sleep
• To promote safety through prevention of accidents, injury, or other trauma and
through the prevention of the spread of infection
• To maintain good body mechanics and prevent and correct deformities
• To facilitate the maintenance of a supply of oxygen to all body cells
• To facilitate the maintenance of nutrition of all body cells
• To facilitate the maintenance of elimination
• To facilitate the maintenance of fluid and electrolyte balance
• To recognize the physiologic responses of the body to disease conditions
• To facilitate the maintenance of regulatory mechanisms and functions
• To facilitate the maintenance of sensory function
• To identify and accept positive and negative expressions, feelings, and reactions
• To identify and accept the interrelatedness of emotions and organic illness
• To facilitate the maintenance of effective verbal and nonverbal communication
• To promote the development of productive interpersonal relationships
• To facilitate progress toward achievement of personal spiritual goals
• To create and maintain a therapeutic environment
• To facilitate awareness of self as an individual with varying physical, emotional,
and developmental needs
• To accept the optimum possible goals in light of physical and emotional limitations
• To use community resources as an aid in resolving problems arising from illness
• To understand the role of social problems as influencing factors in the cause of
illness
VIRGINIA AVENEL HENDERSON
(Nov. 30, 1897 – Mar. 19, 1996)
• first lady of
nursing
• born in Kansas City,
Missouri
• graduated from
the Army School
of Nursing,
Washington
• 14 basic needs
• “assist clients to a peaceful death”
• nursing as "assisting individuals to gain
independence in relation to the performance of
activities contributing to health or its recovery"
• Works: The Principles and Practice of Nursing
• described the nurse's role as substitutive (doing
for the person), supplementary (helping the
person), or complementary (working with the
person), with the goal of helping the person
become as independent as possible.
DOROTHY E. JOHNSON
BSN, MPH
1919 - 1999

• "first four year

generic basic nursing
program in the United
States”
• Behavioral system model
• 7 subsystems: ingestive, eliminative,
affiliative, aggressive, dependence,
achievement and sexual
• “patient’s health is dependent on
nurse’s behavior”
• Works: One Conceptual Model of
Nursing
IMOGENE KING Ed.D.
RN (1971, 1981)
• Goal attainment theory
• "General Systems
Framework" theory
• “nursing as a
profession”
• “nurses help individuals
die with dignity”
• interaction between
nurses and patients.
 King's Conceptual System:
Three Interacting Systems
Personal Systems Interpersonal
Social Systems
Systems
perception interaction organization
self communication authority
growth &
transaction status
development
body image role decision making

space stress

time
MADELINE LEININGER PhD,
LHD, DS, RN, CTN, FRCNA,
FAAN, LL

• Transcultural nursing
model
• Nursing is a humanistic
and scientific mode of
helping a client through
specific cultural caring
process
• Works: Journal of Transcultural Nursing
– The main goal of transcultural nursing is to provide
culturally specific care

• Transcultural Nursing
– focused upon differences and similarities among cultures
• respect to human care, health, and illness
• based upon the people's cultural values, beliefs, and
practices, and
• to use this knowledge to provide cultural specific or
culturally congruent nursing care to people
MYRA ESTRIN LEVINE
(1973)
• Supportive & Therapeutic
• Conservation model
• 4 Principles
– E
– P
– S
– S
Works: Humanities in Nursing
 Betty M. Neuman, R.N.,
B.S.N., M.S., Ph.D., PLC.,
FAAN

• Born 1924 near Lowell,

Ohio.
• pioneer in the field of
nursing involvement in
community mental health
• Health care systems model
– nurses help patients adjust to environmental
stressors
• Works: 'Model for teaching total person
approach to patient problems' in Nursing
Research
• Neuman Systems Model
– wholistic overview of the physiological,
psychological, sociocultural, and developmental
aspects of human beings
DOROTHEA ELIZABETH
OREM
(1914 – June 22, 2007 )

• SELF CARE and

SELF CARE
DEFICIT THEORY
• Self care and Self –care deficit theory

– 'the practice of activities that individuals initiate and

perform on their own behalf in maintaining life, health,
and well-being.'"

– individuals can take responsibility for their health and

the health of others

• 3 nursing systems
– W
– P
– S
 HILDEGARD PEPLAU. EDd
(Sept 1, 1909 - Mar 17, 1999) _

• Interpersonal Relations
in Nursing

• emphasized the nurse-

client relationship as
the foundation of
nursing practice

• Theory is the creation

of a shared experience
 4 Phases of Nurse-Client
Relationship
1. Orientation
2. Identification
3. Exploitation
4. Resolution
DR. MARTHA ELIZABETH
ROGERS
1914 - 1994

• Edited a journal
called: Nursing
Science
• Science of Unitary Human Beings
• “man is an energy field in the environment”
• Man has the capacity for abstraction and
imagery, language and though, sensation
and emotion
• Works: An Introduction to the Theoretical
Basis of Nursing (Rogers, 1970).
SISTER CALLISTA ROY
RN, PhD, FAAN
• Bachelor of Arts with a
major in nursing at Mount
St. Mary's College, in Los
Angeles.

• Nursing’s goal is to
promote adaptation in four
modes: physiologic, self-
concept, role function, and
independence.
• Adaptation model
• “man as a biopsychosocial system” - The
person is an open, adaptive system who
uses coping skills to deal with stressors
• sees the environment as "all conditions,
circumstances and influences that
surround and affect the development and
behaviour of the person"
• six-step nursing process which includes:
assessment of behaviour, assessment of
stimuli, nursing diagnosis, goal setting,
intervention and evaluation.
LYDIA ELOISE HALL
1906 - 1969
• Nursing process
• Concept of CARE, CORE,
CURE
• Hall believed patients
should receive care ONLY
from professional nurses
• Hall was not pleased with
the concept of team
nursing--she said that "any
career that is defined
around the work that has
to be done, and how it is
divided to get it done, is a
"trade" (rather than a
profession).
• According to the Care, Core, and
Cure" model, nurses work in three
arenas: care (hands on bodily care),
core (using the self in relationship to
the patient), and cure (applying
medical knowledge).
• three separate domains: the body
(care), the illness, (cure), and the
person (core).
 JEAN WATSON,
Phd, RN, AHN_BC, FAAN
• Born:West Virginia
• Educated:BSN,
University of
Colorado, 1964
MS, University of
Colorado, 1966PhD,
University of
Colorado, 1973
• She is founder of the
original Center for
Human Caring in
Colorado
• Human caring model
• Transpersonal caring
• Included health promotion and
treatment of illness in nursing
• Her latest book is Caring Science as
Sacred Science (2005)
• TEN CARATIVE FACTORS
1. "The formation of a humanistic-altruistic system of values"(Watson, 1979). This
factor develops at an early age and involves a broad awareness of self.
2. "The instillation of faith-hope"(Watson, 1979). An understanding of and
sensitiviy to an individual's beliefs provides a sense of well-being for the client.
3. "The cultivation of sensitivity to one's self and to others"(Watson, 1979). This
allows the nurse and the client to become increasingly sensitive, and therefore
more genuine.
4. "The development of a helping-trust relationship"(Watson, 1979). Effective
communication techniques such as congruence aids in the creation of this
relationship.
5. "The promotion and acceptance of the expression of positive and negative
feelings"(Watson, 1979). This factor recognizes that the
6. "The systematic use of the scientific problem-solving method for decision
making"(Watson, 1979). The problem-solving method is foundational to the
practice of nursing.
7. "The promotion of interpersonal teaching-learning"(Watson, 1979). The
provision of information empowers a client to make informed decisions about
health and healing.
8. "The provision for supportive, protective, and (or) corrective mental, physical,
sociocultural, and spiritual environment"(Watson, 1979). This factor encompasses
internal and external variables that the nurse is responsible for guiding.
9. "Assistance with the gratification of human needs"(Watson, 1979). Human
needs include all acts of life, ranging from food to the need for achievement.
10. "The allowance for existential-phenomenological forces" (Watson, 1979). The
nurse needs to view each person's reality through the individual's eyes.
It was on Christine Donald's site
 ROSEMARIE RIZZO
PARSE, RN; PhD; FAAN
• Theory of human
being
• Free choice of
personal meaning in
relating value
priorities
• Used terms such as
revealing-concealing,
enabling-limiting,
connecting-separating
BASIC HUMAN NEEDS
( Abraham Maslow)
Maslow’s Characteristics of a
Self-Actualized Person
1. realistic
2. judges people correctly
3. superior perception, is
more decisive
4. clear notion of what is
right or wrong
5. usually accurate in
preceding future events
6. understands art, music,
politics, philosophy
7. possesses humility,
listens attentively
8. dedicated to work, task,
duty, perception
 CONCEPTS OF
HEALTH,WELLNESS AND
ILLNESS
• Health is a state of complete physical, mental and
social well-being, and not just merely the absence
of disease of infirmity (WHO)

• Wellness is well-being. It involves in engaging in

attitudes and behaviors that enhance quality of
life and maximize personal potential

• Illness is a state in which the person perceives

physical, emotional, intellectual, social,
developmental or spiritual functioning to be
decreased.
MODELS OF HEALTH
AND ILLNESS
 HEALTH-ILLNESS
CONTINUUM (DUNN)
• describes the interaction of environment
with well-being and illness
• high-level wellness: towards optimum level
of functioning
• if not going for OLOF, then the person is
towards the illness continuum
HEALTH BELIEF MODEL
(Rosenstock and Becker)
individual perceptions and
modifying factors may
influence health beliefs
and preventive health
behavior
individual perceptions may
include: perceived threat,
perceived susceptibility,
perceived seriousness
modifying factors include:
demographic variables
(age, sex, race),
sociophysilogic variables
(peer group, clubs),
structural variables (
knowledge, contact)
 Concept Definition Application

Define population(s) at risk, risk

levels; personalize risk based
Perceived One's opinion of chances of
on a person's features or
Susceptibility getting a condition
behavior; heighten perceived
susceptibility if too low.
One's opinion of how serious a
Specify consequences of the risk
Perceived Severity condition and its
and the condition
consequences are
One's belief in the efficacy of Define action to take; how,
the advised action to where, when; clarify the
Perceived Benefits
reduce risk or seriousness positive effects to be
of impact expected.

One's opinion of the tangible Identify and reduce barriers

Perceived Barriers and psychological costs of through reassurance,
the advised action incentives, assistance.

Provide how-to information,

Strategies to activate
Cues to Action promote awareness,
"readiness"
reminders.

Confidence in one's ability to Provide training, guidance in

Self-Efficacy
take action performing action.
FIVE STAGES OF ILLNESS
Symptom When the person believes something is
experiences wrong; manifestations of signs and symptoms
(they feel unwell or get a rash)
Assumption of When self-management fails, seeks
the sick role confirmation from family and friends – often
excused from normal role expectations
Medical care When symptoms persist, seeks the advice of
contact a health professional (check- up)
Dependent Becomes dependent on the professional for
client role help with illness (admission to the hospital)
Recovery or Client is expected to gradually become
rehabilitation independent and resume former roles and
duties
STRESS
 MODERN STRESS
THEORY
(HANS SELYE)

• stress is a non-specific response of

the body to any demand made upon it
• A stressor is any stimulus that
produces stress and the disturbs the
body’s equilibrium
 FACTS OF STRESS:
1. stress is not a nervous
energy
2. man tends to adapt to
stress
3. stress is not always
something to be avoided
4. stress does not always
lead to distress
5. a single stress does not
cause a disease
6. stress may lead to
another stress
7. prolonged stress may
lead to exhaustion
8. stress is always a part of
everyday life
 GENERAL ADAPTATION
SYNDROME (GAS)
• whenever a man responds to stress,
the whole body is involved
• Regardless of the cause of stress,
the same chain of physiologic events
occurs
• The GAS is a result of the release of
adrenal hormones, with subsequent
changes in organ systems
 STAGES OF GAS: (ARE)
Stage of Alarm Stage of Stage of
Resistance Exhaustion

person becomes characterized by result from

aware of the adaptation prolonged exposure
presence of threat levels of resistance to stress and
or danger are increased adaptive
levels of resistance person moves back mechanisms can no
are decreased to homeostasis longer persist
adaptive unless other
mechanism are adaptive
mobilized (fight or mechanisms will be
flight reaction) mobilized, death
may ensue
 LOCAL ADAPTATION
SYNDROME (LAS)
• man may respond to stress through a
particular body part or body organ
• response is localized
• It is the reaction of one organ or one
part of the body
• Example: inflammation
HEALTH PROMOTION
 HEALTH PROMOTION

• these are activities directed towards

increasing the level of well-being and
self-actualization
 THREE LEVELS OF
PREVENTION
Primary to encourage optimal health and to increase the person’s resistance to
illness
Prevention activities includes health promotion, health teachings
examples: quit smoking, exercise, immunizations, balanced diet, healthy
lifestyle, avoid alcohol intake, increase water intake, maintain ideal
body

Secondary also known as health maintenance

activities include early diagnosis, detection and screening; prompt
Prevention treatment
examples: PE, pap smear, clinical Breast Exam, sputum exam, stool
exam and rectal exam

Tertiary to support the client’s achievement of successful adaptation to known risks,

optimal reconstitution and/or establishment of high-level wellness
Prevention examples: self-monitoring of blood glucose, physical therapy of a CVA
patient, cardiac rehab after MI, self-management class for DM,
speech therapy after laryngiectomy
NURSING PROCESS
NURSING PROCESS
• Lydia Hall
• G
• O
• S
• H
 CHARACTERISTICS OF
THE NURSING PROCESS
1. problem – oriented, it is comparable with scientific
problem-solving approach
2. goal – oriented
3. orderly, planned, step by step
4. open to accepting new information during its application,
it is flexible to meet the unique needs of the client, group
or community
5. interpersonal – it requires that the nurse communicates
directly and consistently with the client
6. permits creativity among nurses and clients in devising
ways to solve the health problems
7. cyclical – steps may overlap because they are interrelated
8. universal
 ASSESSMENT
• collecting, validating, organizing and recording
data about the client’s health status
• purpose: ______________
TYPES OF DATA: s -
o -
METHODS: 1. interview -
2. observation -
SOURCES: Primary –
Secondary –
NURSING DIAGNOSIS
• 4 parts
• _______: to identify the client’s health care
needs and to prepare diagnostic statements
– PROBLEM:
– ETIOLOGY:
– SIGNS AND SYMPTOMS:
– SECONDARY FACTORS:

EXAMPLE:
“Altered Comfort: Pain related to presence of
incision site at the right lower quadrant
secondary to post appendectomy”
 TYPES OF NURSING
DIAGNOSIS
• Actual –
Example: fluid volume deficit
• Risk –
Example: risk for injury
• Potential –
Example: potential for growth
• Wellness –
Example: family pattern increased
• Syndrome –
Example: altered community pattern
 PLANNING
• Determining the strategies or course of
actions to be taken before implementation
of nursing care
• Purpose: to identify the client’s goals
and appropriate nursing interventions
• Should only have ONE GOAL but may have
MANY OBJECTIVES
 Should be SMART
• SPECIFIC: the goal should be directed to the
patient alone
• MEASURABLE: use of action words like
demonstrate, verbalize, manifest, etc.
• ATTAINABLE: should be well stated in a way that
the goal is achievable
• REALISTIC: suited for the condition of the
specific patient and is applicable
• TIME FRAMED: the time is set for the goal to be
achieved
EXAMPLE: (altered comfort: pain)
“At the end of my 8-hour shift, my patient will
verbalize increased level of comfort as evidenced by:
– Reduced pain scale of 3/10 from 6/10 with 0 as no
pain and 10 as most painful
– Participate in activities of daily living
– Absence of guarding behavior, facial grimacing, and
moaning”
 IMPLEMENTATION
• Putting the nursing care plan into
action
• Purpose: to carry out planned
nursing interventions to help the
client attain goals
 Should be organized in its
presentation
– INDEPENDENT: all nursing actions that needs
NO doctor’s orders (vital signs, turning and
positioning, chest physiotherapy)
– DEPENDENT: all nursing procedures that
NEEDS doctor’s orders (medications, special
procedures)
– INTERDEPENDENT: otherwise known as
COLLABORATIVE, in which other health team
members are being tapped for the care
(speech therapy, respiratory therapy, physical
therapy)
– REFERRAL: endorsed to the superior (NOD,
head nurse, physician)
 EVALUATION
• Assessing the client’s response to nursing
interventions and then comparing the
response to predetermined standards or
outcome criteria
• Purpose: to determine the extent of
which goals of nursing care have been
achieved
 COMPONENTS OF A
NURSING GOAL:
• A. CONCLUSION STATEMENTS
• 1. GOAL MET
• 2. GOAL PARTIALLY MET
• 3. GOAL UNMET
• B. JUSTIFICATIONS - written as “ as evidenced
by”
• EXAMPLE:
• “Goal Met. Patient able to verbalize increased
level of comfort as evidenced by:
– reduced pain scale
– cooperate in the ADL
– no more facial grimacing”
COMMUNICATION
TYPES OF COMMUNICATION:

1. NONVERBAL – actions or behaviors that communicate a

message without speaking
– facial expressions, body language, posture, hand gestures,
use of space and territory
2. VERBAL – transmission of a message using the spoken
language
3. THERAPEUTIC – communication that pertains to treatment
and healing
– important elements contributing to the establishment of the
therapeutic relationship are EMPATHY, ATTENDING,
OBSERVING, and LISTENING
4. NON-THERAPEUTIC – communication that is a barrier to
free
5. ACTIVE LISTENING – attentiveness to the client in a
physical and psychological manner
ESSENTIAL COMPONENTS OF A
THERAPEUTIC COMMUNICATION
(ReGRET)
• RAPPORT – IPR characterized by a spirit of
cooperation, confidence and harmony
• TRUST – a risk-taking process whereby a person’s
situation and feeling of well-being depends on the
actions of another
• RESPECT – a relationship in which one considers
the other in high esteem or regard
• EMPATHY – ability to try and understand what other
person is feeling; Not actually feeling what the other
person is feeling
• GENUINENESS – being as one appears, sincere and
honest
 THERAPEUTIC COMMUNICATION
TECHNIQUES
Listening Facing and leaning towards the client, using eye contact, relaxed
body posture
Broad opening Open-ended comments

Clarification Nurse communicates an understanding of the thought or feeling

tone of the client’s message back to him/her to offer another
perspective in the situation
Reflection Reflects back the feeling or thought

Confrontation Describes contraindications in the client’s behavior or feeling

Giving information Provides facts and information

Seeking validation Asks to give feedback about the accuracy of the nurse’s
perceptions
Self-disclosure Occasionally and cautiously reveals something from her own
experience
Silence To communicate presence and acceptance of the client

Summarizing Progress, evaluates, goals

 NONTHERAPEUTIC
COMMUNICATION
Changing the Nurse communicates an unwillingness to continue with the
subject client’s topic
Interrupting Nurse shows disrespect by breaking into an interfering
with his/her communication
Approving Nurse uses approval and disapproval to control the client
and his/her behavior
Moralizing Nurse passes judgment on the client

Social response Nurse uses superficial, social conversation that is not

client-centered
Belittling Nurse discounts the client’s feelings and experiences as
not being valuable or worthwhile
Giving advice Nurse gives advice to the client
LEGAL ISSUES
• PRIVACY – being apart from others for observation
• INFORMED CONSENT – the health care provider has the
responsibility to communicate pertinent information in a manner that
the client is able to understand
– role of the nurse: advocate
• COMMITMENT – the legal process by which the clients who have
psychiatric problems are brought to and confined in a secure area
because their behaviors are so extreme and severe that they pose a
harm to themselves or to others
• CLIENT RIGHTS
– clients retain all of the basic rights that every citizen has
– clients also expect that the treatment will be individualized and
collaborative with no verbal or physical abuse
– client rights include privacy, confidentiality, and expectation that
treatment will be appropriate to needs with client participation
• HUMANE RESEARCH – entails voluntary participation, informed
consent, and freedom to withdraw from the study at any time for any
reason, without penalty
 LIABILITIES
• MALPRACTICE – incorrect treatment by a professional
that causes injury or harm
• NEGLIGENCE – the commitment of an act that a
reasonable and prudent person would not have done
• INVASION OF PRIVACY – violation of another person’s
rights to be left alone and free from unwarranted contact,
intrusion and publicity
• DEFAMATION OF CHARACTER – any untrue
communication, written (libel) or spoken (slander) that
injures the good name or reputation of another, or in any
way brings that person into disrepute
• FALSE IMPRISONMENT – the intentional, unjustified,
nonconsensual detention or confinement of a client for
any length of time.
• RESPONDEAT SUPERIOR – the employer is ultimately
responsible for the acts of its employees, and is thus liable
for damage to the third parties
VITAL SIGNS
 TEMPERATURE
• balance between the heat produced
by the body and the heat lost from
the body
• body heat is primarily produced by
metabolism
• the heat-regulating center is the
hypothalamus
 2 TYPES:
1. CORE – deep tissues of the body
2. SURFACE – skin, SQ, fats

• normal core body temperature is

between 36.5 C – 37.5 C
• BASAL METABOLIC RATE – the younger
the person, the higher the BMR; the
older the person, the lower the BMR
 PROCESS INVOLVED
IN THE HEAT LOSS
1. RADIATION – the transfer of heat from the
surface of one object to another without contact
between the two objects
2. CONDUCTION – transfer of heat from one
surface to another but with contact between the
two objects
3. CONVECTION – the dissipation of heat by air
currents
4. EVAPORATION – the continuous vaporization of
moisture from the skin, oral mucous, heat
respiratory tract (insensible heat loss)
 ALTERATIONS IN
BODY TEMPERATURE
FEBRILE – from 37.5 C to 38 C
HYPERTHERMIA – from 38 C to
39.5 C
• Febrile and hyperthermia can be
relieved by TSB + antipyretics
PYREXIA – from 39.5 C and above
HYPERPYREXIA – pyrexia +
convulsion
• Pyrexia and hyperpyrexia needs
IV antipyretics +
anticonvulsants
• Very high body temperature
(41-42 C) cause irreversible
brain cell damage
 TYPES OF FEVER
a. INTERMITTENT – temperature fluctuates
between periods of fever and periods of
normal/subnormal temperature
b. REMITTENT – temperature fluctuates within a
wide range over the 24-hour period but remains
above normal range
c. RELAPSING – the temperature is
elevated for few days, alternated with
1 or 2 days of normal temperature
d. CONSTANT – body temperature
is consistently high
 NURSING INTERVENTION
OF CLIENTS WITH FEVER
• 1. monitor VS
• 2. assess skin color and temp – skin flushing
• 3. monitor WBC – NEUTROPHILS will increase f
due to bacterial infection
• 4. remove excess blankets
• 5. Provide adequate food and fluid replacement
• 6. measure I&O
• 7. promote rest
• 8. provide TSB prn
• 9. administer antipyretics
 PULSE
• A wave of blood created by
contraction of the left ventricle of
the heart
• The PR is regulated by the autonomic
nervous system
FACTS:
• 1. females have higher
PR after puberty
• 2. increase in
metabolic rate
increases PR
• 3. increase in blood
loss increases PR
4. thready pulse –
weak and feeble pulse
• 5. bounding – very
strong pulse
 PULSE SITES:
• temporal
• carotid
• apical
• brachial
• radial
• femoral
• posterior tibial
• pedal (dorsalis pedis)
• popliteal
 ASSESSMENT OF THE
PULSE:
A. RATE – the normal pulse rates per minute are as
follows:
• Newborn: 80-180 bpm
• 1 year: 80-140 bpm
• 2 years: 80-130 bpm
• 6 years: 70-120 bpm
• 10 years: 50-90 bpm
• Adult: 60-100 bpm
B. RHYTHM – the pattern and intervals of beats.
Dysrhytmia is an irregular pattern
C. VOLUME (AMPLITUDE) – the strength of the
pulse
• Words to use: strong or full, weak, feeble,
thready
 RESPIRATION
• PHYSIOLOGICAL PROCESSES
1. VENTILATION – the movement of air in and out
of the lungs
2. EXTERNAL RESPIRATION – the exchange of
gases from the alveoli to the capillaries and vice
versa
3. PERFUSION – the transport of oxygen through
oxyhemoglobin throughout the body
4. INTERNAL RESPIRATION – exhange of gases
from the capillaries to the tissue and vice versa
 TYPES OF
BREATHING:
COSTAL (THORACIC) –
involves movement
of the chest

DIAPHRAGMATIC
(ABDOMINAL) –
involves movement
of the abdomen
 RESPIRATORY
CENTERS
A. MEDULLA OBLONGATA – the primary
center; in C3 or C4, where the diaphragm
is innervated by the PHRENIC NERVE
B. PONS –
1. PNEUMOTAXIC CENTER: responsible for
rhythmic quality of breathing (involuntary
breathing)
2. APNEUSTIC CENTER: responsible for deep,
prolonged inspiration
 ASSESSING
RESPIRATION
1. RATE: 16-20 cpm (adult)
2. DEPTH: observe the movement of the
chest. Maybe normal, deep or shallow
3. RHYTHM: observe for regularity of
inhalations and exhalations
4. QUALITY OR CHARACTER: respiratory
effort and sound of breathing
 RHYTHM OF RESPIRATION
(ALTERED BREATHING)
1. CHEYNE-STOKES –
waxing and waning
• Char: deep, shallow with
temporary apnea
• Conditions: increase ICP,
drug toxicity
2. BIOT’S – also known as
CLUSTER RESPIRATION
• Character: shallow breaths
interrupted by apnea
• Condition: CNS disorders
• 3. KUSSMAUL’S –
hyperventilation
• Character: tacypnea +
metabolic acidosis;
deep and rapid
breathing
• Condition: DM
• 4. APNEUSTIC –
prolonged gasping
inspiration followed by
a very short
expiration
 BLOOD PRESSURE
• Measure of the pressure
exerted by the blood as it
pulsates through the arteries
• BP = cardiac output x stroke
volume
 TERMS:
1. SYSTOLIC PRESSURE – pressure of the blood
as a result of contraction of the ventricles (110-
140 mmHg)
2. DIASTOLIC PRESSURE – pressure when the
ventricles are at rest (60-90 mmHg)
3. PULSE PRESSURE – difference between the
systolic and diastolic pressures (normal is 30-
40 mmHg)
4. HYPERTENSION – abnormally high blood
pressure over 140 mmHg systolic and/or 90
mmHg diastolic for at least two consecutive
readings
5. HYPOTENSION – abnormally low blood
pressure, systolic pressure below 100 mmHg
 FACTS:
• increase peripheral
resistance increase BP
• decrease cardiac output
decreases BP
• decrease
compliance/elasticity
increases BP
• increase hematocrit
increases BP
• BP is at lowest in the
morning and highest in
the late afternoon
• KOROTKOFF SOUND –
normal heart sounds
LABORATORY EXAMS
and DIAGNOSTIC
EXAMS
 COMPUTED
TOMOGRAPHY (CT SCAN)
• 3-dimensional image
• INFORMED CONSENT
• No fasting required
(except for abdomen)
• Assess for allergic to
seafoods – contrast
medium of iodine-based
will be used
• Should remain still
• Avoid driving immediately
after the exam
 ULTRASOUND ( UTZ )
/ ULTRASONOGRAPHY
• Use of ultrasonic waves
(sound waves too high in
frequency for a human ear
to detect)
• No special preparation
needed or fasting
• If UTZ of ABD: let the
client void before the
procedure
• If UTZ of KUB: let the
client drink water and not
void till the procedure is
done
MAGNETIC RESONANCE
IMAGING (MRI)
• Non-invasive test which uses
powerful magnetic fields and radio
frequency pulses
• No radiation involved
• Not for pregnant women, those with
metals in the body (artificial
pacemakers, hip replacements,
inserted metals after fracture)
• Bone appears black in the MRI
paper
• Remind that it is a noisy procedure
• Assess for claustrophobia
• Keep still the whole procedure
• INFORMED CONSENT
 CHEST X-RAY
• Show the bony thorax and
structures
• Normal: right is slightly
higher than the left
• Costophrenic angle – junction
between the rib cage and
diaphragm
• No special preparation
• No inform consent needed
• Non-invasive procedure
• Keep still the whole
procedure
POSITRON EMISSION
TOMOGRAPHY (PET)
• Produces images of
metabolic and physiologic
function
• Given strong doses of
radioactive tracers (radio-
nuclides)
• INFORMED CONSENT
• Keep still the whole
procedure
 GASTROINTESTINAL
SERIES (GI SERIES)
A. BARIUM ENEMA
• Examination of the patency
of the lower GI
• NPO post NOC
• Give laxatives before the
procedure
• Cleansing enema before
• Increase fluid intake after
the procedure
BARIUM SWALLOW
• Examination of the
patency of the upper
GI
• Also known as
ESOPHAGOGRAM
• Use of radiopaque when
viewed in the
fluoroscope then
filmed
• Increase fluid intake
after the procedure
 INTRAVENOUS
PYELOGRAPHY
• Radiopaque contrast
medium IV
• Laxative given night
before
• NPO till procedure
is over
• INFORMED
CONSENT
 URINE ANALYSIS

A. CLEAN – CATCH, MIDSTREAM URINE

– for U/A and culture and sensitivity
• The best time to collect urine specimen
is EARLY MORNING, first void specimen
• Provide sterile container
• Do perineal care before collection of
urine
• Discard the first flow of urine
• Collect the midstream: 30-50 ml
• Send the specimen immediately to the
laboratory
 24-HOUR URINE
SPECIMEN
• Discard first voided specimen
• Collect all specimen thereafter until
same time the following day
• Soak specimen in a container with ice
• Add preservative as ordered
 C. SECOND-VOIDED
URINE SPECIMEN
• Discard the first voided specimen
• Give water to drink
• After few minutes, ask to void again,
and collect the urine specimen
• This is need for test for glucose in
urine
 D. CATHETERIZED
URINE SPECIMEN
• Clamp the catheter for 30minutes to 1
hour
• Cleanse the drainage port of the 2-way
foley catheter with alcohol swab
• Use sterile needle and syringe to aspirate
urine specimen from the drainage port
• DON’TS: collect the urine specimen
from the bag; detach the catheter from
the connecting tube
 STOOL SPECIIMEN
A. ROUTINE FECALYSIS
• Assess the gross appearance of stool and
presence of ova or parasites
• Secure sterile specimen container
• Instruct patient to defecate in the bedpan. If
desired, allow the patient to void first. Discard
the urine and wash the bedpan
• Use tongue depressor to collect the stool
specimen
• Collect one teaspoonful or 1 inch of well-formed
stool
• Label the specimen immediately to the laboratory.
Fresh, warm specimen helps detect ova and
parasites
B. STOOL CULTURE AND
SENSITIVITY TEST
• Assess the specific etiologic agent causing
gastroenteritis and bacterial sensitivity to
various antibiotics
• Use sterile test tube and sterile cotton-
tipped applicator
• Label the specimen properly
• Send specimen immediately to the
laboratory
 C. GUAIAC STOOL
EXAMINATION (OCCULT
BLOOD DETERMINATION)
• Microscopic study of stool for presence of
bleeding in the gastrointestinal tract
• Provide hemoglobin-free diet for 3 days
(no meat for 3 days)
• Avoid red or dark-colored foods
• Temporary discontinue iron therapy
• Positive guaiac stool exam, indicates peptic
ulcer disease and gastric cancer
PAIN
• an unpleasant sensory
and emotional experience
associated with actual or
potential tissue damage
or described in terms of
damage
• purpose: serves as a
warning signal of
impending tissue
motivating the patient to
seek professional help
• ALGOLOGY – study of
pain
 PHYSIOLOGIC DIMENSIONS
OF PAIN
1. TRANSDUCTION – conversion of mechanical, thermal, or chemical
stimulus into a neural action potential
2. TRANSMISSION – movement of pain impulses from the site of
transduction to the brain
• Nociceptors – pain receptors
• the fibers (alpha, beta delta)
• C fibers – smallest & unmyelinated; slowest rate; dull sensation
• Dermatomes – areas on the skin that are innervated primarily by single
spinal cord segment
• Dorsal horn processing – in the spinal cord, release of
neurotransmitters to produce activation or inhibition. Endogenous
opioids (enkephalins & B-endorphins) are synthesized by the body to
produce effects same with Morphine.
• Spinothalamic tract – perception of pain is believed to occur at the
cerebral cortex and the efferent neurons will act on it
3. PERCEPTION – occurs when pain is recognized, defined and
responded to by the individual
4. MODULATION – involves the activation of descending
pathways that exert inhibitory of facilitatory effects on the
transmission of pain
 PAIN THEORIES
1. SPECIFICITY THEORY – there are certain
specific nerve receptors that respond to noxious
stimuli
2. PATTERN THEORY – any stimulus could be
perceived as painful if the stimulation were
intense enough
3. GATE CONTROL THEORY – if the gate is closed,
the signal is stopped before it reaches the brain
• Substantia gelatinosa – found at the dorsal horn;
responsible for exciting and inhibiting signals at
the brain
 CYCLE OF PAIN
Stimulus (nociceptors) –
transmission (nerve
fibers) – pain pathway
(spinal Cord) – pain
perception (thalamus) –
pain interpretation
(cerebral cortex) – pain
response
• PAIN THRESHOLD –
awareness and integration
of a stimulus
• PAIN TOLERANCE –
point at which the person
no longer voluntarily
accepts the pain
 CLASSIFICATION OF PAIN
1. DURATION Acute – short term
Chronic – long term

2. QUALITY Sharp – sticking in nature

Dull – annoying but not as intense as sharp
Diffuse – covers a wide area
Shifting – moves from one area to another

3. INTENSITY / SEVERITY Mild – 1-3

Moderate – 4-7
Severe – 8-10

4. PERIODICITY Continuous – constant

Intermittent – repeating
Transient / brief – passes quickly

5. CAUSATION Organic – physiologic origin

Psychogenic – emotional in nature
Psychophysiologic – migraine
Pretended pain – assumed pain
 ASSESSMENT OF
PAIN
• P – provoking factors or precipitating
factors
• Q – quality
• R – region
• S – Severity
• T – timing
PAIN MANAGEMENT
 NON-INVASIVE
1. relaxation technique
2. refraining – converting the negative to positive
ones
3. distraction – focusing one’s attention on
something other than pain
4. guided imagery – using imagination to provide a
substitute for pain
5. humor – laughter is the best
medicine
6. biofeedback – catharsis
7. cutaneous stimulation – stimulating the
skin to control pain
8. hot and cold application
 INVASIVE
WHO 3-step analgesic pain
• step 1 – NSAID (ibuprofen,
mefenamic, paracetamol)
• step 2 – OPIOID
AGONIST (codeine,
meperidine, pentazocine)
• step 3 – AGONISTS-
ANTAGOSNISTS
(morphine, stadol, narcan)
NUTRITION
FOOD PYRAMID
 NUTRIENTS
CARBOHYDRATES
 Primary function: provide the body with energy
 Composed of carbon, hydrogen, oxygen (CHO)
 Glucose provides the most efficient form of
energy
 Provides 4 kcal/gram of energy
 Consists of:
Simple sugars – sucrose, glucose, dextrose,
fructose
Complex sugars – starches and fibers
 PROTEINS
Provide 4.5 kcal/gram of energy
Functions include: structure of bones,
muscles, enzymes, hormones, blood, and
the immune system
Formed by linking amino acids in various
forms
Composed of carbon, hydrogen, oxygen,
nitrogen (CHON)
 FATS
 Lipids are the densest form of energy available
 Produce 9 kcal/gram of energy
 Composed of carbon, hydrogen, oxygen and
oxygen (CHOO)
 Lipids are insoluble in water
 Triglycerides are the primary form of fat in
food
 Fats are divided in three categories:
triglycerides, phospholipids, and sterols
 Function: hormone production and provide
padding to protect vital organs
 MINERALS
Minerals serve structural purpose
and are found in all body fluids and
tissues
16 essential minerals are divided into
2 categories: major and minor
Minerals are plentiful in all foods,
although some may be lost in food
processing
 WATER
 Water provides a means of transportation
for nutrients
 Water acts as a solvent and a lubricant
 It is a by-product of metabolism
 The human body is approximately 60% water
 Need to consume the equivalent of 2 liters
of fluid/day
 Foods with high content of water include
melons, cantaloupe, and berries
 FAT-SOLUBLE VITAMINS
VITAMINS SOURCE DEFICIENCY MANIFESTATIONS

A Yellow fruits and Night blindness, Dryness of the

vegetables, liver,
(retinol) xeropththalmia cornea, blurred
beef, chicken
vision
D Milk products, Ricketts – Soft bones and
tuna, sardines,
(calciferol) children skeletal deformities
margarine, egg,
liver, cheese, Osteomalacia - Brittle bones, bent-
salmon, mackerel adults bones, muscular
weakness
E Wheat, almonds, Rare in humans;
sunflower seeds,
(tocopherol) least toxic form
peanut butter,corn
oil, hazelnuts of vitamin
K Acts as a cofactor hemorrhage Bleeding episodes
for prothrombin
(phytomenadione)
and clotting factors
 WATER-SOLUBLE VITAMINS
VITAMINS SOURCES DEFICIENCIES MANIFESTATIONS

B1 Green leafy Beri-beri Dry skin, irritability, with eventual death

(thiamine) vegetables Wernicke-korsakoff Amnesia secondary to chronic alcoholism
Plant oils syndrome
B2 Green leafy cheilosis Cracking at he sides of the lips
(riboflavin) vegetables
B3 Potato, banana, Pellagra Dermatatis, diarrhea, dementia
(niacin) chicken, egg (3 D’s)
B6 Cereal, potato, Microcytic anemia Weakness, fatigue, dyspnea, low immune
(pyridoxine) banana, chicken, system
oatmeal
B9 Milk and milk Megaloblastic Mentally retarded; neural tube defects,
(folic acid) products; rice anemia; neural tube premature babies
defects
B12 Mollusks, clams, Pernicious anemia Neurologic deficits; constipation, fatigue,
(cyanocobalamin) liver, beef, weakness
cereals
C Citrus fruits and Scurvy; difficult Loose teeth, sore gums, connective tissue
(ascorbic acid) vegetables wound healing problems
H Cereal, potato, Acidosis and Low bp, lethargy
(biotin) banana, chicken, dehydration Due to a diet of raw egg whites ( that have
oatmeal avidin)
NURSING PROCEDURES
 NGT FEEDING
Nursing responsibilities:
1. Assess for patency – a) inject small amount of air;
b)aspirating 20-30ml of gastric secretions; c)
measure the pH of the aspirated fluid
2. High-Fowler’s position – before and after feeding
3. Hang no more htan 4 hours of formula – formula
container should be replaced every 24 hours
4. Check for fod allergies
5. Rinse the tube with water after feeding about 30ml
6. Measure intake and output
7. After feeding, clamp the tube to prevent gas pain
 BOWEL ELIMINATION
NURSING RESPONSIBILITIES
1. Promote regular defecation by providing as much privacy
as possible
2. Encourage the client to defecate when the urge is
recognized, and to establish a routine and time of
defecating
3. Assure an adequate intake of fluids and fiber
4. Constipated: increase OFI and include hot liquids and
fruit juices
5. Diarrhea: increase OFI and small amount of bland foods.
Assess for potassium loss, avoid hot or cold beverages
6. Flatulence: limit carbonated drinks and chewing gum.
Avoid use of drinking straws, avoid gas-forming foods
 ENEMAS
TYPES:
1. Cleansing – given to remove feces; treat constipation;
prevent contamination of sterile field during surgery;
promote visualization of intestine
2. Hypertonic solutions – fleet enema (medicated enema)
3. Hypotonic solution – tap water
4. Isotonic solution – PNSS
5. Carminative enema – release gas, to expel flatus; about
60-80ml of fluid us used
6. Oil retention – to soften feces and lubricate the
rectum and anal canal (mineral oil, olive oil, conttonseed
oil)
7. Return-flow enema – sometimes used to expel flatus
Nursing responsibilities for enemas
1. Provide privacy
2. Lubricate insertion tube
3. Place in left lateral Sim’s position
4. Raise the solution container as advocated
5. As a general rule, the solution should be about 12
inches above the rectum
6. Measure the volume instilled and document results
7. Never release the enema tube when it is in the
rectum
8. Client is instructed to hold the fluid for at least
10-15 minutes
9. Document and do after care
 CATHETHERIZATION
Types:
1. Indwelling / Retention / Foley – for continuous
drainage of urine, for gradual decompression of an
over-distended bladder, and for intermittent
bladder drainage and irrigation
2. Straight – used to drain the bladder for short
periods. They are inserted and removed
immediately after the urine is drained
3. Suprapubic catheter – catheter inserted through a
small incision just above the pubic area.
4. Condom catheter – used for incontinent males
because of the risk for infection is minimal
Nursing responsibilities
1. Explain the procedure
2. Provide privacy
3. Use sterile gloves
4. Place in dorsal recumbent or supine position
5. Cleanse the pubic area
6. Lubricate the tip
7. Instruct to breathe through the mouth
8. Document accordingly
THANK YOU