FUNDAMENTALS OF NURSING (LEC) 7.

Leader
- The ANA Leadership Institute describes a nurse leader as “a nurse who is interested in excelling in a career path,
I.Roles and Functions of the nurse a leader within a healthcare organization who represents the interests of the nursing profession, a seasoned nurse
or healthcare administrator interested in refining skills to differentiate them from the competition or to advance
1. Caregiver to the next level of leadership.” A good nurse leader is someone who can inspire others to work together in
- Being a caregiver is defined as someone who attends to the needs of another person. Nurses are familiar with pursuit of a common goal, such as enhanced patient care. The nursing leader role can be employed at different
the role of professional caregiver since it is their responsibility to address a patient’s cultural, spiritual and mental levels: individual client, family, groups of clients, colleagues, or the community.
needs. Increasing diversity in a growing patient population requires nurses to demonstrate cultural awareness and
sensitivity. Patients may have specific needs and preferences due to their religion or gender, for example. Nurses 8. Manager
need to be respectful of, and knowledgeable about, diverse backgrounds while remaining vigilant in providing - A nurse manager is someone who has decision-making powers and control over certain processes in an
quality care. organization. While their role might not be direct patient care like the role of a bedside nurse, they are still
responsible for the long-term planning of patient care by directing staff, teaming up with an overall healthcare
2. Communicator team (including physicians and others), and coordinating a patient’s continuum of care.
- Good communication between nurses and patients is essential for the successful outcome of individualized
nursing care of each patient. To achieve this, however, nurses must understand and help their patients, 9. Case Manager
demonstrating courtesy, kindness and sincerity. Also they should devote time to the patient to communicate with - Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation
the necessary confidentiality, and must not forget that this communication includes persons who surround the and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through
sick person, which is whykokokokok the language of communication should be understood by all those involved in communication and available resources to promote patient safety, quality of care, and cost-effective outcomes. In
it. Good communication also is not only based on the physical abilities of nurses, but also on education and some situation, nurse case management works with primary or staff nurses to oversee the care of specific case
experience (Kourkouta, and Papathanasiou, 2014). load (Kozier & Erbs, 2016).

3. Teacher III. Expanded Career Roles

- Nurses are expected to be good teachers too. This means it is part of the nurse’s role to make sure that the
clients understood their health condition while teaching clients the effective ways to improve their health. In the 1. Nurse Practitioner
clinical area, frequency of medication intake and route as well as client specific diet were taught by nurses prior to - A registered nurse (RN) who has completed an advanced training program in a medical specialty, such as
discharge. pediatric care. A NP may be a primary, direct health care provider, and can prescribe medications. Some NPs work
in research rather than in direct patient care
4. Client Advocate
- According to the American Nurses Association, being a client’s advocate is “The protection, promotion, and
optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis 2. Clinical Nurse Specialist
and treatment of human response, and advocacy in the care of individuals, families, communities, and - Clinical nurse specialists (CNS) are advanced practice registered nurses (APRNs) that serve as experts in
populations.” The ANA also addresses the importance of advocacy in its Code of Ethics, specifically in Provision 3: evidence-based nursing practice within one of a number of different specialty areas. They integrate their
“The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.” Clearly, advocacy advanced knowledge of disease processes in assessing, diagnosing, and treating patient illnesses, but their role
is a key tenet of nursing practice. extends beyond providing patient care.
- This role is exemplified by representing the client’s need and wishes
to other health professional, like relaying requests for information to the health care provider. More forth in 3. Nurse Anesthetist
assisting clients in exercising their autonomy and helping them in voicing out their rights as patients.unun - Certified registered nurse anesthetists (CRNAs) work as advanced practice registered nurses (APRNs) who
administer anesthesia to patients, typically during surgical, diagnostic, or obstetric procedures. CRNAs must hold a
minimum of a master's degree, although more employers prefer candidates who hold doctor of nursing practice
(DNP) degrees. In addition to their advanced nursing degrees, CRNA candidates must obtain national certification
5. Counselor in their field.
- Being a counselor is exemplified every time nurses help patients and families develop self-care abilities to
maximize functioning and quality of life Or have a dignified death. Moreover, nurses assures the maintenance & 4. Nurse Midwife
promotion health, prevention of illness, restoring health and facilitating coping. - A nurse-midwife is a licensed healthcare professional who specializes in women’s reproductive health and
childbirth. In addition to attending births, they perform annual exams, give counseling, and write prescriptions.

6. Change Agent 5. Nurse Researcher

- A change agent is an individual who has both formal or informal legitimate power and whose purpose is to direct - Nurse researchers are scientists who study various aspects of health, illness and health care. Nurses use research
and guide change (Sullivan, 2012). This person identifies a vision and rationale for the change and is a role model to deliver care. By designing and implementing scientific studies, they look for ways to improve health, health care
for nurses and other health care personnel. Nurses are continually dealing with change in the health care system. services and health care outcomes. They gather and analyze data to glean insights they can apply to facilitating
Technologic change, change in the age of the client population, and changes in medications are just a few of the patient care and pinpointing best practices.
changes nurses deal with daily (Kozier & Erbs, 2016).
6. Nurse Administrator 3. Empathy
- A nurse administrator is an individual who works within a health care environment. - Empathy encompasses a connection and an understanding that includes the mind,
Within this setting, nurse administrators manage nursing teams or a specific nursing unit to ensure the optimal body, and soul. Expressing empathy is highly effective and powerful, which builds patient trust, calms anxiety, and
functioning of the facility. Nursing administrators are fully schooled in the practice of general nursing procedures improves health outcomes. Research has shown empathy and compassion to be associated with better adherence
as well as the implementation of pertinent administrative processes. Individuals who opt to become nurse to medications, decreased malpractice cases, fewer mistakes, and increased patient satisfaction. Expressing
administrators will adopt a leadership position within the workplace setting, and they are comfortable interacting empathy, one patient at a time, advances humanism in healthcare.
with both internal administrators and patients. As a result of all of the administrative tasks they are required to
complete; however, nursing administrators generally do not work extensively with patients 4. Attention to Detail
. - Paying attention to detail is a key part of nursing practice. Missing important detail
7. Nurse Educator can mean the difference between life or death for some patients.
- Nurse educators are employed in nursing programs, at educational institutions, and in hospital staff education.
Nurse educators are responsible for classroom and, often, clinical teaching (Kozier & Erbs, 2016).
5. Problem Solving Skills
8. Nurse Entrepreneur - Effective problem-solving skills and decision-making skills based on sound
- These are nurses who uses their training, knowledge and medical expertise as a nurse to create and develop knowledge are expected from professional nurses. Problem-solving process, which requires creative thinking, is at
their own businesses within the healthcare field through the use of creativity, business systems, problem solving the heart of nursing practices. Nursing is a profession of helping others. The main purpose of helping is to know
and successful investing strategies the served people through communication and interaction based on mutual trust, identify their care needs and, as
a result, help them to cope with their problems more efficiently and satisfy their needs.
9. Forensic Nurse
- Forensic nurses are registered nurses who received specialized education and training to provide care to patients 6. Stamina
who experienced victimization or violence. They are the first point of contact between the victim of crime and the - For a nurse, it is important to have the physical or mental ability to remain active
health care system. And from the bodies of victims of physical injury and violence, living or dead, they collect the for long periods of time. Nursing is a non-sedentary career that requires athleticism and stamina. Nursing is
physical evidence required for criminal investigations. They consult, cooperate, and communicate with law mentally demanding and emotionally draining, there is no place for negativity and stamina is therefore crucial.
enforcement agencies, and can be called on to testify in court as expert witnesses.
7. Sense of Humor
Topic 2. NURSING AS A PROFESSION. - Humor is an inseparable part of daily life, and at times it is regarded as a means of
dealing with one’s problems, and a generally positive and universal experience for people from different cultural
Profession Is a calling that requires special knowledge, skill and preparation. It is an occupation that requires and social backgrounds around the world. Humor can promote nurses’ health and influence nursing care.
advanced knowledge and skills and that it grows out of society’s needs for special services. There have been many
debates about whether nursing a profession rather than an occupation. The profession of nursing consists of 8. Commitment to Patient Advocacy
persons educated in the discipline according to nationally regulated, defined, and monitored standards. To be - One of the most basic ways that nurses can be advocates for their patients is
recognized as profession by the society it serves, nursing must demonstrate an ongoing basis that meets the ensuring they have the right to make decisions about their own health. Especially if a patient is alert and
criteria of a profession (Vati, J. 2015). competent, nurses should take the patient’s decisions seriously, even if the patient declines to take certain
medication or refuses a treatment. When the physician doesn’t agree, the nurse has a responsibility to provide
Personal Qualities of a nurse information so the patient can make informed decisions and to offer support.

1.Caring 9. Willingness to Learn

- Caring is the essence of nursing and connotes responsiveness between the nurse - A good nurse needs to be willing to learn and grow, especially on the job. It’s a
and the person; the nurse co-participates with the person. smart idea to view every work environment as a learning opportunity.

2. Communication Skills
- Nurses who take the time to understand the unique challenges and concerns of 10. Critical Thinking
their patients will be better prepared to advocate on their behalf and properly - “Critical thinking involves interpretation and analysis of the problem, reasoning to find a solution, applying, and
address issues as they arise. finally evaluation of the outcomes,” according to a 2010 study published in the Journal of Nursing Education. This
- Patients who feel like they are receiving all of the nurse’s attention during an definition essentially covers the nursing process and reiterates that critical thinking builds upon a solid foundation
interaction are more likely to disclose the true extent of their feelings and symptoms of sound clinical knowledge. Critical thinking is the result of a combination of innate curiosity; a strong foundation
much quicker. of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab
- Interpersonal communication can satisfy the innate needs of the patient as outlined values; and an orientation for thinking on your feet.
in Maslow’s hierarchy of needs. Those needs include the feelings of safety, love and confidence, all of which are
important during a patient’s treatment and recovery.
11. Time Management TYPES OF HEALTH CARE SERVICES.
- Effective management of time helps get more work done, produces a higher work
quality, and provides fewer missed deadlines. Additionally, there is a better sense of self-control, improved self- Health care services are often described in terms of how they are correlated with levels of disease prevention:
image, and decreased stress with good time organization. Time management is essential to successfully (a) primary prevention, which consists of health promotion and illness prevention;
performing and progressing as a nurse along the continuum (Aggar, Bloomfield, Thomas, & Koo, 2017; Maryniak, (b) secondary prevention, which consists of diagnosis and treatment; and
2019). (c) tertiary prevention, which consists of rehabilitation, health restoration, and palliative care

12. Leadership
- The importance of effective leadership to the provision of good quality care is firmly I. Primary Prevention: Health Promotion and Illness Prevention
established, as is the central role that leadership. It is now also clear that leadership should be found at all levels World Health Organization (WHO) developed a project called Healthy People. The current U.S. Department of
from board to ward and it seems obvious that the development of leadership skills for nurses should begin when Health and Human Services (2010) project that evolved from the original work is called Healthy People 2020 .
training commences and should be something which is honed and developed throughout a nursing career Four overarching goals:
(Feather, 2009).plays in nursing ( (1) Increase quality and years of healthy life,
(2) achieve health equity and eliminate health disparities, (3) create healthy environments for everyone, and
(4) promote health and quality life across the life span.
13. Experience
- Clinical experiences are important throughout a nurse's career – student or
experienced – because they provide a roadmap to patient care decisions and professional development. Without Primary prevention programs address areas such as
this, nurses are unable to function in an autonomous role as patient advocates, as well as contribute to global 1. adequate and proper nutrition,
healthcare initiatives. 2. weight control and exercise,
3. and stress reduction.
The Six C’s of Caring in Nursing
II. Secondary Prevention: Diagnosis and Treatment’s
1. COMPASSION In the past, the largest segment of health care services was dedicated to the diagnosis and
Awareness of one’s relationship to others, sharing their joys, sorrows, pain, and accomplishments. Participation in treatment of illness. Hospitals and physicians’ offices have been the major agencies offering these complex
the experience of another. secondary prevention services. Hospitals continue to focus significant recourses on client who require emergency,
intensive, and around the clock acute care.
2. COMPETENCE
Having the “knowledge, judgment, skills, energy, experience and motivation required to respond adequately to
the demands of III.Tertiary Prevention: Rehabilitation, Health Restoration, and Palliative Care
one’s professional responsibilities”. The goal of tertiary prevention is to help people move to their previous level of health (i.e., to their previous
capabilities) or to the highest level they are capable of given their current health status. Rehabilitative care
3. CONFIDENCE emphasizes the importance of assisting clients to function adequately in the physical, mental, social, economic,
Comfort with self, client, and others that allows one to build trusting relationships. and vocational areas of their lives.

4. CONSCIENCE TYPES OF HEALTH CARE AGENCIES AND SERVICES

Morals, ethics, and an informed sense of right and wrong. Awareness of personal responsibility.
I. Public Health Government (official) agencies
5. COMMITMENT are established at the local, state, and federal levels to provide public health services. Health
The deliberate choice to act in accordance with one’s desires as well as obligations, resulting in investment of self agencies at the state, county, or city level vary according to the needs of the area. Their funds, usually generated
in a task or cause from taxes, are administered by elected or appointed officials.
.
6. COMPORTMENT 1.1 Local health departments- are responsible for developing programs to meet the health needs of the
Appropriate bearing, demeanor, dress, and language that are in harmony with a caring presence. Presenting people, providing the necessary nursing and other staff and facilities to carry out these programs,
oneself as someone who respects others and demands respect continually evaluating the effectiveness of the programs, and monitoring changing needs

1.2 State health organizations -are responsible for assisting the local health departments. In some remote
HEALTH CARE SERVICES areas, state departments also provide direct services to people.

Health Care System -is the totality of services offered by all health disciplines
1.3 The Public Health Service (PHS) of the U.S. Department of Health and Human Services
-is an official agency at the federal level. Its functions include conducting research and providing training in the consist of separate houses, condominiums, or apartments for residents. Residents live relatively independently;
health field, assisting communities in planning and developing health facilities, and assisting states and local however, many of these facilities offer meals, laundry services, nursing care, transportation, and social activities.
communities through financing and provision of trained personnel. .
IX.Rehabilitation Centers
1.4 The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, usually are independent community centers or special units. However, because rehabilitation ideally starts the
administers a broad program related to surveillance of diseases and behaviors that lead to disease and disability. moment the client enters the health care system, nurses who are employed on pediatric, psychiatric, or surgical
By means of laboratory and epidemiologic investigations, data are units of hospitals also help to rehabilitate clients.
made available to the appropriate authorities.
X. Home Health Care Agencies
HOSPITALS offers education to clients and families and also provide comprehensive care to clients who are acutely
,chronically, or terminally ill.
V.1 Military hospitals provide care to military personnel and their families.
XI. Day Care Centers - serve many functions and many age groups.
V.2 Private hospitals are often operated by churches, companies, communities, and charitable organizations. provide care for infants and children while parents work.
Private hospitals may be for-profit or not-for-profit institutions. provide care and nutrition for adults who cannot be left at home alone but do not need
to be in an institution.
V.3General hospitals admit clients requiring a variety of services, such as medical, surgical, obstetric, pediatric, Older adult care centers often provide care involving socializing, exercise programs,
and psychiatric services and stimulation.
Some centers provide counseling and physical therapy.
Other hospitals offer only specialty services, such as psychiatric or pediatric care. provide medications, treatments, and counseling, thereby facilitating continuity between
day care and home care.
V.4 An acute care hospital provides assistance to clients whose illness and need for hospitalization are relatively
short term, for example, several days. XII. RURAL CARE
assesses and identifies interventions for the health care needs of the local population. Nurses in rural settings
V.5 Large urban hospitals usually have inpatient beds, emergency services, diagnostic facilities, ambulatory must be generalists who are able to manage a wide variety of clients and health care problems
surgery centers, pharmacy services, intensive and coronary care services, and multiple outpatient services
provided by clinics. PROVIDERS OF HEALTH CARE

V.6 Small rural hospitals often are limited to inpatient beds, radiology and laboratory services, and basic 1.Nurse -assesses a client’s health status, identifies health problems, and develops and coordinates care.
emergency services. The number of services a rural hospital provides is usually directly related to its size and its
distance from an urban center. 2.Alternative (Complementary) Care Provider - refers to those practices not commonly considered part of
Western medicine.
Hospitals that provide a significant level of care to low-income, uninsured, and vulnerable populations are
referred to as safety-net hospitals. e.g. Chiropractors, herbalists, acupuncturists, massage therapists, reflexologists, holistic
health healers,
VI. Subacute Care Facilities
is a variation of inpatient care designed for someone who has an acute illness, injury, 3. Case Manager -role is to ensure that clients receive fiscally sound, appropriate care in the best setting. This role
or exacerbation of a disease process. is often filled by the member of the health care team who is most involved in the client’s care.
requires the coordinated services of an inter professional team including physicians,
nurses, and other relevant professional disciplines. 4. Dentist - diagnose and treat mouth, jaw, and dental problems. Dentists (and their dental hygienists) are also
is generally more intensive than long-term care and less intensive than acute care. actively involved in preventive measures to maintain healthy oral structures (e.g., teeth and gums).

VII.Extended (Long-Term) Care Facilities 5. Dietitian or Nutritionist - A dietitian has special knowledge about the diets required to maintain health and to
formerly called nursing homes, are now often multilevel campuses that include treat disease in hospitals generally are concerned with therapeutic diets, supervise the preparation of meals to
independent living quarters for seniors, assisted living facilities, skilled nursing facilities (intermediate care), and ensure that clients receive the proper diet, and may design special diets to meet the nutritional needs of
extended care (long-term care) facilities that provide levels of personal care for those who are chronically ill or are individual clients.
unable to care for themselves without assistance .
Traditionally, extended care facilities only provided care for older adult clients, but they now provide care to 6. Emergency Medical Personnel - Several different categories of providers are associated with ambulance or
clients of all ages who require rehabilitation emergency medical services agencies (e.g., fire departments) that provide first - responder care in the community.
VIII. Retirement and Assisted Living Centers these personnel are trained to assess, treat, and transport clients experiencing a medical emergency, accident,
or trauma.
7. Occupational Therapist. (OT) - assists clients with impaired function to gain the skills to perform activities of A discussion is an informal oral consideration of a subject by two or more health care personnel to identify a
daily living (ADL’s). problem or establish strategies to resolve a problem.
The OT teaches skills that are therapeutic and at the same time provide some fulfillment. e.g. weaving is a
recreational activity but also exercises the arthritic man’s arms and hands. A report is oral, written, or computer-based communication intended to convey information to others. For
8. Paramedical Technologist - means having some connection with medicine. instance, nurses always report on clients at the end of a hospital work shift.

CONCEPT OF NURSING The process of making an entry on a client record is called recording, charting, documenting.

The Four Fundamental Concepts of Nursing

1. Human Being The Nursing Process- is a systematic, rational method of planning and providing individualized nursing care. Its
2. Environment purpose is to identify a client’s health status and actual or potential health care problems or needs, to establish
3. Health plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. The client
4. Nursing may be an individual, a family, a community, or a group.

1. Human being- comprises several different aspects to create as a whole: Phases of Nursing Process
➢ psychological 1. Assessment – focus on a client’s responses to a health problem. A nursing assessment should
➢ social include the client’s perceived needs, health problems, related experience, health practices, values, and lifestyles.
➢ physical To be most useful, the data collected should be relevant to a particular health problem. Therefore, nurses should
think critically about what to assess. The Joint Commission (2008) requires that each client have an initial nursing
➢ spiritual
assessment consisting of a history and physical examination performed and documented within 24 hours of
admission as an inpatient.
Cultural aspect is also important especially to a patient.
2. Diagnosis – the nurses use critical thinking skills to interpret assessment data and identify client strengths and
2. Environment- includes where people spend their time and their socio- economic status, as well as the people
problems. The standardized NANDA names for the diagnoses are called diagnostic labels; and the client’s problem
within their environment.
statement, consisting of the diagnostic label plus etiology (causal relationship between a problem and its related
➢ health care
or risk factors), is called a nursing diagnosis that provides the basis for selection of nursing interventions to
➢ social support achieve outcomes for which the nurse is accountable.
➢ environment of the hospital,
The diagnostic process has three steps:
3. Health a state of complete emotional and physical well-being. Healthcare exists to help people maintain this ■ Analyzing data
optimal state of health. ■ Identifying health problems, risks, and strengths
■ Formulating diagnostic statements.
4. Nursing, considered as science and art.
➢ It includes learning 3. Planning- the nurse refers to the client ‘s assessment data and diagnostic statements for direction in
approaches for their immediate health concerns. formulating client goals and designing the nurse interventions required to prevent, reduce, or eliminate the clients
➢ It involves both teaching and learning, ethical and legal training, the ability to work within a team and quick health problems.
reasoning skills.
Types of Planning
Definition of Nursing: 1. Initial Planning - the nurse who performs the admission assessment usually develops the initial
Florence Nightingale (1860) – “the act of utilizing the environment of the patient comprehensive plan of care.
to assist him in his recovery”
2. Ongoing Planning - the nurses obtain new information and evaluate the client’s responses to care; they
Virginia Henderson (1966) – “the unique function of the nurse is to assist the individual, sick or well, in the can individualize the initial care plan further.
performance of those activities contributing to health or its recovery (or to peaceful death) that he will perform
unaided if he had the necessary strength, will or knowledge, and to do this in such a way as to help him
Gain independence as rapidly as possible.” 3. Discharge Planning - anticipating and planning for needs after discharge, is a crucial part of a
comprehensive health care and should be addressed in each client’s care plan. Because the average stay
American Nurse Association (ANA, 1980) – “Nursing is the diagnosis and treatment of human responses to actual of clients in acute care hospitals has become shorter, people are sometimes discharged still needing care.
or potential health problems.”

GUIDELINES/ PROTOCOL/ TOOLS IN DOCUMENTATION RELATED TO CLIENT CARE

The nurse must consider a variety of factors when assigning priorities, including the following: ✓ Three columns for recording are usually used: (1) date and time, (2) focus, and (3) progress notes.
1. Client’s health values and beliefs. ✓ The data category reflects the assessment phase of the nursing process and consists of
2. Client’s priorities. observations of client status and behaviors, including data from flow sheets (e.g., vital signs, pupil
3. Resources available to the nurse and client. reactivity).
4. Urgency of the health problem. ✓ The action category reflects planning and implementation and includes immediate and future
5. Medical treatment plan. nursing actions. It may also include any changes to the plan of care.

Purpose of Desired Goals/Outcomes

1. Provide direction for planning nursing interventions. For example, the SOAP format is frequently used.
2. Serve as criteria for evaluating client progress. S—Subjective data consist of information obtained from what the client says.
3. Enable the client and nurse to determine when the problem has been resolved. 4. Help motivate the client and O—Objective data consist of information that is measured or observed by the healthcare provider.
nurse by providing a sense of achievement. A—Assessment is the interpretation or conclusions drawn about the subjective and objective data. The “A” entry
❖ As goals are met, both client and nurse can see that their efforts have been worthwhile. This provides should be a statement of the problem.
motivation to continue following the plan, especially when difficult lifestyle changes need to be made. P—Plan of care designed to resolve the stated problem.
The SOAP format has been modified. The acronyms SOAPIE and SOAPIER refer to formats that add interventions,
Guidelines for writing Goals/Outcomes evaluation, and revision.
1. Write goals and outcomes in terms of client responses, not nursing activities I—Interventions refer to the specific interventions that have actually been performed by the caregiver.
2. Be sure that the desired outcomes are realistic for the clients capabilities, limitation, and designated time E—Evaluation includes client responses to nursing interventions and medical treatments. This is primarily
span, if it is indicated. reassessment data.
3. Ensure that the goals and desired outcomes are compatible with other professionals. R—Revision reflects care plan modifications suggested by the evaluation. Changes may be made in desired
4. Make sure that each goal is derived from only one nursing diagnosis. outcomes, interventions, or target dates.
5. Use observable, measurable terms for outcomes.
6. Make sure the client goals/desired outcome are important and values them.

4. Intervention - are the actions that a nurse performs to achieve client goals. The specific interventions
chosen should focus on eliminating or reducing the etiology of the nursing diagnosis.

Guidelines for implementing Intervention

1. The nurse must be aware of the scientific rationale
2. The nurse is responsible for intelligent implementation
3. Adapt activities to the individual client
4. Implement safe care
5. Provide teaching, support and comfort.
6. Be holistic
7. Respect the dignity of the client and enhance the client’s self esteem.
8. Encourage the client to participate actively in implementing the nursing

5. Evaluation –is a planned, ongoing, purposeful activity in which clients and health care professionals
determine (a) the client’s progress toward achievement of goals/outcomes and (b) the effectiveness of
the nursing care plan. Evaluation is an important aspect of the nursing process because conclusions drawn
from the evaluation determine whether the nursing interventions should be terminated, continued, or
changed.

The Evaluation Phase has Five Components:

■ Collecting data related to the desired outcomes ■ Comparing the data with desired outcomes
■ Relating nursing activities to outcomes
■ Drawing conclusions about problem status
■ Continuing, modifying, or terminating the nursing care plan.

Topic 2. Focus, Data, Action, Response (FDAR)

Focus charting is intended to make the client and client concerns and strengths the focus of care.
Republic Act No. 9173

THE PHILIPPINE
NURSING ACT
OF 2002
ARTICLE I
Title
Section 1. Title
 This Act shall be known as the
"Philippine Nursing Act of 2002."
 ARTICLE II
Declaration of Policy
Section 2. Declaration of Policy
 It is hereby declared the policy of the
State to assume responsibility for the
protection and improvement of the
nursing profession by instituting measures
that will result in relevant nursing
education, humane working conditions,
better career prospects and a dignified
existence for our nurses.
 The State hereby guarantees the delivery
of quality basic health services through an
adequate nursing personnel system
throughout the country.
 ARTICLE III
Organization of the Board of
Nursing
Section 3. Creation and
Composition of the Board

 There shall be created a Professional

Regulatory Board of Nursing, hereinafter
referred to as the Board, to be composed
of a Chairperson and six (6) members.
 They shall be appointed by the president
of the Republic of the Philippines from
among two (2) recommendees, per
vacancy, of the Professional Regulation
Commission, chosen and ranked from a
list of three (3) nominees, per vacancy, of
the accredited professional organization of
nurses in the Philippines who possess the
qualifications prescribed in Section 4 of
this Act.
Section 4. Qualifications of the
Chairperson and Members of
the Board
a) A natural born citizen and resident of the
Philippines;
b) A member of good standing of the
accredited professional organization of
nurses;
c) A RN and holder of a master's degree in
nursing, education or other allied
medical profession conferred by a
college or university duly recognized by
the Government: Provided, That the
majority of the members of the Board
shall be holders of a master's degree in
nursing: Provided, further, That the
Chairperson shall be a holder of a
master's degree in nursing;
d) Have at least ten (10) years of continuous
practice of the profession prior to
appointment: Provided, however, That the
last five (5) years of which shall be in the
Philippines; and
e) Never been convicted of any offense
involving moral turpitude; Provided, That
the membership to the Board shall
represent the three (3) areas of nursing,
namely: nursing education, nursing service
and community health nursing.
Section 5. Requirements Upon
Qualification as Member of the
Board of Nursing
 Any person appointed as Chairperson or
Member of the Board shall immediately
resign from:
◦ any teaching position in any school, college,
university or institution offering BSN and/or;
◦ review program for the local nursing board
examinations or;
◦ any office or employment in the government or any
subdivision, agency or instrumentality thereof,
including government-owned or controlled
corporations or their subsidiaries as well as these
employed in the private sector.
 He/she shall not have any pecuniary
interest in or administrative supervision
over any institution offering Bachelor of
Science in Nursing including review
classes.
Section 6. Term of Office
 The Chairperson and Members of the
Board shall hold office for a term of three
(3) years and until their successors shall
have been appointed and
qualified: Provided, That the Chairperson
and members of the Board may be re-
appointed for another term.
 Any vacancy in the Board occurring within
the term of a Member shall be filled for
the unexpired portion of the term only.
Each Member of the Board shall take the
proper oath of office prior to the
performance of his/her duties.
 The incumbent Chairperson and Members
of the Board shall continue to serve for
the remainder of their term under
Republic Act No. 7164 until their
replacements have been appointed by the
President and shall have been duly
qualified.
Section 7. Compensation of the
Board Members

 The Chairperson and Members of the

Board shall receive compensation and
allowances comparable to the
compensation and allowances received by
the Chairperson and members of other
professional regulatory boards.
Section 8. Administrative
Supervision of the Board,
Custodian of its Records,
Secretariat and Support
Services
 The Board shall be under the
administrative supervision of the
Commission. All records of the Board,
including applications for examinations,
administrative and other investigative
cases conducted by the Board shall be
under the custody of the Commission. The
Commission shall designate the Secretary
of the Board and shall provide the
secretariat and other support services to
implement the provisions of this Act.
Section 9. Powers and Duties of
the Board

a) Conduct the licensure examination for

nurses.
b) Issue, suspend or revoke certificates of
registration for the practice of nursing.
c) Monitor and enforce quality standards of
nursing practice in the Philippines and
exercise the powers necessary to ensure
the maintenance of efficient, ethical and
technical, moral and professional
standards in the practice of nursing
taking into account the health needs of
the nation.
d) Ensure quality nursing education by
examining the prescribed facilities of
universities or colleges of nursing or
departments of nursing education and
those seeking permission to open
nursing courses to ensure that standards
of nursing education are properly
complied with and maintained at all
times. The authority to open and close
colleges of nursing and/or nursing
education programs shall be vested on
the Commission on Higher Education
upon the written recommendation of the
Board
e) Conduct hearings and investigations to
resolve complaints against nurse
practitioners for unethical and
unprofessional conduct and violations of
this Act, or its rules and regulations and
in connection therewith, issue subpoena
ad testificandum and subpoena duces
tecum to secure the appearance of
respondents and witnesses and the
production of documents and punish
with contempt persons obstructing,
impeding and/or otherwise interfeming
with the conduct of such proceedings,
upon application with the court
f) Promulgate a Code of Ethics in
coordination and consultation with the
accredited professional organization of
nurses within one (1) year from the
effectivity of this Act
g) Recognize nursing specialty
organizations in coordination with the
accredited professional organization
h) Prescribe, adopt issue and promulgate
guidelines, regulations, measures and
decisions as may be necessary for the
improvements of the nursing practice,
advancement of the profession and for
the proper and full enforcement of this
Act subject to the review and approval
by the Commission.
Section 10. Annual Report
 The Board shall submit an annual report
to the President of the Philippines through
the Commission giving a detailed account
of its proceedings and the
accomplishments during the year and
making recommendations for the adoption
of measures that will upgrade and
improve the conditions affecting the
practice of the nursing profession.
Section 11. Removal or
Suspension of Board Members
 The president may remove or suspend
any member of the Board after having
been given the opportunity to defend
himself/herself in a proper administrative
investigation.
GROUNDS FOR SUSPENSION AND
REMOVAL:
a) Continued neglect of duty or
incompetence
b) Commission or toleration of irregularities
in the licensure examination
c) Unprofessional immoral or dishonorable
conduct
 ARTICLE IV
Examination and
Registration
Section 12. Licensure Examination

 All applicants for license to practice

nursing shall be required to pass a written
examination, which shall be given by the
Board in such places and dates as may be
designated by the Commission in
accordance with Republic Act No. 8981,
otherwise known as the "PRC
Modernization Act of 2000."
Section 13. Qualifications for
Admission to the Licensure
Examination
a) Filipino citizen, or a citizen or subject of
a country which permits Filipino nurses
to practice within its territorial limits on
the same basis as the subject or citizen
of such country: Provided, That the
requirements for the registration or
licensing of nurses in said country are
substantially the same as those
prescribed in this Act;
b) He/she is of good moral character

c) He/she is a holder of a Bachelor's

Degree in Nursing from a college or
university that complies with the
standards of nursing education duly
recognized by the proper government
agency
Section 14. Scope of Examination

 Determined by the Board.

 The Board shall take into consideration
the objectives of the nursing curriculum,
the broad areas of nursing, and other
related disciplines and competencies in
determining the subjects of examinations.
Section 15. Ratings
 In order to pass the examination:

◦a general average of at least

75% with a rating of not below
60% in any subject.
 An examinee who obtains an average
rating of 75% or higher but gets a rating
below 60% in any subject must take the
examination again but only in the
subject/s where he/she is rated below
60%. In order to pass the succeeding
examination, an examinee must obtain a
rating of at least 75% in the subject/s
repeated.
Section 16. Oath
 All passers in the examination shall be
required to take an oath of profession
before the Board or any government
official authorized to administer oaths
prior to entering upon the nursing
practice.
Section 17. Issuance of
Certificate of
Registration/Professional
License and Professional
Identification Card
 A certificate of registration/professional
license as a nurse shall be issued to an
applicant who passes the examination
upon payment of the prescribed fees.
Every certificate of
registration/professional license shall
show the full name of the registrant, the
serial number, the signature of the
Chairperson of the Commission and of the
Members of the Board, and the official
seal of the Commission.
 A professional identification card, duly
signed by the Chairperson of the
Commission, bearing the date of
registration, license number, and the date
of issuance and expiration thereof shall
likewise be issued to every registrant
upon payment of the required fees.
Section 18. Fees for Examination
and Registration

 Applicants for licensure and for

registration shall pay the prescribed fees
set by Commission.
Section 19. Automatic Registration
of Nurses

 All nurses whose names appear at the

roster of nurses shall be automatically
or ipso facto registered as nurses under
this Act upon its effectivity.
Section 20. Registration by
Reciprocity

 A certificate of registration/professional
license may be issued without
examination to nurses registered under
the laws of a foreign state or country:
 Provided, That the requirements for
registration or licensing of nurses in said
country are substantially the same as
those prescribed under this Act:Provided,
further, That the laws of such state or
country grant the same privileges to
registered nurses of the Philippines on the
same basis as the subjects or citizens of
such foreign state or country.
Section 21. Practice Through
Special/Temporary Permit

 A special/temporary permit may be issued

by the Board to the following persons
subject to the approval of the Commission
and upon payment of the prescribed fees:
◦ (a) Licensed nurses from foreign
countries/states whose service are either for a
fee or free if they are internationally well-
known specialists or outstanding experts in any
branch or specialty of nursing;
 ◦ (b) Licensed nurses from foreign
countries/states on medical mission whose
services shall be free in a particular hospital,
center or clinic; and
◦ (c) Licensed nurses from foreign
countries/states employed by schools/colleges
of nursing as exchange professors in a branch
or specialty of nursing;
 Provided, however, That the
special/temporary permit shall be
effective only for the duration of the
project, medical mission or employment
contract.
Section 22. Non-registration
and Non-issuance of
Certificates of
Registration/Professional
License or Special/Temporary
Permit
 No person convicted by final judgment of
any criminal offense involving moral
turpitude or any person guilty of immoral
or dishonorable conduct or any person
declared by the court to be of unsound
mind shall be registered and be issued a
certificate of registration/professional
license or a special/temporary permit.
 The Board shall furnish the applicant a
written statement setting forth the
reasons for its actions, which shall be
incorporated in the records of the Board.
Section 23. Revocation and
suspension of Certificate of
Registration/Professional
License and Cancellation of
Special/Temporary Permit
 The Board shall have the power to revoke
or suspend the certificate of
registration/professional license or cancel
the special/temporary permit of a nurse
upon any of the following grounds:
a) For any of the causes mentioned in the
preceding section;
b) For unprofessional and unethical
conduct;
c) For gross incompetence or serious
ignorance;
d) For malpractice or negligence in the
practice of nursing;
e) For the use of fraud, deceit, or false
statements in obtaining a certificate of
registration/professional license or a
temporary/special permit;
f) For violation of this Act, the rules and
regulations, Code of Ethics for nurses
and technical standards for nursing
practice, policies of the Board and the
Commission, or the conditions and
limitations for the issuance of the
temporarily/special permit; or
g) For practicing his/her profession during
his/her suspension from such practice;
 Provided, however, That the suspension of
the certificate of registration/professional
license shall be for a period not to exceed
four (4) years.
Section 24. Re-issuance of
Revoked Certificates and
Replacement of Lost
Certificates
 The Board may, after the expiration of a
maximum of four (4) years from the date
of revocation of a certificate, for reasons
of equity and justice and when the cause
for revocation has disappeared or has
been cured and corrected, upon proper
application therefore and the payment of
the required fees, issue another copy of
the certificate of registration/professional
license.
 A new certificate of
registration/professional license to replace
the certificate that has been lost,
destroyed or mutilated may be issued,
subject to the rules of the Board.
 ARTICLE V
Nursing Education
Section 25. Nursing Education
Program

 The nursing education program shall

provide sound general and professional
foundation for the practice of nursing.
 The learning experiences shall adhere
strictly to specific requirements embodied
in the prescribed curriculum as
promulgated by the CHED's policies and
standards of nursing education.
Section 26. Requirement for
Inactive Nurses Returning to
Practice
 Nurses who have not actively practiced
the profession for 5 consecutive years are
required to undergo 1 month of didactic
training and 3 months of practicum. The
Board shall accredit hospitals to conduct
the said training program.
Section 27. Qualifications of the
Faculty

 (a) Be a RN in the Philippines;

 (b) Have at least 1 year of clinical practice
in a field of specialization;
 (c) Be a member of good standing in the
accredited professional organization of
nurses; and
 (d) Be a holder of a master's degree in
nursing, education, or other allied medical
and health sciences conferred by a college
or university duly recognized by the
Government of the Republic of the
Philippines.
 The dean of a college must have a
master's degree in nursing. He/she must
have at least five (5) years of experience
in nursing.
 ARTICLE VI
Nursing Practice
Section 28. Scope of Nursing
 A person shall be deemed to be practicing
nursing within the meaning of this Act
when he/she singly or in collaboration
with another, initiates and performs
nursing services to individuals, families
and communities in any health care
setting.
 It includes, but not limited to, nursing
care during
◦ conception,
◦ labor,
◦ delivery,
◦ infancy,
◦ childhood,
◦ toddler,
◦ preschool,
◦ school age,
◦ adolescence,
◦ adulthood, and
◦ old age.
 As independent practitioners, nurses are
primarily responsible for the promotion of
health and prevention of illness.
 As member of the health team, nurses
shall collaborate with other health care
providers for the curative, preventive, and
rehabilitative aspects of care, restoration
of health, alleviation of suffering, and
when recovery is not possible, towards a
peaceful death.
It shall be the duty of the nurse to:
(a) Provide nursing care through the
utilization of the nursing process. Nursing
care includes:
 traditional and innovative approaches,
 therapeutic use of self,
 executing health care techniques and
procedures,
 essential primary health care,
 comfort measures,
 health teachings, and
 administration of written prescription for
treatment, therapies, oral topical and
parenteral medications, internal
examination during labor in the absence
of antenatal bleeding and delivery.
 In case of suturing of perineal laceration,
special training shall be provided
according to protocol established;
(b) establish linkages with community
resources and coordination with the
health team;
(c) Provide health education to individuals,
families and communities;
(d) Teach, guide and supervise students in
nursing education programs including the
administration of nursing services in
varied settings such as hospitals and
clinics; undertake consultation services;
engage in such activities that require the
utilization of knowledge and decision-
making skills of a registered nurse; and
(e) Undertake nursing and health human
resource development training and
research, which shall include, but not
limited to, the development of advance
nursing practice;
 This section shall not apply to nursing
students who perform nursing functions
under the direct supervision of a qualified
faculty.
 In the practice of nursing in all settings,
the nurse is duty-bound to observe the
Code of Ethics for nurses and uphold the
standards of safe nursing practice.
 The nurse is required to maintain
competence by continual learning through
continuing professional education to be
provided by the accredited professional
organization or any recognized
professional nursing
organization: Provided, That the program
and activity for the continuing
professional education shall be submitted
to and approved by the Board.
Section 29. Qualification of
Nursing Service Administrators
a) Be a RN in the Philippines;
b) Have at 2 years experience in general
nursing service administration;
c) Possess a degree of Bachelors of Science in
Nursing, with at least nine (9) units in
management and administration courses at
the graduate level; and
d) Be a member of good standing of the
accredited professional organization of
nurses;
 Provided, That a person occupying the
position of chief nurse or director of
nursing service shall, in addition to the
foregoing qualifications, possess:

◦ (1) At least 5 years of experience in a

supervisory or managerial position in
nursing; and
◦ (2) A master's degree major in nursing;
 Provided, further, That for primary
hospitals, the maximum academic
qualifications and experiences for a chief
nurse shall be as specified in subsections
(a), (b), and (c) of this section:
 Provided, furthermore, That for chief
nurses in the public health nursing shall
be given priority.
 Provided, even further, That for chief
nurses in military hospitals, priority shall
be given to those who have finished a
master's degree in nursing and the
completion of the General Staff Course
(GSC):
 Provided, finally, That those occupying
such positions before the effectivity of this
Act shall be given a period of five (5)
years within which to qualify.
 ARTICLE VII
Health Human Resources
Production, Utilization and
Development
Section 30. Studies for Nursing
Manpower Needs, Production,
Utilization and Development
 The Board, in coordination with the
accredited professional organization and
appropriate government or private
agencies shall initiate undertake and
conduct studies on health human
resources production, utilization and
development.
Section 31. Comprehensive
Nursing Specialty Program
 The Board in coordination with the
accredited professional organization,
recognized specialty organizations and the
DOH is mandated to formulate and
develop a comprehensive nursing
specialty program that would upgrade the
level of skill and competence of specialty
nurse clinicians in the country, such as to
the areas of critical care, oncology, renal
and such other areas as may be
determined by the Board.
 The beneficiaries of this program are
obliged to serve in any Philippine hospital
for a period of at least 2 years and
continuous service.
Section 32. Salary
 The minimum base pay of nurses working
in the public health institutions shall not
be lower than salary grade 15 prescribes
under Republic Act No. 6758, otherwise
known as the "Compensation and
Classification Act of 1989":
 Provided, That for nurses working in local
government units, adjustments to their
salaries shall be in accordance with
Section 10 of the said law.
Section 33. Funding for the
Comprehensive Nursing
Specialty Program
 The annual financial requirement needed to
train at least 10% of the nursing staff of the
participating government hospital shall be
chargeable against the income of the PCSO
and PAGCOR, which shall equally share in the
costs and shall be released to the DOH
subject to accounting and auditing
procedures: Provided, That the DOH shall set
the criteria for the availment of this program.
Section 34. Incentives and
Benefits

 The BON, in coordination with the DOH

and other government agencies,
association of hospitals and the accredited
professional organization shall establish
an incentive and benefit system.
 In the form of:
◦ free hospital care for nurses and their
dependents,
◦ scholarship grants and
◦ other non-cash benefits.

 The government and private hospitals are

hereby mandated to maintain the
standard nurse-patient ratio set by the
DOH.
 ARTICLE VIII
Penal and Miscellaneous
Provisions
Section 35. Prohibitions in the
Practice of Nursing

 A fine of not less than P50,000 nor more

than P100,000 or imprisonment of not
less than 1 year nor more than six 6
years, or both, upon the discretion of the
court, shall be imposed upon:
A. any person practicing nursing in the
Philippines within the meaning of this
Act:
1. without a certificate of
registration/professional license and
professional identification card or
special temporary permit or without
having been declared exempt from
examination in accordance with the
provision of this Act; or
2. who uses as his/her own certificate of
registration/professional license and
professional identification card or
special temporary permit of another;
or
3. who uses an invalid certificate of
registration/professional license, a
suspended or revoked certificate of
registration/professional license, or an
expired or cancelled special/temporary
permits; or
4. who gives any false evidence to the
Board in order to obtain a certificate of
registration/professional license, a
professional identification card or
special permit; or
5. who falsely poses or advertises as a
registered and licensed nurse or uses
any other means that tend to convey
the impression that he/she is a
registered and licensed nurse; or
6. who appends B.S.N./R.N. or any
similar appendage to his/her name
without having been coferred said
degree or registration; or
7. who, as a registered and licensed
nurse, abets or assists the illegal
practice of a person who is not lawfully
qualified to practice nursing.
B. any person or the chief executive officer
of a judicial entity who undertakes in-
service educational programs or who
conducts review classes for both local
and foreign examination without
permit/clearance from the Board and the
Commission; or
C. any person or employer of nurses who
violate the minimum base pay of nurses
and the incentives and benefits that
should be accorded them as specified in
Sections 32 and 34; or
D. any person or the chief executive officer
of a juridical entity violating any
provision of this Act and its rules and
regulations.
 ARTICLE IX
Final Provisions
Section 36. Enforcement of this
Act
 It shall be the primary duty of the
Commission and the Board to effectively
implement this Act. Any duly law
enforcement agencies and officers of
national, provincial, city or municipal
governments shall, upon the call or
request of the Commission or the Board,
render assistance in enforcing the
provisions of this Act and to prosecute
any persons violating the same.
Section 37. Appropriations
 The Chairperson of the Professional
Regulation Commission shall immediately
include in its program and issue such
rules and regulations to implement the
provisions of this Act, the funding of
which shall be included in the Annual
General Appropriations Act.
Section 38. Rules and Regulations.
 The Board and the Commission, in
coordination with the accredited
professional organization, the DOH, the
Department of Budget and Management
and other concerned government
agencies, shall formulate such rules and
regulations necessary to carry out the
provisions of this Act. The implementing
rules and regulations shall be published in
the Official Gazette or in any newspaper
of general circulation.
Section 39. Reparability Clause
 If any part of this Act is declared
unconstitutional, the remaining parts not
affected thereby shall continue to be valid
and operational.
Section 40. Repealing Clause
 Republic Act No. 7164, otherwise known
as the "Philippine Nursing Act of 1991" is
hereby repealed. All other laws, decrees,
orders, circulars, issuances, rules and
regulations and parts thereof which are
inconsistent with this Act are hereby
repealed, amended or modified
accordingly.
Section 41. Effectivity
 This act shall take effect fifteen (15) days
upon its publication in the Official
Gazette or in any two (2) newspapers of
general circulation in the Philippines.
Different fields of
nursing
1. Hospital or institutional Nursing
2. Public Health Nursing or Community
Health Nursing
3. Private Duty Nursing
4. Nursing Education
5. Military Nursing
6. School Health Nursing
7. Clinic Nursing
8. Advance Practice Nursing
9. Independent nursing Practice
Hospital or institutional Nursing
Nursing in hospital and related health
facilities such as extended care facilities,
nursing homes and neighbourhood clinics,
compromises the entire basic component
of comprehensive patient care and family
health. The concept of the modern
hospital as a community health center
where in-patient and out-patient care are
continuous describe the goal of medical
care in most general hospital.
The educational qualification for beginning
practitioner is a Bachelor of Science in
nursing degree. The nurse perform
nursing measure that will meet the
patient’s physical, emotional , social and
spiritual health needs while in the
institution and helps him and family plan
for his further health care needs when he
returns homes.
The nurses function involve assessment of
the patient needs for nursing and
planning for giving or providing the care
indicated whether this be personal care,
rehabilitation measure or health
instruction.
Advantages of Staff Nursing in
Hospital
1. There is always a supervisor whom one
can consult if problems exist.
2. Nurses are updated with new trends in
medicine and in the nursing care of
patient.
3. They undergo rotation to different units
and have a chance to determine their
special area of choice before they are
assigned permanently in one area such
as medicine, paediatrics, surgery , ICU-
CCU, Obstetrics, Operating Room,
Delivery Room.etc
4. They have an eight –hour day and a
forty- hour week duty which provide for
two days of rest away from duty. They
have provisions for sick leaves, holidays
and vacations with pay acc.. to
personnel policies of the institution.
5. They have the chance to get promoted
to higher positions if they are qualified.
6. Salary increase are given periodically
acc. To merit system thereby increasing
their initiative and best efforts.
7. They are considered an important
member of the health team in providing
care to the pt.
8. More staff development programs are
available in hospitals.
Disadvantages of Staff Nursing
in Hospital
1. There is a great possibility of
understaffing w/c may require nurses to
put in overtime work and sacrifice some
of their plans. This is especially true in
hospitals where budget for personnel is
limited
2. Because of the bulk of works, some staff
nurses do not find time to improve their
skills through continuing education
program. Or, if the hospitals are far-
flung, no continuing education programs
are provided.
3. Administrative problems and overworks
may tend to dissatisfy the staff nurse
Qualifications of Nursing
Service Administration
Section 29 of RA 9173 specifies that a
person occupying supervisory or
managerial positions requiring knowledge
of nursing must:
◦ Be a registered nurse in the Philippines
◦ Have at least two (2) years of experience in
general nursing service administration
◦ Possess a degree of Bachelor of Science in
Nursing, with at least nine (9) units in
management and administration courses at the
graduate level; and
◦ Be a member of good standing of the
accredited professional organization of nurses
 Chief Nurse or Director of Nursing
Service Shall in addition to the
foregoing qualification, possess;
◦ At least five(5) years of experience
in a supervisory or managerial
position in nursing
◦ A master’s a degree major in
nursing
Memorandum Circular No. 2000-05, series
of 2000 of the Professional Regulation
Commission, Board of Nursing, mandates
the implementation of this provision of the
Philippine Nursing Act.
Nursing Specialty Certification
In this country, a nursing Specialty
Certification Program has been adopted
by the Board of Nursing through the
resolution No. 14 series of 1999, and
created a Nursing Certification Council
under it to oversee the administration of
new programs by the Specialty
Certification Boards.
Sec. 29. Comprehensive Nursing Specialty
Program. -Within ninety (90) days from
the effectivity of this act. The Board in
coordination with the accredited
professional organization, recognized
specialty organization and the
Department of Health is hereby mandated
to formulate and develop a
comprehensive nursing specialty program.
The beneficiaries of this program are
obliged to serve in the Philippines hospital
period of atleast two (2) years of
continuous service.
Sec.33. Funding for the Comprehensive
Nursing Specialty Program. The annual
financial requirement needed to train at
least ten percent (10%) of the nursing
staff of the participating government
hospital shall be chargeable against the
income of the Philippines Charity
Sweepstakes Office and the Philippines
Amusement and Gaming Corporation .
Benefits of Certification
 Nurses certified above minimum standard
improve the quality of patient care.
 Certification measure expertise beyond
that which is measured in basic licensure.
 Certification ensures continued
competence in the changing world of the
health care.
 Certification means of confronting the
demands of health care.
 It is lifelong learning that advance nursing
skill and knowledge to move the
profession forward.
 It enhances the nurse’s self image and
the public’s view of the profession.
Public Health Nursing or
Community Health Nursing

 Prevention is better than Cure.

Advantages of Public Health
Nursing
 The focus of nursing care is only on family
and community health rather than on
individual basis. Here, the nurse will be able
to see the total picture of family and
community health.
 It gives burse better perspective of the
health conditions of the community and the
health programs conceived and implemented
by the government, and to appreciate the
nurse’s role in nation building.
 It maximizes effort to improvise where there
are no sufficient facilities, supplies, and
equipment.
 It enables the nurses to utilize various
community resources and maximize
coordination with other member of the health
team.
 Focus of care is more on educational and
preventive aspects. Thus, nurses have the
privileges of contributing to the program for
healthy citizenry especially among the rural
poor.
 Individuals, families and communities are
motivated to assume responsibility for their
own health care.
Disadvantages of Public Health
Nursing
 Cases found in public health nursing are
limited mostly to chronic and/or
communicable diseases.
 There are more hazards in public health than
in hospital nursing, such as exposure to
elements (inclement weather, heat of sun
rain), dog or snake bites, accidents, etc.
 There are no fixed hours of work. the nurse
maybe called upon any time of the day or
night
 Sometimes claim that public health
nursing is not exciting or as glamorous as
hospital work.
 Facilities for care of the sick are limited so
that practice or skills may also limit.
 The public health nurse may not be
immediately aware of changes or trends
in the field of medicine or nursing.
 Public health nursing is not a place for
introverts. a nurse has to be outgoing to
meet people
 There is no immediate supervisor to
consult in case of emergency.
NURSES IN THIS FIELD NEED:
 Skills in nursing practice, therefore they must
have experience of at least two years basic
nursing practice.
 Understanding of skills in teaching
supervision and consultation.
 Understanding of the relationship of this
person to the process of administration and
research.
 understanding of the broad problem and
desirable practices in patient care planning
 understanding of and skill in the use of
problem solving approach to solve
everyday problems in the practice of
nursing and in service education in the
areas of concern
 understanding of the role and function of
there revising personnel in this area of in
service education
 Understanding or self and other involved
in in-service education within the various
agencies in nursing; and
 Ability to plan and implement programs
for different kinds of nursing personnel
Private Duty Nursing
A private nurse is a registered nurse who
undertakes to give comprehensive nursing
care to a client on a one on one ratio,
she/he is an independent contractor. The
patient may be provided care in the
hospital or in the home.
Private duty nurse practitioner are
grouped into two categories

1. General Private Duty Nurse

2. Private Duty nurse specialist
1. General Private Duty Nurse- it has
the capability for providing basic nursing
care at any type of patient, among which
are;
◦ Assessment of the physical conditions
and interpretation of the significance of
hi/her findings as basis for planning the
nursing care.
◦ Identification of emotional and social
factors and relating these to sign and
symptoms observed.
◦ Application of scientific principles in the
performance of nursing techniques.
◦ Working with pts. Family so that they
gain understanding of his/her illness and
cooperate toward promoting early
recovery of the pt.
◦ utilization of laboratory ad diagnostic
test in promoting progress of care and
enhancing his/her own usefulness as a
health teacher and counsellor
◦ knowledge and recognition of
pharmacological effects of drugs and
medication, their implication for nursing
actions as needed
◦ interpretation of doctor’s orders
concerning medicines and treatment and
communicating at the same effectively
to the patient and carrying them out
2. Private Duty nurse specialist-
foregoing abilities expected of the
general nurse practitioner and as a
result of his or her specialized
preparation a private nurse specialist
should also demonstrate the ff.
◦ skill in handling , operating and
monitoring other complicated
devices
◦ interpreting ECG, EEG, laboratory
result
◦ skill in observing s/s and their
favourable or untoward significance
in the progress
◦ promptness and adeptness in
instituting appropriate nursing
measures
Occupational health nursing or
industrial nursing
 In 1958 industrial nurses in the United States
elected to call themselves occupational health
nurses to reflect the broader and changing
scope of practice within the specialty. The
practice focuses on promotion, protection,
and supervision of workers health within the
context of a safe and healthy worker
environment. it is autonomous and
occupational health nurses make independent
nursing judgement in providing health
services.
 Most occupational nurses have to bargain
individually for there salaries. Only few
employers hire enough nurses to make up
a bargaining unit. This is hurt salaries in
industrial nursing to an extent and pay is
probably less than in hospital work. But
there a compensation. Often nurse
working only during day hour... There are
a seniority wage increases, pension and
insurance.
Nursing Education
 Career opportunities in nursing education
are better today than ever before. There
is a chronic teacher shortage in all nursing
education programs. Nurses who like to
consider teaching as their field expertise.
 is an interesting, important, and
challenging field and the opportunities for
well prepared nursing educator are
numerous
Personal qualities and special
abilities of faculty member
include;
 capability to promote interest in the
subject they teach ; s
 competence in the particular field they
teach
 resourcefulness with infinite patience
 expertise in providing nursing care in the
chosen field
Military Nursing
The Nurse Corps (NC)
 History:
◦ Military nursing in the Philippines may said
to have begun in the time of “Tandang
Sora” during the katipunan revolution in
1890.
◦ Commonwealth Act No. 1 “National Defense
Act”
 Provided for the establishment of a medical
service in the Philippine army.
 However, the component corps was not specified.
◦September 5, 1938
the national defense act was
amended by commonwealth act
no. 385 whereby the different
corps of the medical services was
explicitly spelled out, with the
nurse corps being one of them.
Date celebrated by the nurse
corps as its foundation day.
◦ May 12, 1948
 Approval of R.A. 203 by Pres. Elpidio
Quirino
 Placing the nurse corps in proper
perspective among the other military
organizations.
◦ June 10, 1950
 R.A. 203 was amended by R.A. 479
 It provide basis for determining the
grade and rank, seniority, and
retirement of NC officers.
 ◦ August 1952
 Title Army Nurse Corps, Medical
Service was changed to Nurse Corps,
AFP.
 Elvegia R. Mendoza
◦ The first military nurse to hold the
rank of Brigadier General.
Functions of the NC, AFP:
 3 broad areas:
1. To meet the nursing needs of today’s
patient in AFP medical facilities.
2. To prepare each NC officer for future
assignments at a higher level of
responsibility in the different stations and
general hospitals in times of peace and war.
3. To teach and train enlisted personnel who
perform nursing functions under
supervision. Special emphasis is on enlisted
members who function in settings where
there are no nurses.
Qualifications of the Military
Nurse:
 Principle: The nurse consciously and
scientifically intervenes in the health and
illness environment for the purpose of
ensuring that the soldier, his family and other
significant groups will have adequate
personal care, maintenance, safety, and
comfort.
 Rationale: the military nurse works at
different health settings with various levels of
responsibilities. As such, he/she must have
the professional, personal and other
qualifications commensurate with job
responsibilities.
Criterion I- qualifications for
commission in the reserve force,
NC:
 BSN degree
 Licensed to practiced nursing
 Natural born-Filipino citizen
 Single or never been married for both male and
female. Female applicants must not positively be
found to have given birth to a living or still born
child.
 Mentally and physically fit
 Pleasing personality and good moral character
 Skilled in:
1.Applying the nursing process in meeting
health/nursing needs of
individuals/families/groups/communities
2.Communicating and relating with others
3.Making sound/rational judgment in a given
situation
 Willing to work during peace and war
 Not more than 32 years old
 Height: 62 inches for males and 60
inches for female
Qualifications for commission in
the regular force, NC:

 Passed the rigid screening and battery

test for the purpose
 Height: 64 inches for males and 62 inches
for female
 Not more than 26 years old
Qualifications for Call to Active
Duty (CAD)

 Must be commissioned
 At least 1 year nursing experience in a reputable
health agency
 Cleared by appropriate security agency
 Passed the physical and mental exam
Qualifications for General Duty
Nurse

 Must have rank of 2nd lieutenant

 Have adequate knowledge of general nursing
theory and practice, including about
biological, social, and medical science and
their application
 Knowledge on latest development in nursing
field
 Perform comprehensive nursing care
Benefits and privilege of a military
nurse:

1. Highly salary rate and allowances according

to rank:
a. 2nd Lieutenant- initially receives the same base
pay as officers of equivalent ranks.
b.Flight pay for flight nurses- 50% of base pay
c. Hazard pay- 20% of base pay
d.Cold weather clothing allowance
e. Overseas pay
2. Glamour and prestige of the uniform, rank and position
3. Free hospitalization and medical benefits for parents,
dependents, authorized relatives with specialists’ care.
4. Military schooling and basic training at the Armed
Forces Medical Service School at V. Luna Medical
Center (VLMC).
5. Opportunity to meet people who hold key positions in
the AFP and in government
6. Opportunity to attend gala, social functions and parade
7. Opportunities to travel abroad
Flight Nursing- one field of nursing that is
considered peculiar only to the military
and to the Air Force is flight nursing or
aero-space nursing. A flight nurse is
responsible for patients, military or
otherwise, who have been evacuated from
battle areas to the nearest installation for
treatment.
School Health Nursing
Responsible for the school’s activities in the
areas of health service, health education
and environmental health and safety.
Responsibilities:
1. Organizing and implementing the school
health programs
2. Coordinating school health programs
3. Undertaking functions directly related to
pupil’s health
4. Evaluating school health programs
5. Carrying out functions related to the health of
school personnel.
 Advantage:
Hours are usually good and there is no shift
duty.
 Disadvantage:
Unaware of changes in the nursing practice
due to lack of updates.
Clinic Nursing
Teaching patients and their families has
become an important function of the clinic
nurse. Nurse in this field must have
excellent teaching and communication
skills, exhibit organizational and
leadership ability, possess good
assessment skills, and have good insight
in order to anticipate and interpret the
needs of their patients.
Advance Practice Nursing
An umbrella term for nurses who have
specialized education and experience
beyond the basic nursing program. This
field covers the roles of the clinical nurse
specialist.
Independent nursing Practice
Nurse is self-employed and provides
professional nursing services to clients
and their families.
Predicted outcomes of the new
role of nurses as Independent
Nurse Practitioner:
The growing interest in independent nursing practice is
expected to contribute much to the improvement of
health care in the country.
1. It will encourage professional nurses to extend their
capabilities and assume greater responsibilities for
designated areas of generalized nursing practice.
2. The amount of health care will be more
increased and accessible to people.
3. The nurse’s involvement in the client’s
family or community will increase the
nurse’s sensitivity and response to their
client’s needs.
4. Improvement of health services will
help prevent serious illnesses and
maintain positive community health
programs.
5. It will provide data for nursing
education, to validate and legitimize
extended role practices for nurses.
THE END
THANK YOU!!!
 Fundamentals of Nursing
 Self-esteem
THEORETICAL FOUNDATIONS OF NURSING  Love and belongingness
Theory – set of concepts to explain a phenomenon
Paradigm – pattern  Safety and Security
o Being free from harm or danger
4 Metaparadigms of Nursing o 2 forms: Physical safety (free from physical harm)
 Person - Most important because knowing the client will and Psychological safety (explaining the
make your nursing care individualized, holistic, ethical, and procedure to the patient)
humane.  Physiologic (priority)
 Health o If all the needs are within the physiologic level
 Environment High Priority needs – (life threatening needs) Airway,
 Nursing Breathing, Circulation
Medium priority needs – (Health threatening needs)
Concepts of Man Elimination, Nutrition, Comfort,
 Man is a bio-psychosocial and spiritual being who is in Low Priority needs – (Person’s developmental needs)
constant contact with the environment.
 Man is an open system in constant interaction with a NURSING THEORISTS
changing environment. Florence Nightingale
 Man is a unified whole composed of parts, which are  Environment Theory
interdependent and interrelated with each other.  May 12, 1830 – August 13, 1910
 Man is composed of parts, which are greater than and  Environmental sanitation
different from the sum of all his parts.
o Simply saying, you cannot remove 1 system from Hildegard Peplau
man.  Psychodynamic Theory of Nursing
 Man is composed of subsystems and suprasystems.  Interpersonal Process
o Subsystem (within) Example: biological,  Phases of Nurse-patient relationship:
psychological, emotional. 1. Orientation (client seeks)
o Suprasystem (outside) Example: Family, 2. Identification (independence, dependence)
community, population 3. Exploitation (accept service of nurse)
4. Resolution
CONCEPTS OF NURSING
Florence Nightingale Virginia Henderson
 Act of utilizing the environment of the patient to assist him  14 Fundamental needs of the person
in his recovery.
Faye Abdellah
Sister Callista Roy  Typology of 21 Nursing problems
 Theoretical system of knowledge that prescribes a process  Patient-centered approach
of analysis and action related to the care of the ill person. o The client’s needs are the basis of the nursing
problems
Martha Rogers Lydia Hall
 Nursing is a humanistic science dedicated to the  3 C’s:
compassionate concern with maintaining and promoting 1. Core (therapeutic use of self) – Patient
health and preventing illness and caring for and 2. Care (nursing function) – Nurse
rehabilitating the sick and disabled. 3. Cure (medical) – Doctor
o Levels of prevention
 Primary – Health promotion and disease Jean Watson
prevention  Human Caring Theory
 Secondary – Treatment, curative  Caring is an innate characteristic of every nurse.
 Tertiary – Rehabilitation  10 Carative factors

Ida Jean Orlando-Pelletier

Dorothea Orem (Self-care and Self-care deficit theory)
 Dynamic Nurse-Patient Relationship Model
 Helping or assisting service to persons who are wholly or
 Nursing Process Theory
partly dependent, when they, their parents and guardians,
o Nursing as a process involved in interacting with
or other adults responsible for their care are no longer able
an ill individual to meet an immediate need.
to give or supervise their care.
 Four Practices Basic to Nursing
o I.e. – completely assisted, partially assisted, and
o Observation, reporting, recording, and actions
self-assisted.
Madeleine Leininger
ANA (American Nurses Association)
 Transcultural Theory of Nursing
 Nursing is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury,
Myra Levine
alleviation of suffering through the diagnosis and
 4 Principles of Conservation
advocacy in the care of individuals, families, communities,
1. Conservation of energy
and populations (2003).
2. Conservation of structural integrity of the body
3. Conservation of personal integrity
Abraham Maslow’s Hierarchy of needs
4. Conservation of social integrity
 Self-actualization

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing

Sister Callista Roy

 Adaptation Model FILIPINO NURSING THEORISTS
 Individuals cope through biophysical social adaptation
 4 mode of adaptation Carmencita Abaquin
o Role function, interdependence, physiological,  Chairman of Board of Nursing
self-concept  PREPARE ME intervention
 P – presence which in
Dorothea Orem  RE – reminisce therapy
 Self-care and Self-care Deficit Theory  P - prayer
 Universal self-care requirement (nutrition, oxygenation),  Re - relaxation
developmental self-care requirement (developmental  ME – medication
tasks), health care deviation self-care requirement
 3 Nursing systems: wholly compensatory ,partially Sr. Caroline Agravante
compensatory, supportive-educative compensatory  The CASAGRA Transformative Leadership model
 5 C’s for Transformational leadership: creative, caring,
Dorothy Johnson critical, contemplative, collegial
 Behavioral Systems Theory
 Man is composed of subsystems and these systems exist in Carmelita Divinagracia
dynamic stability.  COMPOSURE Behavior for wellness
 COMpetence
Martha Rogers  Presence of Prayer, Open mindedness, Stimulation,
 Science of Unitary Human Being Understanding, Respect, Relaxation, Empathy
 Unitary man is an energy field in constant interaction with
the environment. Mila Delia Llanes
 Conceptual model on Core Competency Development
Imogene King
 Goal Attainment Theory Ma. Irma Bustamante
 Interacting systems framework - The effects of the Nursing Self-Esteem Enhancement
 Nurses purposefully interact with the patient and mutually (NurSe) Program to the Self-Esteem of Filipino Abused
set the goal, explore, and agree to means to achieve the Women
goals.
Sr. Letty Kuan
Betty Neuman - Retirement and Role Discontinuity
 Total Person Model
 3 types of stressors: intra-personal, extra personal, St. Elizabeth of Hungary - Patroness of nurses
interpersonal St. Catherine of Siena – The 1st lady with the lamp
 Primary, secondary, tertiary levels of prevention Clara Barton – Founder of American Red Cross
 The goal of nursing is to assist individual families and groups Fabiola – Wealthy Matron who donated her wealth to build a
in attaining and maintaining a maximal level of total hospital the Christian world
wellness by purposeful interventions. T. Fliedner – Founder of the first organized school of nursing
Rose Nicolet – Helped establish the first school of nursing in the
Parse Philippines
 Theory of Human Becoming Lilian Wald – Founder of Public Health Nursing
 emphasizes how individual chose and bear responsibility
for patterns of personal health
HISTORICAL DEVELOPMENT OF NURSING
Patricia Benner
 Novice – Expert Theory Intuitive
Stage 1: Novice - Practiced during the prehistoric, nursing was untaught,
Stage 2: Advance beginner rendered by the mothers (by intuition, it is the woman who
Stage 3: Competent (2-3 years) is more caring).
Stage 4: Proficient (3-5 years) - Out of love, sickness caused by black spirits, based on
Stage 5: Expert instinct
 Skills acquisition - Shamans, spells, rituals

Joyce Travelbee *Trephining – boring a hole into a skull without anesthesia to release
 Human to Human Relationship evil spirits
*Egyptians – art of embalming, anatomy and physiology
Ernestein Weidenbach *Moses – Father of Sanitation, asepsis, art of circumcision
 Clinical Nursing: A Helping Art *China – material medica – book of pharmacology
*Babylonians – Bill of Rights, Code of Hammurabi (made by King
Nola Pender Hammurabi which include freedom to refuse treatment), medical
 Health Promotion Model fee
*India – Shushurutu – list of function of the nurse – combination of
masseur, caregiver

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
*Romans – Fabiola – a rich matron who contributed her home to - First true nursing law
serve as first hospital - Board of Examiner for Nurses (BEN)
- 1 Doctor and 2 Nurses
- 1920 – First board examination
Apprentice - Anna Dulgent – first board exam topnotcher
- Known as the “on the job training” period, under the  GN Program (Graduate Nurse) – 1 year
supervision of a more experienced person, but yet there is  After World War II, BSN degree for four years was given by
no formal education. UST (1946). Managerial, teaching and supervision position.
- Experienced (through trial and error) nurse teaches new Equal to Master’s degree.
volunteer nurses who usually came from religious orders  RA 877 – BEN is composed of BSN
- Nursing the sick and wounded from the wars  1966 – Master’s degree needed
- Charles Dickens – novel “Martin Chuzzlewit” about Sairy  RA 6136 – can administer intravenous meds as long as
Gump and Betsy Prag (exemplification of nurses in the Dark physician, violaion of professional autonomy; did not
Period of Nursing) materialize but instead nurse prepared medication and
- Pastor Theodore Fliedner (Protestant) – first training school doctor administered until 1992 but it had conflict with the
for Nursing, “Deaconess School of Nursing”, 6 months drug administration principle of “administer what you
program at Kaiserswerth,Germany prepare”
-  1960s – 5-year curriculum
Educated  1976 – 4-year curriculum; GN program was phased out,
Florence Nightingale School of Nursing practicing GNs must go back to 4th year to earn a BSN
- First theory author, first nurse-researcher degree but they won’t take board exam anymore since
- Lady with a Lamp/ Mother of Modern Nursing they are already licensed
- 3 months of study from Kaiserswerth  1980 – overlapping of 4 and 5 year curriculum graduates
- Developed her own training “Nightingales System of  RA 7164 (1992) – IV training for nurses by ANSAP, signed by
Nursing Education” which is implemented in St. Thomas Cory Aquino, valid only after 2 months
Hospital in London  RA 9173 (2002) – New Nurse Practice Act
- Correlate theory and practice, updates, continuing
education, research, self-supporting nursing school HEALTH, DISEASE, AND ILLNESS
(separate from hospital)
- Changed image of nursing, revolutionized practice Health – Defined as the merely the absence or presence of disease
- Professionalized as a nursing or infirmity. WHO defined health is a state of complete physical,
- Notes of Nursing: What it is, What it is not, Notes on mental, and social well-being and not just merely the absence of
Hospitals disease or infirmity.
Nursing as a profession is not as old as mankind but nursing as an act
itself is. Disease – Malfunctioning of the body system.

Contemporary Illness – It is a state wherein the person’s physical, emotional, and

- Modern nursing practice social well-being is thought to be diminishing. Felt by the patient. It is
highly subjective.
Anastacia Giron-Tupas  2 types
- Grand lady of Philipine Nursing o Acute – Sudden onset, short duration, may or
- Founded PNA may not require immediate intervention.
Hilaria Aguinaldo – Development of Red Cross o Chronic – Gradual/slow onset, long duration,
Loreto Tupas – Florence Nightingale of Iloilo lessen complications or debilitating effects of the
Melchora Aquino – Tandang Sora condition for the client to be able to function
given the limitations of the condition.
HISTORY OF NURSING IN THE PHILIPPINES
Models of Health
 First hospital – Hospital de Real de Manila (1577)
 1578 – San Lazaro Hospital, Intramuros – leprosy and mental Judith Smith
illness Clinical Model
 Hospital de San Gabriel – Chinese General Hospital - Absence of the signs and symptoms of a disease.
 Aliping sagigilid and aliping namamahay – first volunteer - Narrowest
nurses who served as apprentice in the first hospitals Role Performance Model
 1878 – Escuela de Practicantes (UST) - Able to perform job
– First school for Nursing (short-lived) Adaptive Model
 1906 – Iloilo Mission Hospital School for Nursing - Capable of adjusting
– 6 months training, no board exam (NON-EXISTENT) - Although there is infirmity, he is able to find ways to cope.
 Mission Hospital (1901) – still existent Eudemonistic Model
 1907 – PGH Hospital, St. Lukes Hospital, St. Paul Hospital - Individual is able to achieve the apex of Maslow’s
 Normal Hall in PNU is used as training ground – Same Hierarchy of needs (self-actualization).
instruction (central school idea) for 6 months then go back - Maximization of potential and mission in life
to hospital - Fulfillment of his purpose in life
 Act 2493 (1915) – Medical act which included Sec.7 & 8
about nursing practice which mandated registration and Levell and Clark
examination Ecologic Model of Health
 Act 2808 (1919) - Epidemiological triad –agent, host, environment

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
- Any of these triad must be manipulated or enhanced to Distress – harmful to health
maintain health Body adapts to the changes in the environment which leads to
Homeostasis (Walter B. Cannon)
Cloud Bernard – called homeostasis as “therapeutic milieu”
Multiple Causation Theory of Disease
- health is affected by different factors in the environment Adaptation - change to maintain integrity of the environment
Rosenstoch – Becker’s Health Belief Model
- Individual perception affect modifying factors which may Models of Adaptation
influence likelihood of action Biological/Physiological – GAS and LAS; compensatory physical
changes
Travis’ Illness-Wellness Continuum Emotional/Psychological – involves a change in attitudes or
- Health is in a spectrum which moves into polarity of behavior
directions Socio-cultural – changes in the person’s behavior in accordance
- Premature of death  Disability/Disease  Symptoms  with norms, conventions and beliefs of various groups.
Signs  Awareness  Education  Growth  High level Technological – involves the use of modern technology
wellness
Principles of Homeostatic Mechanisms
Dunn’s High Level Wellness Grid - Automatic, self-regulatory
- Health-illness Continuum - Compensatory
- health axis “Favorable/Unfavorable environment” - Negative feedback except for uterine contraction during
Quadrants: labor
1. High level wellness in a favorable environment - Has limits
2. Emergent high levels in Level Wellness in an One physiologic error is corrected by several homeostatic
unfavorable environment mechanisms
3. Poor Health in an Unfavorable Environment
4. Poor health in a favorable environment STRESS RESPONSE
Lazarus’ Stress Response Theory
Schumann’s Stages of Illness Behaviors General Adaptation Syndrome (GAS) – a physiological response is a
1. Symptom experience systemic response
2. Assumption of sick role Local Adaptation Syndrome (LAS) - Only a part of the body
3. Medical care contact
4. Dependent client role General Adaptation Syndrome Stages
5. Convalescence/ Rehabilitation  Alarm
- Awareness of stressor
Opposite of health is illness, not disease - Increase in vital signs
- Mobilization of defense
STRESS - Decreased body resistance
 Organisms reacts as a unified whole - Increased hormone level
 Fabric of life  Resistance
- Repel of stressor; overcome
Models of Stress - Adaptation
Response Based Model (Selye) - Normalization of hormone levels and vital signs
– Non-specific response of the body to any demand made upon it - Increase in body resistance
- Going back to pre-stress state
Transaction-based Model  Exhaustion
– Individual perceptual response rooted in psychological and - Unable to overcome stressor
cognitive process - Decreased energy level
- Breakdown in feedback mechanism
Stimulus Based Model - Organ/tissue damage; decreased physiological
– Disturbing or disruptive characteristics within the environment function
- Exaggeration of
Adaptation Model
– Anxiety provoking stimulus General Adaptation Response
– People experience anxiety and increased stress when they are Sympathoadreno-medullary Response (SAMR)
unprepared to cope with stressful situations - activation of sympathetic system which stimulated adrenal
medulla
CRISIS - Release of epinephrine and norepinephrine ---- > inc.
- disequilibrium, not merely psychological but physiologic as physiological activities
well (shock) - Sympathetic stimulation (inc. HR, RR, BP, visual perception,
- spontaneous resolution is 6 weeks metabolism – glycogenolysis in liver, dec. GI, GU)
- grieving process: 4 years - Propanolol (Inderal) – bronchoconstriction
Stressor
- Internal/ intrinsic Adrenocortical Response
- External / extrinsic Anterior pituitary gland Adreno corticotropic hormone  adrenal
- Developmental/ Maturational cortex
- Situational (1) release of aldosterone  kidneys  increase Na
reabsorption
Eustress – helpful stress (2) release of cortisol  fats & CHON catabolism  glucose

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
Tertiary Intention – “Delated primary intention”, suturing or closing of
Neurohypophyseal Response the wound is delayed i.e. due to poor circulation in the area
Posterior pituitary gland release
(1) Antidiuretic hormone  kidneys  inc. Na, H2O NURSING PROCESS
reabsorption  dec. urine output, inc. blood volume, inc. A – Assessment
BP D - Diagnosis
(2) Inc. oxytocin (aids in ejaculation/sperm motility)  uterine P – Planning
contraction I - Implementation
E – Evaluation
Methods to decrease stress: An overlapping of process can be noted since it is cyclic
- Progressive relaxation – muscle tension
- Benzon relaxation method – dimming the light, music ASSESSMENT
- Yoga, meditation
- Ventilation of feelings Types
- Initial assessment
Local Adaptation Syndrome - Problem focused assessment
Inflammatory Response - Emergency assessment
All infections cause an inflammatory response - Time-lapsed assessment
Not all tissue damage results to inflammation
Inflammation can heal spontaneously as long as the body can Data Collection – first step in assessment
manage  Primary/ Secondary
 Object (over)/ Subjective (covert)
I. Vascular Stage
(1) Vasoconstriction which limits injury and contain damage Methods of Gathering Data
(transient) Interview
(2) Release of chemical mediators – kinins  Therapeutic and non-communication
a. Bradykinin – most potent vasodilator/ universal  Health history
pain stimulus, inc. chemical activity  warmth o Medical history – disease focused (physiological)
(calor), redness (rubor) o Nursing history – needs, psychosocial dimension,
b. Prostaglandin spiritual aspects
(3) Capillary permeability  swelling (tumor), pain (dulor),  Personal space
temporary loss of function (function laesa) o Intimate Space – 1 ½ foot
o Personal Space – 1 ½ - 4 feet
II. Cellular Stage o Social Space – 4 –12 feet
(1) Neutrophils – bands and segmenters in differential count; o Public Space – 12–15 feet
first one to arrive. If elevated, it suggests acute infection
(2) Lymphocytes, Monocytes, or Macrophages – suggests Observation
chronic infection.  Use of senses to gather data
(3) Eosinophils – allergy  Clinical eye – comes with practice and experience
(4) Basophils – healing Examination
 Inspection, Palpation, Percussion, Auscultation (general)
III. Exudating  Inspection, Auscultation, Percussion, Palpation
Types of Exudate (abdominal)
 Serous – plasma (watery)
 Sanguinous/hemorrages – blood Steps in assessment
 Serosaguinous – pink 1. Collection of data
 Pus – purulent/ suppurative 2. Validation of data
 Catarrhal – mucin 3. Organization of data
 Fibrin fibers – fibrinous 4. Categorizing or identifying patterns of data
5. Making influences or impressions of data
IV. Reparative
Phagocytosis – ingestion of foreign substances After data collection, synthesis, analysis and validation are
Macrophages  Monocytes performed
Chemotaxis – movement of substances to a chemical signal
Healing methods: DIAGNOSIS
 Cold compress for first hours then warm compress after Problem + etiology +defining symptoms
 Nutrition and fluid intake *Guided by the NANDA
Knowledge deficit – kulang sa kaisipan
Types of wound healing Knowledge deficiency – kulang sa kaalaman (preferred)
Primary Intention – Wound edges are well approximated (closed), Self-care deficit – acceptable
minimal tissue damage i.e. surgically created wound; this can be
done with stitches, staples, etc. Types of Nursing Diagnosis
 Actual
Secondary Intention – Wound edges are not well approximated,  Risk for/ Potential for
moderate to extensive tissue damage and edges can’t be brought  Wellness - readiness and enhancement/ achieve higher
together i.e. Decubitus ulcer level of functioning
 Syndrome – “syndrome”

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 Fundamentals of Nursing
 Possible – vague/ unclear – possible/probable 5. Charting by Exception (CBE) – only significant change is
Prioritization of Nursing Diagnosis documented
 Airway, breathing, circulation
Case Management done with a Critical Pathway Variance
– Comprehensive and make sure that it won’t legally be implicated
PLANNING
 Short Range PHYSICAL EXAM (Plan Order)
 Long Range - Cephalo-caudal
*Must be SMART (Specific, Measurable, Attainable, Realistic, Time o Inspect, palpation percussion, auscultation
bound) o Inspection, auscultation, percussion, and
Classify as dependent, interdependent, and collaborative palpation sequence on abdomen to prevent
stimulation of peristalsis and for the patient to
IMPLEMENTATION follow a more comfortable to least comfortable
 Reassess if the patient still needs intervention examination
 Determine if you need assistance
 Carry out intervention, ensure that we have background Focused Assessment – on specific part/symptom
 Document
Process of implementing Bruit – normal if with AV fistula, abnormal in other since it may signify
- Reassess client arterial occlusion
- Determine nurses’ needs for assistance
- Implementing nursing interventions Auscultate the scrotum in inguinal hernia since it may have bowel
- Supervising the delegated care sounds
- Documenting nursing activities
Compare each body part to the other
EVALUATION
POSITIONING
Purposes of evaluation
 Sitting
Determine the:  High Fowlers (90%)
- Client’s progress or lack of progress  Orthopneic position (leaning on a table, hands extended)
- Overall quality of care provided  Supine, Back Lying, Dorsal, Horizontal Recumbent
- Promote nursing accountability  Flat on Bed – no pillow
Guidelines for evaluation  Dorsal Recumbent – legs flexed to relax abdominal
- Systemic process muscles, abdominal palpation/ exam – followed by
- On-going basis diagonal draping
 Standing/Errect – curvature of the spine
- Revision of the plan of care when needed
 Prone/ Face – lying position
- Involve the client, significant others, and other  Sim’s Position, Left lateral, Side-lying
members of the health team – Rectal exam, suppository insertion, enema administration
- Must be documented  Knee Chest position/ Geno-pectoral position/ Jack Knife
Process - nurse position
Structure - system – Rectal exam, dysmenorrhea
Outcome – patient  Kraaske – inverted V
 Lithototomy – stirrups
DOCUMENTATION or CHARTING  Trendelenburg – foot up; head down
 STAT – now  Reverse trendelenburg – head up, foot down
 Ad lib – as desired  Modified trendelenburg – only 1 leg up for shock: L
 PRN – as required
 OD – right eye/ once a day MCNAP – training to perform internal examination
 OS – left eye
 OU – both Chest
 AD – right ear - Pectus excavatum – funnel chest (congenital);
 AS – left ear compression of heart and breathing
 AU – both ears - Pectus carinatum – pigeon chest – deformity for rickets (Vit
 Ss – half D deficiency); AP diameter decreased
ERROR: draw a straight line, signature, initials Posture
- Kyphosis
Types of Documentation - Lordosis
1. Source Oriented Recording – narrative account by nurse; - Scoliosis – lateral
all the sheets in the patient’s chart (Standing Order, Skin
Physician’s Order etc.) - Capillary refill test = 1-2 seconds
2. Problem Oriented Recording (POR) – problems ranked - Icteric sclera
according to priority by the health care team, date - Cyanosis – late sign of oxygen deprivation
dissolved, progress notes, problem list - Vitiligo
a. FDAR – Focus, Data, Action, Response (patient) - Erythema
b. SOAPIER – subjective, objective, assessment, - Pallor
planning, implementation, evaluation, revision
3. Computer Assisted Recording – problem with privacy Nail Beds
4. Flow Chart - Clubbing - Beyond 180 degree due to dec. oxygen

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- Koilonychia -Spoon shaped nail due to iron deficiency Gurgles (rhonchi) – Continuous, low-pitched, course, gurgling, harsh
anemia sounds with moaning / snoring quality
- Onycholysis/Oncolysis – separation of nail - rubbing hair in wide airway
- Paronychia – severe inflammation of nail Friction rub – Superficial grating or creaking sounds
- Unguis incartatus - ingrown toenail Vocal (tactile) fremitus – Faintly perceptible vibration felt through
the chest wall when the client speaks
PALPATION Stridor – noisy breathing
- Light (indentation half an inch) Stertor – laryngeal spasm
o Fontanels, buldges, pulses, lymph nodes, thyroids, Cardiac Sounds
symmetry, neck veins, edema - 5th ICL MCL at the PMI
- Deep - Llllleft – Pulmonic valve
- Rrrrrr- Aortic valve
NPH – Ntrmediate
IE is a form of palpation Humulin R- rapid
Chest expansion must be symmetrical Glargular – rapid
Tactile fremitus - sound that is palpable Bowel Sounds
- Increase in consolidation, pneumonia - Normoactive: 5-30 bowel sounds per minute
- Decrease in pneumothorax - Wait 3-5 mins before concluding that bowel sounds are
Thrill – palpable murmur absent
Edema – on dependent area and may occur in legs - Hyperactive – Borborygmus
- Pitting/Non-Pitting - Paralytic ileus – paralysis after surgery
Anasarca – generalized edema
Peri-orbital edema – about the eye Voice Transmitted Sounds
- Egophony – say “E” but hears “A”
PERCUSSION - Whispered Pertoriloquy – whisper but we hear it loudly,
- Touch and healing secondary to consolidation
- Vocal fremitus
Tuning Fork Shifting dullness to check for ascites
- Weber’s test/ Lateralization test – conduction hearing
- Rhinne’s Test – bone-air conduction LABORATORY EXAMS
- Properly collect the specimen
Indirect Palpation - Give instructions correctly
- Flexor – Hiitting
- Pleximeter – Receiving Urinalysis
Sounds - Color: Amber, tea-colored (biliary d/o), urobilinogen
- Dull – organ - Odor: Aromatic/ Ammoniacal (decomposed urine)
- Flat – bones, muscles - pH: Acidic – does not favor bacterial growth
- Tympany – abdoment - Specific gravity: 1.050-1.025, if elevated urine is
- Resonant – lungs concentrated, suspect dehydration
- Hyperresonance – abnormal (emphysema) - Phosphates/Urates: Normal
- Glycosuria – Diabetes (BS is more than 200mg)
Typanism – “kabag” - Hematuria – Stones, BPH, renal diseases, UTI
DTR - +2: NORMAL, above it hyper resonant, below it is hyporesonant - Albuminemia – protein in urine, eccampsia
- Pyuria – UTI
Parts of the Stethoscope - Cyllinduria – cast in urine (stones)
Diaphragm – high pitched; lung sounds - First voided urine, mid-stream to clean the urethra first
Bell – low pitched; heart sounds - Sterile specimen
- Indwelling catheter – wait in the end of the catheter for 30
Adventitious breath sounds – no abnormal sounds mins
- Indwelling catheter – aspirate from 10ml syringe
Respiratory Sounds - Wee bag (*)
Normal Breath Sounds
Vesicular – Soft intensity, low pitched Urine Culture & Sensistivity Test
- T5 onward - Exact microbe
- Peripheral lung, base of the lung - Result is final only after 5-7 days
Bronchovesicular – Moderate intensity, moderate pitch - Same collection process but less amount
- T3-T5 - Ideal is catheterized cath
- Between scapulae lateral to the sternum
Bronchial – High pitch, loud harsh sounds Chemical Tests for Urine
- T1-T3 - Clinitest – way to determine sugar in urine (glycosuria)
- Anteriorly over the trachea - Benedict’s test – used Benedict’s solution then heat to
check for potency: must remain blue; if not blue, discard
Adventitious Breath Sounds - NO BOILING
Wheeze – Continuous, high-pitched, squeaky musical sounds o Then add 3-10 drops of urine then heat
- narrowed airway; asthma, bronchitis o Negative results
Crackles (rales) – Fine, short, interrupted crackling sounds o Negative: Blue
- rubbing hair in small airways; retained secretions; o +1 - Green
o +2 - Yellow

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 Fundamentals of Nursing
o +3 – Orange - prick at the side since low blood vessels
o +4 - Red
o Collected before meals Thoracentesis
- Heat and Acetic Acid Test – test of albuminuria; divide into - aspiration of pleural fluid through a needle
3 parts then add 2/3 urine, then 1/3 acetic acid - orthopneic position
- informed consent
- Fluid - 7-8 or 8-9 in intercostal posterior axillary line
o Turbid/Cloudy – positive - Air - 2-3, 3-4 in intercostals
o Not reliable since no microscopic instruments - Needs chest x-ray
were used - Positioned lying on unaffected side
o Done mostly in the community, NO BOILING
Thoracostomy
Quantitative Urine Exam - to return to negative pressure
- 24-hour Urine Collection – HCG, urinary amylase, urinary
catecholamines, urinary creatinine, urine albumin, Abdominal Paracentesis
corticosteroids - Aspiration of peritoneal fluid in ascites
o 6pm order, discard urine on 6pm, start on 6:01pm - Semi-sitting/sitting position
o Whole amount of urine, need not be midstream - Void before procedure
o Preserve in ice – cold storage - May be therapeutic or diagnostic
o Leeway of 15-30mins; get urine after deadline as - Watch out for hypovolemia
long as not too far
- Fractional Urine Collection – shorter span; time determined Lumbar Puncture/ Tap
by doctor - L3, L4, L5, subarachnoid space
- Paralysis risk low
Fecalysis - Fetal position – widens the angle of the lumbar spine
- Color of stool is influenced by stercobilin - 50-200mm – normal CSF pressure
- Clay colored = acholic stool = biliary track obstruction - Prepare 4 test tubes since every test requires a different
- Hematochezia = red = lower GI bleeding test tube
- Melena = blood = upper GI bleeding - Label test tubes and seal with appropriate cover; not with
- Steatorrhea = fat = gall bladder rpoblem cotton
- Foul smelling – indole and skatole - Xanthochromic – hemolyzed blood; yellowish discoloration
- Soft/formed - Flat on bed after procedure (6-8 hours) to prevent spinal
- Dead bacteria, fibers, amorphous phosphates – normal headache
- Live bacteria – abnormal
- After 1 hour, the stool cannot be used for fecalysis Diagnostic Exams
- Collect abnormal looking feces, not the one which is well - Visualization procedures
formed - Endoscopy
o direct visualization; lighted instrument
Stool Culture and Sensitivity - X-Ray – graphy
- Determining exact microorganism o Contraindicated in pregnant women due to
- Result also final after 5-7 days terratogenic effect
- Sterile container - Transformed
o Ultrasound/ Sonogram
Guiac Test
- Occult blood test Electroencephalography (EEG)
- No meat, highly colored food, iron preparation, Vit. C in - Shampoo hair before and after procedure
diet - Sedative must be withheld
- 3 days occult blood sample - Determining seizure disorders
-
Sputum Exam Electrocardiography (ECG)
- Done in early morning since secretions already pooled
- Sputum C &S – may give oral hygiene to remove mouth Electromyogram (EMG)
bacteria - Invasive
- Acid Fast Bacilli – 3 consecutive days - Phase 2 – insertion of needle into muscle
- Sputum Cytology – cancer cells
- Eosinophil determination – to determine allergic reaction CBC needs a heparinized syringe
- If unconscious, suction may be done: mucus trap
Magnetic Resonance Imaging
Blood Examinations - CI: steel implant and pace maker
- FASTING - Some ortho implants/prosthesis are allowed
o Triglyceride (1-12 hours), BUN (6-8 hours), HDL, - Assess for claustrophobia
LDL, FBS, Total Protein, Albumin Globulin ration, - Needs consent since it’s expensive
uric acid - With contrast in special procedures
- NON FASTING - NPO – to avoid aspiration in case of untoward reaction
o Crea, Na, K, Ca, CBG (but pre meals)
Computed Tomography Scan
CBG - Lesion must be bigger
- before meals - Dye and NPO

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- Enema to evacuate barium to prevent fecal impaction
Positron Emission Tomography
- Radioactive glucose (Fluorine) Lower GI Series
- Cancer cells have strong affinity for glucose; detect - Barium enema
cancer sites of metastasis - Outline of colon
- Laxative and cleansing enema until it is clean
- Pink phosposoda (oral cleansing enema)
Nuclear Medicine Thyroid Scan - Evacuate barium through enema to prevent fecal
- Nodule/tumor on thyroid impaction
For abdominal scans laxative, (castor oil/ Dulcolax) and NPO may
be necessary Excretory Urography
- Intravenous Pyelography
Opthalmoscopy o Hypaque- - made from iodine substance; check
- Opthalmoscope for allergy for seafoods
- Used in determining cataract o Laxative + NPO
- Dim the light and focus light of opthalmoscope in the eye o Given through IV port and the xray series is made
- Fundoscopy may be determined o Assesses kidney’s ability to filter
o Assesses presence of stones
Otoscopy o If reverse, retrograde pyelography
- Otoscope - Oral Cholecystography
- A cannula is inserted in the external auditory canal o Iapanoic acid (Telepaque) – taken every 5-10
- No need for written consent minute interval; 6 tablets
- 3 y/o above – up & back o Low fat meal the day before the exam
- 3 y/o below – down & back o Laxative + NPO

Rhinoscopy Ultrasound/ Sonogram

- Rhinoscope - US Brain
- Hyperextend the neck - US Heart (2D ECHO, Echocardiography)
o Regurgitation
Endoscope o Stenosis
- Can be used for surgery, biopsy - US Lungs
- Pharyngoscopy - US Breast/ Sonomamogram
- Bronchoscopy o Needs tranducer
- Langyngoscopy - US Abdomen
- Esophagogastroduedenoscopy o Colon – laxative, NPO
- Anoscopy o Kidney – KUB
- Proctoscopy – rectum o Pelvic ultrasound – drink 6-8 glasses to have a full
- Sigmoidoscopy bladder; do not allow to void
- Coloscopy – anus to ileum o Gallbladder ultrasound
o Cleansing enema until clear - Transvaginal Ultrasound
- Remove dentures o Will outline fallopian tube, uterus and ovaries
- Remove gag reflex by local anesthetic agent and check o consent
gag reflex - Transrectal Ultrasound
- Resume food only when gag reflex is present o Consent
- Consent and NPO o Empty the bladder for comfort and good
- Urethroscopy visualization
- Cystoscopy – bladder, written consent, cystoclysis set up o Visualization of uterus/ prostate
(continuous flow of sterile water which also exits)
- Colposcopy – vaginal examination, needs vaginal ADMITTING A CLIENT
speculum Types of Bed
o Shirodkar – tying the cervix so that miscarriage is - Closed – in anticipation for an admission
avoided; incompetent cervix - Open
- Post-Op/ Surgical/ Anesthetic/ Heater bed
Roentgenography - Occupied
- Electromagnetic radation photography
- Xray but without contrast medium Principle of Bed-making
- Chest X-Ray - Body Mechanics: Bed from knees, wide base of support
o Not definitve of TB - Obtain help
- Mammography - Asepsis, do not let linen touch uniform
o Examination of breast - Do not let the linen fall into ground
- Scout Film of Abdomen - Finish one side of bed first
- KUB - Remove wrinkles to have aesthetic value
o Top sheet – excess linen in foot part
Upper GI Series o Bottom sheet – excess linen in head part
- Esophagus, stomach, duodenum CHANGING GOWN
- Barium swallow (dye) – outline the GI system, flavored, has - Remove with free arm first in changing gown
constipating effect – inc. fluid - If both with contraption, any arms
- Uses laxative, NPO ORIENTING THE CLIENT

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ASSESSMENT  Course / Plateau phase: absence of chills, feels warm, up
HISTORY TAKING HR, RR, thirtst
PHYSICAL EXAM  Abatement phase: flushed skin, sweating, reduced
VITAL SIGNS shivering
DOCUMENT
- chief complaint only found on admission sheet Average: 36˚ - 38˚ degrees
DISCHARGE OF PATIENT Hypothermia: 36˚ degrees below
- may be against medical advice (DAMA) but it needs Death: 34˚ degrees
doctor’s order
- health instruction Types of Fever
- Illegal detention (false imprisonment) Intermittent – fluctuates from febrile to afebrile
Remittent – febrile, temperature fluctuation is minimal
VITAL SIGNS Relapsing – fluctuates in days
Children – Respiratory Rate, Pulse Rate, Temperature Constant / Continuous – febrile, temperature fluctuation is wide (+2)
* Blood Pressure can also be obtained in children
Heat Stroke – depletion of fluid, hypothalamus does not regulate
Hypothermia – induced (surgery), extreme temperature

Nursing interventions
Feels chilled – provide extra blankets
TEMPERATURE Feels warm – remove excess blankets; loosen clothing
Types of Temperature Adequate nutrition and fluids
Core temp. – more important; can’t be affected by environment Reduce physical activity
Surface temp. – more important in children since hypothalamus not Oral hygiene
yet developed Tepid Sponge Bath – increase heat loss (conduction, convection,
evaporation)
Poikilothermia – temp is same with environment; newborn
Homeothermia – different with the environment Unexpected Situation and Associated Interventions
During rectal temperature assessment, the patient reports feeling
Factors that affect Body Temperature lightheaded or passes out  Remove the thermometer
1. Age immediately. Quickly assess the patient’s BP and HR. Notify
2. Ovulation – temp is higher; progesterone physician. Do not attempt to take another rectal temperature on
3. Activity – inc. BMR this patient.
4. Environment
Temperature conversion PULSE
C-F multiply 1.8 + 32 - Temporal
F-C subtract 32/ 1.8 - Carotid – cardiac arrest
- Apical
Methods of taking body temperature - Brachial
- Oral – contraindicated in brain damage, mental illness, - Radial – thumb site
retarded, problem with nose and mouth, tooth extraction, - Femoral
contraption in nose and mouth, altered LOC, dyspnea, - Popliteal
seizures, 7 y/o below
o 2 mins under the tongue Affected by the following:
- Rectal – contraindicated in imperforate anus, rectal 1. Age – the younger, the faster
polyps, hirschprung’s disease, diarrhea, increase ICP, 2. Activity
cardiac disease (may cause vagal stimulation) 3. Stres
o Not safe since it can cause rectal trauma 4. Drugs
o 1 min  Increase – anticholinergic, sympathomimetic
- Axillary – 3mins  Decrease – cardiac glycoside
- Tympanic – external ear. contraindicated in otitis, ear
surgery; most Palpation
accurate Pattern of Beat (Rhythm)
- Temporal Scanner - done in temporal; most convenient - Regular (60 – 100 bmp)
- Irregular (arrhythmia)
Temperature can be checked every 30 mins since hypothalamus o Bigeminal pulse – 1, 2, disappear
can only fluctuate the temperature every 30 mins o Trigeminal pulse – 1, 2, 3, disappear

Spot Vital Signs – HR, RR, BP Pulse Strength = pulse volume

Thermopacifier – for crying babies +1 – collapsible. thready
Plastic strip Thermometer – Amitemp +2 – normal
+3 – full
Alterations in body temperature +4 – full, bounding
Hyperpyrexia: 41˚ degrees +
Pyrexia: 37.5˚ - 38˚ degrees + Corrigan pulse/ Waterhammer pulse – thready and with full
 Onset / Chill phase: up HR, up RR, shivering, cold skin, expansion followed
cessation of sweating by sudden collapse.

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Auscultation
Apical (PMI) Kinds
 3rd – 4th ICS MCL (below 7 years old) - Direct – venous pressue, CVP, invasive, cutdown (5-
 4th - 5th ICS MCL (7 years old and aboe) 12mmHg)
Unexpected Situations and Associated Interventions - Indirect
The pulse is irregular  Monitor the pulse for a full minute. If the pulse o Palpatory
is difficult to assess, validate pulse measurement by taking the o Ausultatory
apical pulse for 1 minute. If this is a change for the patient, notify the
physician. Pulse pressure – 40 mmHg
Pulse deficit (systolic - diastolic)
You cannot palpate a pulse  Use a portable ultrasound Doppler to Mean Arterial Pressure ([2D+S]/D)
assess the pulse. If this is a change in assessment or if you cannot
find the pulse sing an ultrasound Doppler, notify the physician. Classification SBP DBP Lifestyle
mmHg mmHg Modification

RESPIRATION Normal: 16-20 bpm Optimal <120 And <80 Encouraged

Pre- 120-139 Or 80-89 YES
Three processes
hypertension
Ventilation – the breathing in and breathing out
Stage 1 HPN 140-159 Or 90-99 YES
 Intact CNS
 Clear airway Stage 2 HPN >160 Or > 100 YES
 Intact thoracic cavity Stage 3 HPN > 180 Or > 110 YES
 Compliance and recoil
Diffusion – movement of gases from higher to lower concentration Choose the higher BP
 Adequate concentration of gases Sources of error is BP Assessment
 Normal lung tissue High BP reading
Perfusion – circulation of the oxygenated blood to the different  Bladder cuff too narrow
tissues of the body  Arms unsupported
 Insufficient rest before the assessment
Inhalation / Inspiration – 1 to 1.5 seconds  Repeating reassessment too quickly
Exhalation / Expiration – 2 to 3 seconds  Deflating cuff too slowly
 Assessing immediately after a meal or while client smokes
Alterations in Breathing Patterns or has pain
Rate Low BP reading
Tachypnea – fast breathing  Bladder cuff too wide
Bradypnea – slowed breathing  Deflating cuff too quickly
Apnea – absence of breathing  Arm above the level of the heart
Eupnea – normal breathing  Failure to identify auscultatory gap

Rhythm
Biot’s – shallow breathing with periods of apnea OXYGENATION
Cheyne-Strokes – deep breathing with apnea
Kussmaul’s – deep, rapid breathing (If with respiratory acidosis – to Respiratory Modalities
blow off excess carbon dioxides) Abdominal (diaphragmatic) and purse-lip breathing
Volume  Semi / high fowlers position
Hyperventilation – leads to respiratory alkalosis  Slow deep breath, hold for a count of 3 then slowly exhale
Hypoventilation – leads to respiratory acidosis through mouth and pursed lip
 5 – 10 slow deep breaths every 2 hours on waking hours
Ease of effort
Dyspnea – difficulty of breathing Coughing exercise
Orthopnea – difficulty of breathing within supine position  Upright position
(best position for this is orthopneic position)  Contraindicated: post brain, spinal or eye surgery
Katupnea - Difficulty of breathing while in sitting position  Take two slow deep breaths; on the third breath, hold for
Trepopnea - ease when in side-lying position dew seconds, cough twice without inhaling in between
Hyperpnea – inc. rate and depth of respiration  May splint surgical incisions
 Every 2 hours while awake
BLOOD PRESSURE
Factor’s Affecting Blood pressure Incentive spirometry
- Age, Gender  A breathing device that provides visual feedback that
- Activity, exercise, stress encourages patient to sustain deep voluntary breathing
- Time of the day and maximum inspiration.
 10 times every 1 to 2 hours
Korotkoff sounds
Phase 1 – sharp tapping (systolic) Chest Physiotherapy
Phase 2 – swishing or wooshing sound  Postural drainage
Phase 3 – thump softer than the tapping in phase 1  Percussion
Phase 4 – softer blowing muffled sound that fades (end = diastolic)  Vibration
Phase 5 – silence

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 Positioning > percussion > vibration > removal of secretions  Safety precuations: “NO SMOKNG” and “O2 IN USE” signs
by coughing or suction at the door
o Contraindications:
 ICP more than 20mmHg, head and neck injury, Nasal Cannula (approx. 20-40% of oxygen)
active hemorrhage, recent spinal surgery, active  1L/min = 24%
hemoptysis, pulmonary edema, confused or  2L/min = 28%
anxious patients, rib fracture  3L/min = 32%
 4L/min = 36%
Postural Drainage  5L/min = 40%
 When = morning, at bedtime, 30 minutes – 1 hour before or  6L/min = 40%
1-2 hours after meal Priority nursing interventions:
 Each position = assumed for 10 – 15 minutes o Check frequently that both prongs are in the patient’s
 Entire treatment should last only for 30 minutes nares.
o Encourage the patient to breathe through the nose,
Percussion with mouth closed.
 Rhythmical force provided by clapping the nurse’s o May be limited to no more than 2-3L/min to patient
cupped hands against the client’s thorax with chronic lung disease.
 Over affected segment for 1-2 minutes Face mask
Simple face mask (approx. 40-60%)
Vibration  5-6L/min = 40%
 Perform by contracting all the muscles in the nurse’s upper  7-8L/min = 50%
extremities to cause vibration while applying pressure to  10L/min = 60%
the client’s chest wall Priority nursing interventions:
 One hand over the other o Monitor patient frequently to check the placement of the
mask.
Suctioning o Support patient if claustrophobia is a concern.
Purposes o Secure physician’s order to replace mask with nasal
 Maintain patent airway cannula during meal time
 Promote adequate exchange of O2 and CO2
 Substitute for effective coughing Partial rebreather mask (approx. 60-80%)
Size  6-10L/min = up to 80%
 Adult: Fr 12-18 Priority nursing interventions:
 Child: Fr 8-10 o Set flow rate so that mask remains two-thirds full during
 Infant: Fr 5-8 inspiration
Length o Keep reservoir bag free of twists or kinks.
 From tip of nose to earlobe (5 in.)
 Nasopharyngeal = 5-6 inches Nonrebeather mask
 Oropharyngeal = 3-4 inches  10L/min = 80-100%
 Nasotracheal = 8-9 inches Priority nursing interventions:
 ET = lenth of ET + 1 inch o Maintain flow rate so reservoir bag collapses only slightly
 Tracheostomy = length of trachea + 1 cm during inspiration.
Suctioning o Check that valved and rubber flaps are functioning
 Duration of suction: 5-10 seconds properly (open during expiration and closed during
 Intermittent suctioning upon withdrawal using rotating inhalation)
motion o Monitor SaO2 with pulse oximeter.
 If to repeat: 1-2 mins interval
 Limit suctioning in a total of 5 minutes Venturi mask (most accurate and precise oxygen concentration
delivery)
Unexpected Situations and Associated Interventions  4L/min = 24%
Patient vomits during suctioning  If patient gags or becomes  4L/mins = 28%
nauseated, remove the catheter; it has probably entered the  6L/min = 31%
esophagus inadvertently. If the patient needs to be suctioned  8L/min = 35%
again, suction catheter because it is probably contaminated.  8L/min = 40%
 10L/min = 50%
Secretion appear to be stomach content  Ask the patient to
extend the neck slightly. This helps to prevent the tube from passing Oxygen Tent
into the esophagus. Unexpected Situations and Associated Interventions
Child refuses to stay in the tent  Parent may play games in the tent
Epistaxis noted with continued suctioning  Notify the physician and with child. Alternative methods of O2 delivery may need to be
anticipate the need for a nasal trumpet. considered if child still refuses to stay in tent.

It is difficult to maintain an O2 level above 40% in the tent  Ensure

Oxygen Therapy that the flap is closed and edges of tent are tucked under blanket.
Special consideration: Check O2 delivery unit to ensure that rate has not been changed.
 Given with a doctor’s order
 Careful and continuous assessment to evaluate the need Patient was confined on O2 delivered by nasal canula but now is
for and its effect on the patient cyanotic, and the pulse oximeter reading is less than 05%  Check
to see that O2 tubing is still connected to the flow meter.

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becomes cyanotic or patient becomes
When dozing, patient begins to breathe through the mouth  bradycardic  Stop suctioning. Auscultate lung
Temporarily place the nasal cannula near the mouth. If this does not sounds. Consider hyperventilating patient with
raise the pulse oximetry reading, you may need to obtain an order manual resuscitation device. Remain with
to switch the patient to a mask while sleeping. patient.

Inhalation Therapy o Patient is accidentally extubated during tape

Moist inhalation – Steam inhalation = 12- 18 inches; 15 – 20 mins. change.  Remain with the patient. Instruct
Dry inhalation – Metered dose inhaler = use of spacer; hold breath assistant to notify physician. Assess patient’s vital
for 10 seconds with 5 minutes interval signs, ability to breathe without assistance and O2
saturation. Be ready to administer assisted breaths
**Water with a bag-valve mask or administer O2.
Child – has 70- 90 percent water Anticipate need for reintubation.
Adult – has 50-70 percent water
Males have more water than females since they have more adipose
tissue
o Patient is biting on ET  Obtain a bite block. With
Artificial Airways the help of an assistant, place the bite block
Oropharyngeal airway around the ET or in patient’s mouth.
 Prevents tongue from falling back against the posterior
pharynx o Lung sounds are greater on one side  Check
 Measurement: from opening of the mouth to the ear (back the depth of the ET. If the tube has been
angle of the jaw) advanced, the lung sounds will appear greater
 Check for loose teeth, food and dentures on one side on which the tube is further down.
Remove the tape and move tube so that it is
Unexpected Situations and Associated Interventions placed properly.
o The patient awakens  Remove the oral airway
o The tongue is sliding back into the posterior pharynx, Tracheostomy
causing respiratory difficulties  Put on disposable gloves  To maintain patent airway and prevent infection of
and remove airway. Make sure airway is the most respiratory tract.
appropriate size for the patient.  Care of patient with tracheostomy:
o Patient vomits as oropharyngeal airway is inserted  o Sterile technique: acute phase
Quickly position patient onto his side to prevent aspiration o Clean technique: home care
o 1st 24 hours: tracheostomy care every 4 hours
Nasopharyngeal Airway / Nasal Trumpets o Prevent aspiration
 Indications Clenched teeth, enlarged tongue, need for Unexpected Situations and Associated Interventions
frequent nasal suctioning o Patient coughs hard enough to dislodge
 Measurement: from the tragus of the ear to the nostrils plus tracheostomy  Keep a spare tracheostomy and
one inch obturator at the bedside. Insert obturator into
 Proper lubrication for easy insertion tracheostomy tube and insert tracheostomy into
stoma. Remove obturator. Secure ties and
Endotracheal auscultate lung sounds.
 Indications: route for mechanical ventilation, easy access
for secretion removal, artificial airway to relieve Pulse Oxymetry
mechanical airway obstruction.  Purpose: measure arterial blood O2 by external sensor
 Care for patients with ET: (non-invasive)
o Repositioned at least every 24-48 hours  Placement
o Depth and length during insertion should be o Adult: usually on the finger
maintained o Pedia: usually on the big toe
o Level of tube: gumline / biteline o Other sites: earlobes, nose, hand and feet
o Maintain cuff pressure of 20-25 mmHg
o Check lips for cracks and irritation NUTRITION
Unexpected Situations and Associated Interventions
o Patient is accidentally extubated during Principles in the Promotion of Good Nutrition
suctioning  Remain with the patient. Instruct  The body requires food to:
assistant to notify physician. Assess patient’s vital o Provide energy for organ function, movement,
signs, ability to breathe without assistance and O2 and work.
saturation. Be ready to administer assisted breaths o Provide raw materials for enzyme function,
with a bag-valve mask or administer O2. growth, replacement of cells and repair.
Anticipate need for reintubation.  The process of digestion, absorption, and metabolism work
together to provide all body cells with energy and
o Oxygen saturation decreases after suctioning  nutrients.
Hyperoxygenate patient.  Man’s energy requirement vary and is influenced by many
factors: Age, body size, activity, occupation, climate,
o Patient develops signs of intolerance to sleep, physiological stress, pathological disorders, lifestyle,
suctioning; O2 saturation level decreases and and gender.
remains low after hyperoxygenating, patient

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 Fundamentals of Nursing
Foods are described according to the density of their nutrients.
Nutrient density – the proportion of essential nutrients to the number **Kaesselbach’s plexus – prone to epistaxis
of kilocalories.
Macronutrients – Give off calories for energy B Vitamins – Metabolism since these have enzymatic activity
 Fat soluble viramins: Vit. A, D, E, and K Vit B1 (Thiamin)
Micronutrients – No calories, vitamins and nutrients - Deficiency: Beri-beri; Wernicke-Korsakoff Syndrome
 Water soluble vitamins: Vit. C, B1, B2, B3, B6, B9, and B12 - Edema in wet Beri-beri
Calorie (kcal) – unit of energy measurement; amount of heat
required to raise the temperature of 1kg of water to 1°C Vit B2 (Riboflavin)
- Deficiencies: Ariboflavinosis, cheilosis
Sources: o Angular stomatitis - mouth fissures
CHO – 4 calories/gm; first to be burned
FATS – 9 colories/gm; stored as adipose tissue Vit B3 (Niacin)
CHON – 4 calories/gm; meat - Deficiency: Pellagra – butterfly sign, cassel’s collar
Alcohol – 7 calories/gm
Vit B5 (Pantothenic Acid)
Vitamins - Keeps integrity of hair
- Fat soluble - ADEK - Deficiency: alopecia
- Water soluble – B complex , C
Macrominerals – 100 mg or more Vit B6 (Pyridoxin)
Microminerals – Less than 100 mg; Zinc, iron, iodine - Deficiency: Neuritis

**Potato – highest in potassium Vit B12 (Cyanocobalamin)

**The tip of the banana has the highest amount of potassium - Definition: pernicious anemia, neuritis

Iodine – prevent cretinism Vit C (Ascorbic)

Zinc – to improve appetite - Inc. absorbtion of iron
Iron - correct anemia - Deficiency : scurvy – easy bruising, gums, perifollicular
Hypervitaminosis – increase in vitamins intake; occurs commonly in lesion, hemorrhage
fat soluble Types of Diet
Regular
No hypervitaminosis in water soluble since it is easily eliminated in – Has all essentials, no restrictions
urine – No special diet needed
Clear liquid
Overweight – increase in macronutrients; may progress to obese – “see-through foods” like broth, tea, strained juices, gelatin
Marasmus – Recovery from surgery or very ill
- calorie malnutrition Full liquid
- Old man facie, intercostals and subcostal retractions – Clear liquids plus milk products, eggs
Kwashiorkor – Transition from clear to regular diet
- moon face, Globular abdomen, edema Soft diet
- protein malnutrition – Soft consistency and mild spice
– Difficulty swallowing
VITAMIN DEFICIENCIES Mechanically soft
Vit A (Retinol) – Regular diet but chopped or ground
- Healthy eyes, skin, and gums – Difficulty chewing
- Deficiency: Xeropthalmia (night blindedness) – Bitot’s spot Bland
- Severe: Keratomalacia (irreversible) – Chemically and mechanically non stimulating, no spicy
Vit D (Calciferol) food
- Not coming from the sun; but sunlight activates it – Ulcers or colitis
- Enhances calcium and phosphorus absorption Low residue
- Deficiency: Ricketts – No bulky foods, apples or nuts, fiber, foods having skins and
- Severe: Osteomalacia seeds
o Bow legged – genu varum – Rectal disease
o Knock knee – genu valgum High calorie
o Pectus carinatum (Harrison’s groove) – High protein, vitamin and fat
o Spinal deformity – Malnourished
o Stunted growth Low calorie
You can store calcium up to 31 years – Decreased fat, no whole milk, cream, eggs, complex CHO
– Obese
Vit E (Tocopherol) Diabetic
- Antioxidant: remove free radicals – Balance of protein, CHO and fat
- Amount should not go 400 units because if it exceeds. It – Insulin-food imbalance
becomes prooxidant High protein
- En hances RBC maturation – Meat, fish, milk, cheese, poultry, eggs
- Deficiency: anemia – Tissue repair and underweight
Vit K (Menadione) Low fat
- Anti-hemorragic – Little butter, cream, whole milk or eggs
- Deficiency: hemorrhagic, bleeding – Gallbladder, liver or heart disease

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
Low cholesterol pressure to remove the clog; Never use a stylet to unclog
– Little meat or cheese the tubes; Tube may have to be replaced.
– Need to decrease fat intake
Low sodium Gastrostomy / Jejunostomy Feeding
– No salt added during cooking  Long term nutritional support, more than 6 – 8 weeks
– Heart or renal disease  Place in high fowler’s position
Nutritional Problems  Check the patency of the tube: Pour 15-30 cc of water
1. Antropometric Measurement  Check the patency of the tube: Pour 15-30 cc of water
a. BMI – kg/m2  Check for residual feeding
i. Underweight – below 18  Hold asepto-syringe 3-6 inches above ostomy feeding
ii. Normal – 18-24  Frequently assess for skin breakdown
iii. Overweight – 24 above
2. Biochemical Assay – laboratory exams Unexpected Situations and Associated Interventions
3. Clinical signs – sx/s o Gastrostomy tube is leaking large amount of drainage 
4. Dietary History Check tension of the tube; Apply gentle pressure to tube
a. Food habits while pressing the external bumper closer to the skin; If
tube has an internal balloon holding it in place, check to
Anorexia – no eating make sure that the balloon is inflated properly.
Bulimia – binge-purge syndrome o Skin irritation around the insertion site  Stop the leakage,
as prescribed previously and apply a skin barrier.
Management: o Site appears erythematous and patient complains of pain
- Hygiene at the site  Notify physician, patient could be developing
- Small frequent feeding cellulitis at the site.
- Serve attractively French is directly proportional to size
Gauge is inversely proportional to size
Enteral and Parenteral Nutrition
Parenteral Nutrition **Intravenous Hyperalimentation/ TPN
 Nonfunctional GIT - Kabiven
 Extended bowel rest - Watch out for gylcosuria and blood sugar
 Preoperative TPN - May necessitate insulin
Enteral Nutrition - Large needle since it is central route
 Cancer - Monitor for complications
 Neurological and Muscular disorder ELIMINATION
 Gastrointestinal disorder
 Respiratory failure with prolonged intubation URINE ELIMINATION
1200 – 1500cc/day
Nasogastric Tube Feeding/ Levine’s Tube Normal output: 30ml/hour
 Position: sitting Urge to urinate: 300-500ml
 Head: hyperextend and slightly flexed
 Insertion: NEX (Tip of the nose – Earlobe – Xyphoid Process) Poliacuria – frequent, scanty urine
 pH gastric content: 4 – 6 Urgency – urge but unproductive of urinate
 Confirmation: By X-ray Retention – stimulate urination, running water, warm water over
perineum, warm compress, and straight catheterization
Gavage
 Position: sitting Catheterization
 Gastric aspirate: >1000mL – withhold feeding; put back the Indication:
residue  Decompression
 If with medication and is not gastric irritant: 20-30cc  Instillation
flushing > meds > feeding > 20-30cc flushing  Irrigation
 Specimen collection
Lavage  Urine measurement: Residual urine; Hourly urine output
 To irrigate the stomach in case of gastric bleeding, food  Promotion of healing of GUT
poisoning or ingestion; if corrosive substance: do not Catheter size
irrigate  Children: Fr 8-10
 Position: sitting  Female adult: Fr 14-16; Fr 12 for young girls
 Gastric aspirate: discard  Male adult: Fr 16-18
 Amount of irrigating solution: 750mL – 1L Position
 Female: dorsal recumbent
Unexpected Situations and Associated Interventions  Male: supine with thighs slightly abducted
o Tube found not to be in the stomach or intestine  Replace Length of insertion
the tube  Female: 2-3 inches (5 – 7.5 cm)
o Patient complains of nausea after tube feeding  Ensure  Male: 7-9 inches (17 – 22.5 cm)
that the head of the bed remains elevated and that Anchor
suction equipment is at bedside; Check medication record  Female: inner thigh
to see if any antiemetics is ordered.  Male: Top of thigh or lower abdomen
o When attempting to aspirate contents, the nurse notes that Unexpected Situations and Associated Interventions
tube is clogged  Try using warm water and gentle

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
o No urine flow is obtained and you note that catheter is in Stimulant / Irritant – Irritates / stimulates (Dulcolax, Senokot, Castor
vaginal office  Leave catheter in place as a marker; Oil)
Obtain new sterile gloves and catheter set; Once new Lubricant – Lubricates (Mineral Oil)
catheter is correctly in place, remove the catheter in Saline / Osmotic – Draws water into intestine (Epsom salts, Milk of
vaginal orifice. Magnesia)
o Patient complains of extreme pain when you are inflating Enema
the balloon  Stop inflation of balloon; Withdraw solution Types
from the balloon. Cleansing Enema
 Prior to diagnostic test, surgery
Bladder Irrigation  In cases of constipation and impaction
Open system (intermittent)  Either be: High enema (12-18 in.) or Low enema (12 in.)
– For installation of medications or irrigation of catheter Carminative Enema
Closed system (Intermittent or Continuous)  To expel flatus
– For those who had genitourinary surgery  60 – 80 mL of fluid
– For instillation of medications, promoting homeostasis, Retention Enema
flushing of  Solution retained for 1-3 hours
clots or debris  Oil enema, antibiotic enema, anti-helminthic enema,
nutritive enema
**NEVER INFLATE THE BALLOON UNLESS URINE FLOWS Return-flow Enema
**If inserted in vagina, keep in place but insert another one  To expel flatus
 Alternating flow of 100-200 mL of fluid in and out of the
Catheter can be placed in one month as long as no signs of rectum
infection
Condom Catheter – must be secured through a belt Enema Administration
Fides’ Maneuver – application of pressure in the bladder to stimulate Appropriate Size
urine  Adult: Fr 22-30
 Child: Fr 12-18
Correct Volume
BOWEL ELIMINATION  Adult: 750 – 1,000 mL
 Adolescent: 500 – 750 mL
Assessment  School-aged: 300 – 500 mL
 Inspection – Auscultation – Percussion – Palpation  Toddler: 250 – 350 mL
approach  Infant: 150 – 250 mL
 Bowel sound (4 quadrants) Length of Insertion
o Active – every 5-20 seconds  Adult: 3-4 inches
o Hypoactive – 1 per minute  Child: 2-3 inches
o Hyperactive – every 3 seconds  Infant: 1 – 1 ½ inches
o Absent – None heard in 3-5 minutes
 Fecalysis – an inch of formed stool, 15-30 mL of liquid stool Commonly Used Enema Solutions
 Fecal occult blood testing / Guiac test Hypertonic – Draws water into colon (Sodium phosphate solution)
Hypotonic – Distends colon, stimulates, softens (Tap water)
Fecal Elimination Problems Isotonic – Distends colon, stimulates, softens (Normal saline)
Diarrhea – watery stools; ORESOL; banana rice apple Soap suds – Irritates mucosa, distends colon (3-5 mL soap to 1L of
Constipation – hard stools; laxative; Psilium (bulk-formers), Castor oil water)
(GI irritant) Oil – Lubricates feces (Mineral, olive, cottonseed)
Tenesmus – urge to but unproductive of stool

Fecal impaction Unexpected Situations and Associated Interventions

- constipation and seepage of watery stools o Solution does not flow into the rectum  Reposition
- No enema rectal tube, if solution will still not flow, remove tube
- Digital/Manual extraction with doctor’s order and check for any fecal contents.
- Monitor for vagal stimulation; stop if signs are noted o Patient cannot retain enema solution for adequate
amount of time  Patient needs to be placed on
Eructation/ Belching bedpan in the supine position
- Expulsion of gases through mouth o Patient cannot tolerate large amounts of enema
solution  Amount and length of administration may
Flatulence/Typanism have to be modified if the patient begins to complain
- Avoid gas forming foods: cauliflower, cola of pain
- Carminative enema – expel flatus o Patient complains of severe cramping with
- Rectal tube insertion – inserted in anus then placed in introduction of enema solution  Lower solution
water for 20 mins; if need to be repeated wait for 2-3 mins. container and check temperature and flow rate; If
to prevent anal sphincter damage the solution is too cold, or too fast, severe cramping
may occur.
Types of Laxatives
Bulk forming – Increases fluid, gaseous or solid bulk (Metamucil, Colostomy
Citrucel)  Size of stoma will be stabilized within 6-8 weeks
Emolient / Stool Softener – Softens and delays drying of feces  Effluent; Foul-smelling and irritating to the skin = ileostomy
(Colace) Guidelines for Ostomy Care

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
 Keep patients as free of odors as possible. Empty ostomy  Decrease inflammation
appliance frequently.  Local anesthetic effect
 Inspect stoma frequently
 Normal color of stoma, pinkish-red, moist. Pale or bluish Inflammation – first 24 hours = cold; then heat
indicates cyanosis or decreased circulation in the tissue Pain – cold; to block nerve
 Note the side of the stoma
 Keep skin around the peristomal area clean and dry Dry heat
 Intake and output - Hot water bags temperature: 110-125 degrees F
- Disposable hot packs
Unexpected Situations and Associated Interventions - Floor lamp / gooseneck lamp / heat cradle
o Peristomal skin is excoriated or irritated  Make sure o Bulb = 25 watts
appliance is not cut too large; Assess for presence of o Distance = 12-24 inches
fungal skin infection; Thoroughly cleanse skin and Dry cold application
apply skin barrier; Allow to dry completely; Reapply - Ice cap
pouch - Compress
o Patient continues to notice odor  Check system for - After 15 mins
any leaks or poor adhesion; Thoroughly empty pouch
Tepid Sponge Bath
MEDICATIONS - Do anterior first
Parenteral - Use 1 washcloths
Intradermal
- Gauge 25 -25 Sitz Bath
- Insert only the bevel; zero to 15 degree angle - immersion of 110-115 degrees Fahrenheit
- Epidermal - do not remove rectal pack, remove rectal dressing
- Sensitivity test - may have cerebral hypoxia – put ice cap on forehead
Subcutaneous
- Stretch if fat, pinch if thin
- Adipose layer of the buttocks, arms WOUND MANAGEMENT
- Best site is abdomen, below the umbilicus! No gauze cause it can stick to skin
- Gauge 23-25, 5/8 inch inserted Center to outer when cleaning
- If long needle, insert 5/8; if short 90 degree
Intramuscular Jackson Pratt
- Must be strictly 90 percent - keep in negative pressure; remove drainage
- 1-1.5 inch - in head injury, can have JP but not on negative pressure
- Gauge 22-23 since it can interfere with ICP

Z-track technique
- Deep IM HYGIENIC MEASURES
- Prevent leakage of solution to tissue
Perineal care
**NO INSERTION IN GLUTEUS MAXIMUS, BUT ON MINIMUS AND MEDIUS - Female: Dorsal recumbent; front to back
- Male: Supine; circular
Intravenous - one stroke, one direction
IV Push – check backflow, if none do not insert Oral Care
- Brushing – sulcular technique
IV infusion pump – for more accurate drip - Lemon-glycerine swab, mineral oil
Soluset – chamber up to 100cc; microset calibration Oral hygiene for unconscious
- supine, head turned to one side
Opthalmic solution – lower conjunctival site; 1-2 drops at maximum - antiseptic solution
Bed Bath
Rectal Suppository – go beyond the anal sphincter - Water temperature: 43-46C or 110-115F
Inhaler – may use spacer - Arms: Long, firm strokes, distal to proximal
- Breasts: Female – circular; Male – Longitudinal
DO NOT USE INHALER IN STEROIDS TO PREVENT MOUTH SORES!

HEAT AND COLD APPLICATION EXERCISE AND ACTIVITY

 Do not prolong more than 20 mins. because of rebound Active-assitive – one side help the affected side
Isotonic – jogging; change in length
Heat Isometric – mucle tension no change in length
 Vasodilation Isokinetic – weights
 Increase capillary permeability
 Increase cellular metabolism Aerobic – exceed oxygen needs
 Increase inflammation Anerobic – does not exceed oxygen needs
 Sedative effect
Cold Massages
 Vasoconstriction Effleurage – smooth, long gliding stroke
 Decrease capillary permeability Petrissage – large pinch of skin; “kneading”
 Decrease cellular metabolism Tapotement – side of each hand, sharp hacking movement

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
PAIN
Immobility - Subjective
- Thrombus formation - May have psychogenic pain as well
- Edema - Acute – less than 6 months
- Constipation - Chronic – more than 6 months
- Urinary stasis – stones- calculi - Intractable – not relieved
- Atrophy
- Disuse syndrome Wong and Baker Scale – 1-10 rating
- Trochanter roll to prevent external rotation of femur Phantom pain – pain from amputated limb

Pressure Ulcer Gate Theory of Pain - Substantia gelatinosa

- Decubitus ulcer/ bed sore
- Prone in bony surfaces Pain threshold
- 1 – non blanchable erythema - May be psychological/ physiological
- 2 – open lesion o Heat and cold
- 3- with fat exposed o Imagery and distraction
- 4 – exposed mucles and bones
DEATH
Dressing Thanantology – study of death
- Transparent barrier
- Gauze not used Stages of Grieving by Kubler Rosss
- To absorb exudates
- Hydrocolloid Post-mortem care
- Must be pronounced dead by physician

SLEEP Rigor Mortis - stiffening

Rest – State of calmness; relaxation without emotional stress or Algor Mortis – change in temperature
freedom from anxiety. Livor Mortis – color change
Sleep – State of consciousness in which the individual’s perception
and reaction to the environment are decreased.

Physiology of Sleep
Reticular Activating System (RAS) – responsible in keeping you
awake and alert
Bulbar Synchronizing Region (BSR) – causes sleep

Types of Sleep

NREM (Non-Rapid Eye Movement/ deep, restful sleep / slow-wave

sleep)
Stage I: very light; drowsy; relaxed, eyes roll from side-to-side; lasting
a few mins.
Stage II: light sleep; body processes slow further (decrease PR/RR),
eyes are still; lasts about 10-20 mins.
Stage III: domination of the PNS; difficult to arouse; not disturbed by
sensory stimuli; snoring; muscles totally relaxed.
Stage IV: delta sleep; deep slow-wave sleep

REM (Rapid Eye Movement)

 Where most dreams take place.
 Brain is highly active, hence, paradoxical sleep

Common Sleep Disorders

Insomnia – warm bath, massage, milk (tryptophan), medication
Parasomnia – periods of waking up while asleep
Somabulism – sleep walking; lock the door
Soliloquy – sleep talk
Notcurnal enuresis (night)/Diurnal enuresis (morning) – Bed wet,
place diaper
Bruxism – anxiety; grinding of teeth
Hypersomnia – excessive sleep; may have hypothyroid, DKA
Narcolepsy – uncontrolled desire to sleep; ampethamine - taken
after breakfast, anorexiant

University of Santo Tomas – College of Nursing / JSV

 FUNDAMENTALS OF NURSING-RLE

WEEK 2-HANDWSHING AND GLOVING

- To protect yourself and the healthcare environment from

OUTLINE
harmful patient germs.
I. Hand Hygiene IV. Applying and Removing Gloves 5) After touching equipment in the patient’s surrounding areas.
II. Hand washing Checklist Checklist - To protect yourself and the health care environment from
III. Gloving Technique V. Glove Use Information Leaflet harmful patient germs.
5 MOMENTS FOR HAND HYGIENE
I. HAND HYGIENE 1) Before Patient Contact
BACKGROUND When: Clean your hands before touching a patient.
 Nosocomial pathogens- viruses, bacteria, microorganism Examples: Examinations, helping a patient to move, checking name
 Hygiene - is the single most important measure to prevent bands
transmission of infection and is the cornerstone of infection 2) Before an Aseptic Task
prevention and control (IPC). When: Clean hands before and after as aseptic task.
 Proper hand hygiene can prevent transmission of microorganisms Examples: Oral care, secretion aspiration, wound care, catheter
and decrease the frequency of Health care-associated infection placement, patient feeding, medication administration
(HAIs.) 3) After Body Fluid Exposure
 The goal of hand hygiene is to remove soil, dirt, and debris and When: Clean your hands immediately after an exposure to a bodily
reduce both transient and resident flora. fluid and after removing gloves
 Hand hygiene can be performed using Alcohol-based hand rub 4) After Patient Contact
(ABHR) or by washing hands with water and plain or antimicrobial When: Clean your hands after any patient contact
soap (bar or liquid) that contains an antiseptic agent such as Examples: After activities of daily living, handling of a patient’s
chlorhexidine, iodophors, or triclosan. (WHO 2009a) personal effects, after positioning a patient for an exam or
DIFFERENCE: procedure
Hand Hygiene (composed of) 5) After Contact with Patient Surroundings
 Process of removing soil, debris, and microbes by cleansing When: Clean your hands after you have had contact with a surface
hands using soap and water, alcohol based hand-rub (ABHR), anti that a patient may have touched.
septic agents, or anti-microbial soap. Example: After cleaning up the patient’s bedside and over bed table,
Hand washing making up the bed, moving wheel chairs or walkers
 Process of mechanically removing soil, debris, and transient flora The Steps for Routine Handwashing
from hands using soap.
PURPOSE:
 To reduce the number of microorganisms on the hands.
 To reduce the risk of transmission of microorganisms to clients.
 To reduce the risk of cross contamination among clients .
 To reduce the risk of transmission of infectious organisms to
oneself.
HAND HYGIENE OPPORTUNITIES:
 The World Health Organization (WHO) has five recommended
points in time when hand hygiene should occur to prevent
transmission of Health care-associated infection (HAIs).
These recommendations are called the “My 5 Moments for Hand
Hygiene” and focus on the following times:
(How to properly wash your hands)
1) Before contacting a patient
AVOIDING CONTAMINATION OF HANDS DURING
- to protect the patient against harmful germs carried on your
HANDWASHING
hands.
 Since microorganisms grow and multiply in moisture and in
2) Before performing a clean/aseptic task, including touching
standing water, the following are recommended to prevent
invasive devices
contamination of hands during handwashing:
- to protect the patient against harmful germs,including the
 Avoid bar soaps when possible because they can become
patient’s own ,from entering his/her body .
contaminated, leading to colonization of microorganisms on
3) After performing a task involving the risk of exposure to a body
hands. There is some evidence, however, that the actual
fluid, including touching invasive Devices.
hazard of transmitting microorganisms through handwashing
-To protect yourself and the health care environment from
with previously used bar soaps is negligible. If bar soap is
harmful patient germs.
4) After patient contact.
 used, provide small bars and use soap racks that drain the water d. Backs of fingers to opposing palms with fingers interlocked.

after use. (WHO 2009a)

 Do not add liquid soap to a partially empty liquid soap dispenser. e. Rotational rubbing of left thumb and each finger individually

This is known as “topping off.” The practice of topping off paying attention to areas between fingers and knuckles

dispensers may lead to bacterial contamination of the soap. Using and then vice versa.
f. Rub the fingertips against the palm of the opposite
refill packets avoids this problem but if they are not available,
hand and vice versa.
dispensers should be thoroughly cleaned and dried before refilling.
(WHO 2009a) 9. Rub and wash the wrist above 1 -2 inches moving forward

 Filter and/or treat water if a health care facility’s water is and backward. .

suspected of being contaminated; this will make the water 10.Clean fingernails carefully under running water using an orange

microbiologically safer. (WHO 2009a) stick.

 Use running water for hand hygiene. In settings where no running 11. Rinse elbow down to hands completely, keeping hands lower
water is available, water “flowing” from a pre-filled container with a than elbows.
tap is preferable to still-standing water in a basin. Use a container
12. Dry hands thoroughly with towel starting from the fingertips,
with a tap that can be turned off preferably with the back of the
hands and then wrist and forearm.
elbow (when hands are lathered) and turned on again with the
13. Turn off faucets with a hand towel or tissue paper
back of the elbow for rinsing. As a last resort, use a bucket with a
14. Used hand lotion if desired.
lid or a pitcher and a mug to draw water from the bucket, with the
help of an assistant, if available. (WHO 2009a) Evaluation

 Avoid dipping hands into basins of standing water. Even with the 15. Inspect hands and nails for cleanliness.
addition of an antiseptic agent (e.g., Dettol or Savlon), Documentation
microorganisms can survive and multiply in these solutions.
16. Record time when hand washing is done
(Rutala 1996)
III. GLOVING TECHNIQUE
 If a drain is not available where hands are washed, collect water
Overview of Gloving Method
used from hand hygiene in a basin and discard it in a drain or in a
 Before the late 1800s, no surgeon wore gloves.
latrine.
 Surgical rubber gloves were introduced more than 100 years
 Dry hands properly because wet hands can more readily acquire
ago at Baltimore's Johns Hopkins Hospital.
and spread microorganisms. Dry hands thoroughly with a method
 The introduction of the surgical glove in 1889 had a massive
that does not recontaminate the hands. Paper towels or single-use
impact on the safety of surgery and saved countless lives.
clean cloths/towels are an option. Make sure that towels are not
 Few people realize that the reason they were introduced to
used multiple times or by multiple individuals because shared
using rubber gloves has its roots in a love story.
towels quickly become contaminated. (WHO 2009a)
Brief Hx of Rubber
Alcohol-Based Handrub (ABH)’
II. HAND WASHING CHECKLIST
COMPETENCY PERFORMANCE CHECKLIST MEDICAL
THE (G)LOVE STORY
HANDWASHING
 William Stewart Halsted was one of the “Big Four” founding
PROCEDURE
professors of the Johns Hopkins Hospital.
Assessment
 Responsible for the development and introduction of radical
1. Assess the hands for visible soiling, breaks or cuts in the skin
mastectomy for breast cancer, as well as the establishment of
and cuticles.
Planning
the first training program and residency system for young
surgeons.
2. Assemble the equipment.

Implementation
 Caroline Hampton was a member of a prominent American

3. Remove jewelry and watch and push long sleeves above

southern family.

elbows. Don’t allow the uniform to touch the sink.

 She rebelled against her family wishes and entered nursing
school in New York City, graduating in 1888.
4. Adjust the water to appropriate temperature and flow
 In 1889 she moved to Baltimore, and it was here the two met,
5. Wet elbow and hands under running water always keeping hands and their love story begun.
lower than the elbow.  She was appointed chief nurse to William Halsted, and before
6. Lather hands with liquid soap or if bar soap is used wash soap and long the two become romantically involved.
lather hands.  Halsted decided to use a combination of carbolic acid and
7. Return bar soap on the soap dish without touching the dish. mercuric chloride as a disinfectant during his surgical
8. Performed hand hygiene for about 20 seconds using plenty of procedures.
friction and lather.  Hampton, acting as his scrub nurse would have to handle
a. Rubbed palms using firm circular motion. these chemicals regularly, and as a consequence, she
b. Right palm over left dorsum with interlaced fingers and vice developed severe contact dermatitis on her hands.
versa.
c. Palm to palm with fingers interlaced.
 Halsted could not bear to see her go through this and reached out TYPES OF GLOVES
to the Goodyear Rubber Company to create a rubber glove that (according to composition)
she could wear during surgery to protect her hands. VINYL GLOVES
Hx of Surgical Gloves  Made of polyvinyl chloride (PVC)
 By the early 1900s, all surgeons were wearing sterile rubber  Are latex-free
gloves.  Least expensive of the three types
 The first disposable latex medical gloves were manufactured in  Limited elasticity
1964 by the Ansell Rubber company. NITRILE GLOVES
 These gloves were sterilized the using gamma irradiation and were  Manufactured using synthetic latex, contain no latex proteins,
then disposed of following surgery. and are three times more puncture resistant than natural
 Disposable surgical gloves are now the standard in the operating rubber.
room and many surgeons ‘double glove’ when performing  These gloves are preferred choice for staff with latex allergy.
procedures to reduce the danger of infection from glove failure or LATEX GLOVES
puncture.  Manufactured using a milky fluid derived from the rubber tree,
 Talcum powder was introduced to make the donning of gloves Hevea brasiliensis.
easier, but over recent years evidence has arisen that this is linked  These gloves provide the best protection.
to the development of post-operative scars and inflammation. LATEX ALLERGY
 In December 2016, the use of powdered gloves was banned.  The protein in rubber can cause an allergic reaction in some
 Another recent development is the introduction of non-latex gloves. people. This reaction can range from sneezing to anaphylactic
The constant wearing of latex gloves has led to an increasing rate shock, which is a serious condition that requires immediate
of latex allergy in both medical professionals and patients, and medical attention.
gloves made of non-latex materials, such as polyvinyl chloride and Overview:
neoprene have become widely used.  Latex allergy is a reaction to certain proteins found in natural
NATURE AND DEFINITION OF GLOVING rubber latex, a product made from the rubber tree. If you have
Gloves a latex allergy, your body mistake latex for a harmful
 Is one of the most commonly used barrier for the spread of substance.
infection. Causes:
 It is made of latex rubber.  Direct contact
 Use for protecting the client as well as the health care providers in  Inhalation of latex particles
transmitting microorganisms. Symptoms:
 Cannot be reused again especially when contaminated.  Itching
PURPOSES OF USING GLOVES  Skin Redness
Nurses wear gloves because?  Hives or Rash
 to enable the nurse to handle or touch sterile objects freely without  Sneezing
contaminating them.  Runny nose
 to reduce the chance that the nurse’s hands will transmit  Scratchy throat
microorganism from one clients to another.  Difficulty breathing
 to protect the hands especially when handling any body Prevention:
substance. Stay away from

 to reduce the likelihood of nurses transmitting their own  Dish washing gloves
endogenous microorganisms to individuals receiving care.  Balloons
TYPES OF GLOVES  Rubber toys
(according to use)  Hot water bottles
SURGICAL GLOVES  Baby bottle nipples
 These gloves should be used when performing invasive medical or  Some disposable diapers
surgical procedures.  Rubber bands
 Ex: Assisting in the Operating Room.  Erasers
EXAMINATION GLOVES  Condoms
 Medical examination gloves provide protection to the nurse when  Diaphragms
performing many routine activities. METHODS FOR APPLYING STERILE GLOVES
 These gloves help prevent contamination between caregivers and Open Method
patients.  This method is used most frequently outside the Operating
 These gloves are used during procedures that do not require Room.
sterile conditions, for example drawing blood for a blood test.  Usually done when performing procedures that require the
UTILITY GLOVES sterile technique (changing dressing).
 These gloves are used for processing instruments, equipment and Closed Method
other items; for handling and disposing of contaminated waste;  This method is commonly used by the nurse along with the
and when cleaning contaminated surfaces. surgical gown in the sterile environment e.g. Operating room.
 DOONING AND REMOVING STERILE GLOVES Purposes:
(Open Method)
1. To enable the nurse to handle or touch sterile objects
1) Grasp the outer edge of the glove near the wrist with the opposite freely without contaminating them.
gloved. Ensure skin of forearm does not touch the outer glove
surface. 2. To prevent transmission of potentially infective organisms
from the nurse’s hands to clients at high risk for infection.
2) Peel the glove away, turning it inside out
3) Hold the glove in the other gloved hand.
4) To remove the second glove, insert two ungloved fingers under the
Assessment:
glove cuff and peel off the gloves.
5) Remove gloves by rolling it down the hand and turning it into a bag 3.Review the client’s record and orders to determine
containing both gloves. exactly what procedure will be performed that requires
sterile gloves.
6) Discard gloves safely according to your facility’s requirements. 4. Check the client record and ask about latex allergies. Use
7) Perform hand hygiene for at least 20 seconds with alcohol hand nonlatex gloves whenever possible.
1Preparation:
rub or washing with soap and water.
5. Prior to performing the procedure, introduce self and
GLOVE REQUIREMENT FOR CLINICALPROCEDURES
verify the client’s identity using agency protocol.
Blood pressure check NO
Temperature check NO 6. Explain to the client what you are going to do, why it is
necessary.
Injection YES 7. Provide for client privacy.
Blood drawing YES
IV insertion YES PROCEDURE

Catheterization YES Performance:

Pelvic examination YES 8. Remove jewelleries particularly rings.
Vaginal Delivery YES 9. Ensure the sterility of the package of gloves.

Cesarean Section YES

10. Perform hand hygiene and observe other appropriate
Handling and cleaning instruments YES
infection prevention procedures.
Handling contaminated wastes YES
Cleaning blood or body fluid spills YES 11. Remove outer wrapper carefully by separating and
peeling apart sides and lay it on clean, flat and dry
ACCIDENTAL CONTAMINATION OF STERILE GLOVES
surface.
Glove Accidents: 12. Open inner wrapper and touching only the outside,
 Tearing or puncturing the glove. secure both flaps in open position.
 Touching any non sterile object with the glove.
 Touching the outside of a glove with an ungloved hand. 13. Identify right and left glove. Each glove has cuff
SOME DOS AND DON’TS ABOUT GLOVES approximately 5 cm and 2 inches wide. Glove first the
Reminders! dominant hand.
14. With thumb and first two fingers of non – dominant
 Do wash hands or use an antiseptic hand rub before putting on
hand grasps the inner fold of the cuff. Lift the glove,
gloves and after removing them.
holding away from the body. Slip dominant hand
 Do wear the correct size glove, particularly surgical gloves. A
touching only the inner surface of the glove.
poorly fitting glove can limit your ability to perform the task and
15. With gloved dominant hand, slip four fingers
may be damaged (torn or cut) more easily.
underneath second glove cuff.
 Do change surgical gloves periodically during long cases as the
16. Lift the glove away from the body. Slide the second
protective effect of latex rubber gloves decreases with time and
hand into the second glove, touching only the inner
unapparent tears may occur.
part of the glove.
 Do keep fingernails trimmed moderately short to reduce the risk of 17. Adjust fingers of both gloves using gloved hand.
tears.
 Do use water-soluble (nonfat-containing) hand lotions and 18. Raise gloved hand above waist level.
moisturizers often to prevent hands from drying , cracking, and 19. Grasp outside of one cuff with other gloved hand,

chapping due to frequent hand washing and gloving. avoid touching the wrist.

 Don’t use oil-based hand lotions or creams, because they will 20. Pull glove off, turning it inside out. Discard
damage latex rubber gloves. in receptacle.
 Don’t hand lotions and moisturizers that are very fragrant
(perfumed) as they irritate the skin. V. GLOVE USE INFORMATION LEAFLET
 Don’t store gloves in areas where there are extremes in Medical gloves are defined as disposable gloves used during
temperature. These conditions may damage the gloves, thus medical procedures; they include:
reducing their effectiveness. 1) Examination gloves (non sterile or sterile)
III. APPLYING AND REMOVING GLOVES CHECKLIST 2) Surgical gloves that have specific characteristics of thickness,
elasticity and strength and are sterile
3) Chemotherapy gloves – these gloves are not addressed within this Type of gloves to be used:
document  As a general policy, selection of non-powdered gloves is
Rationale for using medical gloves: Medical gloves are recommended since this avoids reactions with the
recommended to be worn for two main reasons: alcohol-based handrub in use within the health-care facility
1. To reduce the risk of contamination of health-care workers hands Re-use/reprocessing:
with blood and other body fluids.  As medical gloves are single-use items, glove
2. To reduce the risk of germ dissemination to the environment and decontamination and reprocessing are not recommended and
of transmission from the health-care worker to the patient and vice should be avoided, even if it is common practice in many
versa, as well as from one patient to another health-care settings with low resources and where glove
Gloves should therefore be used during all patient-care activities that supply is limited.
may involve exposure to blood and all other body fluid (including contact  At present no standardized, validated and affordable
with mucous membrane and non-intact skin), during contact procedure for safe glove reprocessing exists
precautions and outbreak situations Every possible effort should be made to prevent glove reuse in
 The efficacy of gloves in preventing contamination of health-care health-care settings, such as educational activities to reduce
workers’ hands and helping to reduce transmission of pathogens inappropriate glove use, purchasing good quality disposable gloves
in health care has been confirmed in several clinical studies. and replenishing stocks in a timely manner.
Nevertheless, health-care workers should be informed that gloves Summary of key messages for practical medical glove use:
do not provide complete protection against hand contamination.  Gloves are effective in preventing contamination of
Pathogens may gain access to the caregivers’ hands via small health-care workers’ hands and helping reduce transmission
defects in gloves or by contamination of the hands during glove of pathogens dependent upon two critical factors:
removal. Hand hygiene by rubbing or washing remains the basic to a) They are used appropriately
guarantee hand decontamination after glove removal. b) Timely hand hygiene is performed using the method of
Key learning point: gloves do not provide complete protection against hand rubbing or hand washing.
hand contamination.  Safe glove use involves:
 The impact of wearing gloves on adherence to hand hygiene a) Using the correct technique for donning gloves that
policies has not been definitively established, since published prevents their contamination
studies have yielded contradictory results. However, the b) Using the correct technique for removing gloves that
recommendation to wear gloves during an entire episode of care prevents health-care workers’ hands becoming
for a patient who requires contact precautions, without contaminated (see figure Technique for donning and
considering indications for their removal, such as an indication for removing non-sterile examination gloves).
hand hygiene, could actually lead to the transmission of germs.  The unnecessary and inappropriate use of gloves results in a
Key learning point: prolonged use of gloves for contact precautions in waste of resource and may increase the risk of germ
the absence of considering the need to perform hand hygiene can result transmission.
in the transmission of germs.  Health-care workers should be trained in how to plan and
Glove use and the need for hand hygiene: perform procedures according to a rational sequence of
 When an indication for hand hygiene precedes a contact that also events and to use non-touch techniques as much as possible
requires glove usage, hand rubbing or hand washing should be in order to minimize the need for glove use and change.
performed before donning gloves.  If the integrity of a glove is compromised (e.g., punctured), it
 When an indication for hand hygiene follows a contact that has should be changed as soon as possible and complemented
required gloves, hand rubbing or hand washing should occur after with hand hygiene.
removing gloves.  Double gloving in countries with a high prevalence of HBV,
 When an indication for hand hygiene applies while the health-care HCV and HIV for long surgical procedures (>30 minutes), for
worker is wearing gloves, then gloves should be removed to procedures with contact with large amounts of blood or body
perform handrubbing or handwashing. fluids, for some high-risk orthopaedic procedures, is
Inappropriate glove use: considered an appropriate practice.
 The use of gloves when not indicated represents a waste of  Use of petroleum-based hand lotions or creams may
resources and does not contribute to a reduction of adversely affect the integrity of latex gloves and some
cross-transmission. alcohol-based handrubs may interact with residual powder on
 It may also result in missed opportunities for hand hygiene. health-care workers’ hands.
 The use of contaminated gloves caused by inappropriate storage, Summary of the recommendations on glove use:
inappropriate moments and techniques for donning and removing, A. In no way does glove use modify hand hygiene indications or
may also result in germ transmission replace hand hygiene action by rubbing with an alcohol-based
Key learning point: : it is important that health-care workers are able to product or by handwashing with soap and water.
differentiate between specific clinical situations when gloves should be B. Wear gloves when it can be reasonably anticipated that
worn and changed and those where their use is not required (see figure contact with blood or other body fluids, mucous membranes,
The Glove Pyramid). Moreover, the health-care worker should be non-intact skin or potentially infectious material will occur.
accurately informed on the moment (see Table) for donning and C. Remove gloves after caring for a patient. Do not wear the
removing gloves. same pair of gloves for the care of more than one patient.
D. When wearing gloves, change or remove gloves in the following Technique for donning and removing non-sterile
situations: during patient care if moving from a contaminated body examination gloves
site to another body site (including a mucous membrane, HOW TO DON GLOVES:
non-intact skin or a medical device within the same patient or the 1) Take out a glove from its original box.
environment). 2) Touch only a restricted surface of the glove
E. The reuse of gloves after reprocessing or decontamination is not corresponding to the wrist (at the top edge of the
recommended. cuff)
Summary of the indications for gloving and for glove removal: 3) Don the first glove
Gloves on 4) Take the second glove with the bare hand and touch
1. Before a sterile procedure only a restricted surface of glove corresponding to
2. When anticipating contact with blood or another body fluid, the wrist
regardless of the existence of sterile conditions and including 5) To avoid touching the skin of the forearm with the
contact with non-intact skin and mucous membrane gloved hand, turn the external surface of the glove to
3. Contact with a patient (and his/her immediate surroundings) during be donned on the folded fingers of the gloved hand,
contact precautions. thus permitting to glove the second hand
Gloves off 6) Once gloved, hands should not touch anything else
1. As soon as gloves are damaged (or non-integrity suspected) that is not defined by indications and conditions fro
2. When contact with blood, another body fluid, non-intact skin and glove use
mucous membrane has occurred and has ended HOW TO REMOVE GLOVES:
3. When contact with a single patient and his/her surroundings, or a 1. Pinch one glove at the wrist level to remove it,
contaminated body site on a patient has ended without touching the skin of the forearm, and peel
4. When there is an indication for hand hygiene. away from the hand, thus allowing the glove to turn
The Glove Pyramid – to aid decision making on when to wear (and inside out.
not wear) gloves 2. Hold the removed glove the gloved hand and slide
 Gloves must be worn according to STANDARD and CONTACT the fingers of the ungloved hand inside between the
PRECAUTIONS. The pyramid details some clinical examples in glove and the wrist. Remove the second glove by
which gloves are not indicated, and others in which examination or rolling it down the hand and fold into the first glove
sterile gloves are indicated. Hand hygiene should be performed 3. Discard the removed glove
when appropriate regardless of indications for glove use. 4. Then, perform hand hygiene by rubbing with and
alcohol-based hand rub or by washing with soap and
water.
 4. Self-administered bath: this is the same as in bed bath
except the patient is assisting in taking a bath
Bathing keeps the skin healthy and can help prevent infections. It's
5. Tub bath or bathroom bath: this bath is allowed to the
a good time to check the skin to look for sores or rashes. Bathing
patient only if he has enough confidence for self-help and
also helps your loved one feel fresh and clean.
to withstand the procedure
The amount of help your loved one needs when bathing depends
on how well he or she can move.
PROCEDURE AND RATIONALE IN BED BATH
You may be caring for someone who has short-term trouble with
self-care because he or she is recovering from an illness or
surgery. Or you may be taking care of an older person who has
memory problems. The person may not remember how to bathe.
Or you could be caring for someone who has a long-term inability
to move, such as a person who is paralyzed. This person will need
much more of your care when bathing.

A person who has to stay in bed for a short time and who can
move a little may be able to take a shower with some help once or
twice a week. Or the person may prefer a partial bath at the sink or
with a basin every day.

A person who can't move well or who can't move at all needs a
bed bath. This is often called a sponge bath, but washcloths are
often used too. You can give a full bath in bed without getting the
bed sheets wet.

BED BATHING

- Bed bath means bathing a patient who is confined to bed

and cannot have the physical and mental capability of
self-bathing \
- Bath is the act of cleaning the body. Baths are given for
therapeutic purposes

PURPOSE OF BED BATH

● Bathing is an important part of personal hygiene; To
cleanse body of dirt, debris and perspiration
● Bathing cleanses the skin makes the patient more
comfortable
● It stimulates circulation and relaxes the patient.
● It’s a good opportunity to serve and observe the client
body and as well as communicate with the patient; to
maintain an effective nurse-patient relationship

EQUIPMENTS OF BED BATH

1. 2 Wash basin * bath blanket

2. 2 Bath towel * 2 wash cloth
3. Patient gown * hamper for soiled linen
4. Clean Gloves (optional) * soap
5. Hygiene supplies (lotion, powder, deodorant)
6. Bedpan/ urinals

TYPES OF PATIENTS NEEDING BED BATH

- Unconscious or semiconscious patients

- Postoperative patients
- Patients with strict bed rest
- Paraplegic patients
- Orthopedic patients in plaster–cast and traction
- Seriously ill patient
HAIR SHAMPOO
TYPES OF CLEANSING BATH:
The condition of their hair and how it is styled is an important part
1. Bed bath: it is the bathing of a patient who is confined to of patients’ identity and wellbeing, so assisting them with hair care
bed is a fundamental aspect of nursing care.
2. Therapeutic bath: doctor specifies the temperature of
the water, medications to be added and the body part to Hair care is an essential part of personal hygiene and has an
be treated important role in maintaining self-esteem and quality of life.
3. Partial bath: it is the act of cleaning particular areas in Supporting patients to maintain hair care when they cannot do this
the body part. They are the face, axilla, and genitalia, themselves is a fundamental aspect of nursing care.
upper and lower-limbs.
 PROCEDURE AND RATIONALE IN DOING BED SHAMPOO
This article outlines the procedure for washing patients’ hair when
they are confined to bed. Supporting patients to maintain their
hygiene needs while in hospital is a fundamental aspect of nursing
care yet there is very little evidence to support practice (Coyer et
al, 2011).

Personal hygiene includes care of the hair, skin, nails, mouth,

eyes, ears, perineal areas (Dougherty and Lister, 2015) and facial
shaving (Ette and Gretton, 2019).

Helping patients to wash and dress is frequently delegated to

junior staff, but time spent attending to a patient’s hygiene needs is
a valuable opportunity for nurses to carry out a holistic
assessment.

SHAMPOOING
- Washing or cleaning of the hair with the use of shampoo
or a cleaning agent for weak or bedridden clients.

PURPOSE OF BED SHAMPOOING

1. To cleanse the hair and scalp.

2. To stimulate scalp circulation
3. To remove dirt and soil from the scalp.

EQUIPMENTS:

● Bath blanket
● Two (2) pails
● comb/hair brush
● Rubber sheet/waterproof pad
● Shampoo
● clean gloves(optional)
● 2 Cotton balls
● Two (2) bath towels
● Kelly pad
● Pitcher
● Warm water
● 2 washcloth

]
FUNDAMENTALS OF NURSING RLE
TRANSFERRING OF CLIENT FROM BED TO WHEELCHAIR
BSN 2-2
Transcriber: Kayle L. Pellos
OVERVIEW Step 2. Stand the patient up

A transfer can be viewed as the safe movement of a person from one - Have the patient scoot to the edge of the bed.
place or surface to another, and as an opportunity to train an individual to - Assist the patient in putting on skid proof socks or shoes.
enhance independent function. In both cases the clinician must choose
the most efficient and safest method. Controlling a patient's movement, - Put your arms around the patient's chest, and clasp your hands behind
while moving the patient from one position, or surface, to another, or his or her back. Or, you may also use a transfer belt to provide a firm
preventing a patient falling requires that the clinician be close to the handhold.
center of motion (COM) of the patient, which is typically located between - Supporting the leg farthest from the wheelchair between your legs, lean
the shoulders and the pelvis. When these points of control are used, back, shift your weight, and lift.
patient transfers are more efficient and patient safety is enhanced. The
most efficient way to enhance the movement of the patient (unless he or
Step 3. Pivot toward chair
she is totally dependent) is to encourage movement of the distal
component of the body—the part of the body that is farthest from the
- Have the patient pivot toward the chair, as you continue to clasp your
trunk. For example, when assisting a patient to stand from a seated
hands around the patient.
position, a common verbal cue is to ask the patient to lean his or her trunk
- A helper can support the wheelchair or patient from behind.
forward. In addition, it is also important to have the patient look in the
direction of the transfer's destination to encourage correct head turning.
Step 4. Sit the patient down

- As the patient bends toward you, bend your knees and lower the patient
TOPIC: PATIENT TRANSFERS into the back of the wheelchair.
- A helper may position the patient's buttocks and support the chair.
One of the purposes of transfers is to permit a patient to function in - Reposition the foot rests and the patient's feet.
different environments and to increase the level of independence of the
patient. Because of advancements in recent years, a number of moving Step 5. To put him back to bed
and lifting devices (total body lifts and sit-to-stand lifts) have been
designed and incorporated into the healthcare system. However, because - Assist patient to stand, help to turn and stand on stool and back to bed.
of the expense and sometimes the inconvenience of these devices, - Support patient while he sits on the side of bed.
manual transfers continue to be commonly used. In these cases, the best - Remove robe and slippers.
body mechanics possible should be used to maximize the ability to - Pivot to a sitting position in bed, supporting her head and shoulders with
encompass a task with minimal effort and maximum safety. It is important one arm and her knees with the other arm, and lower slowly to bed in
to note that certain transfers increase the risk for injury necessitating lying position.
additional care and attention. Depending on the functional ability of the - Draw up bedding.
patient, a transfer may be performed independently by the patient, with - Document
assistance from the clinician (minimal, moderate, maximal, or standby
supervision), or dependently.
TRANSFERRING TECHNIQUE

TRANSFERRING A PATIENT FROM BED TO A WHEELCHAIR DEFINITION

• Patient safety is often the main concern when moving patient - It is the use of proper body mechanics in repositioning, lifting and
from bed. But remember not to lift at the expense of your own transferring client’s safety.
back. This transfer often requires the patient’s help so clear
communication is essential if the patient cannot help much, you PURPOSE:
will need two people or a fully body sling lift.
- Positions and prepares client for a variety of clinical procedure.
Purpose: - The movement maintains and restores muscle tone.

1. To strengthen the patient gradually. 1. ASSISTING CLIENT FROM BED TO WHEELCHAIR/CHAIR

2. To provide a change in position.
EQUIPMENT
Equipment: - Bed
- Wheelchair/chair
• Gait or Transfer belt - Transfer belt/support
• Chair or wheelchair
• Patient’s robe and slippers PROCEDURE RATIONALE
• Pillows 1. Check doctor’s order and • To determine any
• Blanket, sheet or draw sheet
• Footstool
client’s diagnosis and contraindications/limitations
restrictions. on the client’s physical
Safety considerations: activity
• Check room for additional precautions. 2. Assess the client’s ability, • To provide information
• Introduce yourself to patient. level of comfort, muscle about the client’s physical
• Confirm patient ID using two patient identifiers (e.g., name and
date of birth). strength, presence of abilities to ensure safe
• Listen and attend to patient cues. paralysis, and ability to follow transferring
• Ensure patient’s privacy and dignity. instructions.
• Assess ABCCS/suction/oxygen/safety. 3. Wash hands • To prevent the transfer of
• Ensure tubes and attachments are properly placed prior to the microorganisms.
procedure to prevent accidental removal.
• A gait belt and wheelchair are required. 4. Obtain equipment needed • To avoid accident while
and check its condition. moving the client.

 Remember: When patients are weak, brace your

knees against theirs to keep their legs from buckling. Also,
5. Identify client. Inform client
about the desired purpose
• To reduce client’s anxiety
and increase cooperation
transfer toward patient's stronger side if possible. and destination.

6. Adjust the height of the • To reduce distance that

Step 1. Sit the patient up bed to lowest possible the client has to step down,
position. thus decreasing risk of
- Position and lock the wheelchair close to the bed. Remove the injury
armrest nearest to the bed, and swing away both leg rests. 7. Slowly raise the head of • Minimize lifting, thereby
- Help the patient turn onto his or her side, facing the wheelchair. the bed, if not minimizing discomfort both
- Put an arm under the patient's neck with your hand supporting the
contraindicated by client’s for client and the health
shoulder blade; put your other hand under the knees.
condition. care provider.
- Swing the patient's legs over the edge of the bed, helping the
patient to sit up.

Page 1 of 2
8. Place one arm under the • To support client while
client’s leg and one behind sitting him/her on the edge
the client’s back. Slowly pivot of the bed.
the client so the client’s legs
are dangling over the edge
of the bed.

9. Allow the client to dangle • To allow for assessing

for 2 to 5 minutes. Support client’s response to sitting
client if necessary. to reduces possibility of
orthostatic hypotension.

10. Bring the chair or • To allow client to bear

wheelchair close to the side weight on strong side
of the bed. Place it at 45-
degree angle of the bed. If
the client has a weaker side,
place the chair/wheelchair on
the client’s strong side.
11. Lock wheelchair brakes • To provide stability.
and elevate the foot pedals.
12. Put transfer belt or other • Provides safe balance
transfer aid if needed, and hold on client without
secure. stressing joints or limbs.

13. Lifters knees are well • Transfer belt is grasped

flexed with back straight, at each side to provide
hands gripping each side of movement
transfer belt.
14. Rock client’s body up to • Rocking motion gives a
standing position in the count client body movement and
of three, while straightening requires less muscular
hips and legs, keeping knees effort to lift the client
slightly flexed.
15. Lifter and client pivot turn • Less effort for lifter and
so lifter is facing chair and client
client’s back is toward chair,
lifter still holding the transfer
belt.
16. Instruct client to use arm • To increase client’s
to rest on chair. stability.
17. Flex hips and knees • Presents injury to client
while lowering client into from poor body alignment.
chair/wheelchair.
18. Assess client for proper • To make client
alignment for sitting position. comfortable.
Support weak side with
pillow, if needed.
19. Secure the safety belt, • To ensure client’s safety;
place client’s feet on foot to prepare client for
pedals and release brakes. If movement
you will move the client
immediately. If client is sitting
on chair, offer a foot stool if
available.
20. Wash hands. • To reduce the
transmission of
microorganism.
21. Record effect of the • To provide accurate data
transfer. in the care of client.

Page 2 of 2
 Amputations- is a nonsurgical removal of the limb from the body.
Wound care is a very important part of nursing procedure in any
Bleeding is heavy and requires a tourniquet to stop the flow. Shock
healthcare setting. Wounds come in all sizes and forms, and each
is certain to develop in these cases.
one offers unique challenges to infection prevention.

Things usually used when doing wound dressing:

Wound is a type of injury in which a skin is torn, cut or punctured
(open wound) or where blunt force trauma causes contusion
Sterile tray
(closed wound).
Sterile gauze
Vaseline gauze
Dressing is an adjunct used by a person for application to a wound
Adhesive gauze
to promote healing and or/ prevent further harm. A dressing is
NaCl and Betadine
designed to be in direct contact with wound, which makes it
Lidocaine spray
different from a bandage, which is primarily used to hold a
Clean gloves
dressing in place.
Syringe
CORE PURPOSES OF A DRESSING:
Dressings for dry wounds
A dressing can have a number of purposes, depending on the
● Transparent: gas exchanged between wound &
type, severity and position of the wound, although all purposes are
environment but bacteria prevented from entering.
focused towards promoting recovery and preventing further harm
Creates moist healing environment.
from the wound.
Example: tegaderm
1. Stem bleeding- helps seal the wound to expedite the
● Hydrogels: high water content enhances epithelialization
clotting process.
and autolytic debridement. Needs cover dressing and
2. Absorb exudates- soak up blood, plasma and other fluids
wound edge barrier.
exuded from the wound, containing it in one place.
Example: Carrasyn
3. Ease pain- some dressing may have a pain relieving
effect and others have placebo effect.
● Wet to moist gauze dressings: keeps wound bed moist.
4. Debride the wound- removal of slough and foreign
Minimizes trauma to granulation tissues.
objects from the wound.
5. Protection from infection and mechanical damage
● Hydrocolloid: hydrophilic particles mix with water to form
6. Promote healing- though granulation and epithelialization.
a gel. Wound stays moist. DO NOT use in infected
wounds.
Example: Duoderm
SIZE OF WOUND:

● Absorption materials: beads, powderm, rope or sheets

Large wounds- are more serious than small ones, they usually
that absorb large amounts of exudate.
involve more severe bleeding, more damage to the underlying
Example: Calcium alginate
organs ot tissues, and greater degree of shock.

● Foam: made of hydrophilic material. Highly absorbent.

Small wounds- are sometimes more dangerous than large ones;
Example: Allevyn
they may become infected more readily due to neglect.

● Dry gauze: Can absorb wound drainage. Can be

LOCATION OF THE WOUND
impregnated with agents to promote healing.
- Since the wound may involve serious damage to deeper
structures, as well as to the skin and the tissues
Irrigations:
immediately below it, the location of the wound is
important.
- Cleanses a wound using pressure
- Sterile normal saline= usually prescribed
TYPES OF WOUNDS:
- Avoid caustic agents ie: peroxide, iodine
- Pressure between 4-15 pounds per square inch (psi) ie:
Abrasions- made when skin is rubbed or scraped off. Rope burns,
60ml syringe with catheter tip.
floor burns and skinned knees or elbows are common examples of
abrasions. It can be infected easily because dit and germs may be
Other therapies:
embedded in the tissues.
- Wound V.A.C- negative pressure vacuum assisted
closure system. Removes drainage and helps wounds
Incisions- commonly called CUTS, are wounds made by sharp
close.
cutting instruments such as knives, razors, and broken glass. It
- Hydrotherapy- pulse lavage, whirlpool. Aids in
tends to bleed freely because the blood vessels are cut cleanly
debridement and cleansing, warm water vasodilation
and without ragged edges.
- Hyperbaric oxygen
- Electrical Stimulation- electrical signals direct cell
Lacerations- wounds are torn rather than cut. They have ragged
migration in wound healing.
irregular edges and masses of torn tissue underneath. Usually
made by blunt, rather than sharp objects.
TYPES OF TOPICAL WOUND DRESSINGS
Punctures- caused by objects that penetrates into tissues while
● Hydrocolloid dressings
leaving a small surface opening. Wounds made by nails, needles,
○ Made up of pectin based wafer material
wire and bullets are usually punctures.
○ Absorb minimal to moderate exudate
○ Occlusive – should not be used on infected
wounds
Avulsions- tearing away of tissue from a body. Bleeding usually
○ Come in various shapes and sizes
heavy. In certain situations, the torn, tissue may be surgically
○ Should not be used if you need to change more
reattached.
than 2-3 days
 ● Hydrogel dressings 2. Place package on a clean, dry, waist-level table.
○ Made up of primarily water in a polymer to
maintain moist wound base ● A clean, dry surface is required to set up a sterile field.
○ Come in amorphous or sheet formulations ● Items below waist level are considered contaminated.
○ Should be used in dry wounds ● Prepare sterile field as close to the time of procedure as
○ Should not be used in more than minimally possible.
exudating wounds
○ Should not be used with an absorbant dressing, 3. Place the package at the center of the work area.
e.g. hydrocolloid, foam, etc.
● Alginate dressings 4. Pull the top flap wrapper between your thumb and index
○ Made up of seaweed from the North Sea finger away from you.
○ Absorb moderate amounts of drainage
○ Dry formulation, that becomes a gel when it ● The one-inch border on the sterile field is considered
comes into contact with wound fluid through non-sterile. Make sure your arm is not over the sterile
Calcium/Sodium ion exchange field.
○ Should not be used with hydrogels ● The inside of the sterile packaging is your sterile drape.
● Hydrofiber dressings ● Stand away from your sterile field when opening sterile
○ Work the same as alginates but absorb ~ 30 % packaging.
more exudate.
○ Use with caution in mildly draining wounds.
● Transparent film dressings 5. Open side flaps, opening the top flaps first. Right hand for
● Foam dressings the right flap, & the left hand for the left flap.
○ Made up of polyurethane foam
○ Absorbs moderate to large amounts of drainage 6. Pull the innermost flap toward you.
○ Available in various sizes and shapes
○ Some types may macerate periwound skin if it ● Touch only the one-inch border on the sterile field. Do not
allows drainage to wick laterally reach over the sterile field.
● Absorbent dressings
○ Frequently made with “diaper” technology to 7. Open sterile item while holding outside wrapper.
absorb more drainage than traditional ABD pad
○ Many are covered with non-adherent layer, e.g. 8. Supplies can be opened (following packaging directions),
ExuDry then gently dropped onto the sterile field.
● Gauze dressings ● Gently drop items onto the sterile field or use sterile
● Composite dressings forceps to place sterile items onto the field.
● Biologic dressings ● If using equipment wrapped in linen, ensure sterility by
○ SIS (Sterile intestinal submucosa) - Oasis checking the tape for date and to view chemical indicator
● Specialty Dressings (stripes on the tape ensure sterility has been achieved).
○ Silver dressings – e.g. Acticoat ● When using paper-wrapped items, they should be dry
○ Biologic Dressings – SIS (Oasis) and free from tears. Confirm expiry date.
○ Skin Substitutes – Appligraf/ Dermagraft ● Do not flip or toss objects onto the sterile field.
● Silver dressings
○ Antimicrobial to reduce bioburden of wound 9. Peel wrapper onto dominant hand.
through slow release of silver ion into the wound
● Skin substitutes 10. Dispose outer wrapper.
○ Appligraf
○ Dermagraft
TO ADD SOLUTION TO A STERILE FIELD:
!!! BEFORE PROCEEDING TO WOUND CARE, YOU MUST
FIRST PREPARE AND ESTABLISH A STERILE FIELD 11. Read the solution label and strength three times.
12. Remove the lid and place sterile side up onto a clean surface.
STERILE FIELD 13. Pour the liquid from 6-8 inches above the sterile container in
the sterile field.
- Aseptic procedures require a sterile area in which to work 14. Pour slowly.
with sterile objects. A sterile field is a sterile surface on 15. Avoid reaching over the sterile field.
which to place sterile equipment that is considered free
from microorganisms WOUND DRESSING/ WOUND CARE
- A sterile field is required for all invasive procedures to
prevent the transfer of microorganisms and reduce the STEPS TO FOLLOW FOR A WOUND DRESSING:
potential for surgical site infections.
- Sterile fields can be created in the OR using drapes, or at Assessment
the bedside using a prepackaged set of supplies for a
sterile procedure or wound care. 1. Verify the client’s diagnosis and doctor’s order for the wound
- Many sterile kits contain a waterproof inner drape that care.
can be set up as part of the sterile field.
- Sterile items can be linen wrapped or paper wrapped, 2. Assess the client’s physical abilities, level of comfort and ability
depending on whether they are single or multi-use. to follow instructions.

STEPS TO FOLLOW IN SETTING UP A STERILE FIELD Planning

TO OPEN A STERILE WRAPPED PACKAGE ON A SURFACE: 3. Prior to performing the procedure, introduce yourself, identify
the client’s identity and explain the procedure to the client why it is
1. Perform hand hygiene, gather supplies, check equipment necessary.
for sterility, and gather additional supplies (gauze, sterile
cleaning solution, sterile gloves, etc.). 4. Position patient appropriately and comfortably.

● Gathering additional supplies at the same time will help 5. Provide privacy for the client.
avoid leaving the sterile field unattended. Prepackaged
sterile kits may not have all the supplies required for each 6. Gather the necessary equipment and check for the
procedure. completeness of supplies.
Implementation - Drainage coming from or around the incision or wound
and it: is not decreasing after 3 to 5 days, increasing and
7. Use good body mechanics: position bed or over bed table to a becoming thick, tan or yellow or smells bad.
working level.

8. Prepare the sterile field.

9. Pour the cleansing solution over the sterile container making

sure that the opening the container would not touch the sterile
container and avoiding spilling of solution over the sterile field.

10. Prepare the client and expose only the previously dressed
wound.

11. Drape the client with water-resistant under pad (optional)

12. Wash hands and apply clean gloves.

➢ Wipe the wound with sterile gauze (inside – outside

direction / circular motion)
➢ Discard the gauze in the waste bin and continue pouring
hydrogenperoxide until you can see few bubbles from the
wound.
➢ Soak the gauze in the cup of Sodium Chloride and wipe
the wound.
➢ Remove some blood surrounding it.

13. Loosen edges of tape of the old dressing. Stabilize the skin
with one hand while pulling the tape in the opposite direction.

14. Beginning at the edges of the dressing, lift the dressing toward
the center of the wound.

15. If the dressing sticks, moisten it with 0.9% normal saline before
completely removing it.

16. Observe the removed dressing for drainage, especially noting

amount, color and odor (if any) of drainage.

17. Dispose of soiled dressing and gloves in a biohazard bag.

Remove gloves and perform hand hygiene.

18. Open sterile dressing supplies and sterile gloves using sterile
technique. Recognize and verbalize action if contamination occurs.

19. Don sterile gloves without contaminating or recognizing

contamination.

20. Use sterile cotton balls or gauze to cleanse wound: “Clean to

dirty” and “top to bottom”

a. Clean the incision line first going from top to bottom

b. Clean the along each side of incision with a separate
cotton ball, going from top to bottom.

21. Pick up new sterile dressing and place it over center of wound.

22. Place large sterile dressing over the wound dressing.

23. Secure edges of dressing to skin with tape.

24. Discard all the used materials in the appropriate receptacle.

25. Remove gloves and perform hand hygiene. Assist patient to

comfortable position and lower the bed.

Evaluation and Documentation

26. Document the wound care procedure including the

assessment of the wound, time, date and evaluate the response of
the patient upon and after wound care.

Call doctor when:

- More redeness
- More pain
- Swelling
- Bleeding
- Wound is larger or deeper
- Wound looks dried out or dark]
- Temperature above 100F for more than 4 hours
-
 FUNDAMENTALS OF NURSING RLE

MODULE 2: VITAL SIGNS

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Vital Signs (Cardinal Signs)

-Temperature is measured in either Celsius or Fahrenheit, with a fever
-Reflect the body's physiologic status and provide information critical to defined as greater than 38-38.5 C or 101-101.5 F.
evaluating homeostatic balance.
Old people, people with disabilities, babies and young children typically
Includes: feel more comfortable at higher temperatures.
• Temperature Normal range of findings
• Pulse rate
• Respiratory rate The normal temperature is influenced by:
• Blood pressure 1. Age: Wider normal variations occur in the infant and young child
Vital signs are physical signs that indicate and individual is alive, such as because of less effective heat control mechanisms.
heart beat, breathing rate, temperature, blood pressures and recently In older adults' temperature is usually lower than in other age groups, with
oxygen saturation. a mean of 36.2 degrees centigrade (92.7 F) via the oral route. Rectal
temperature remains 0.5 degrees or higher than the oral temperatures in
Purpose:
older adults.
▪ To obtain base line data about the patient condition
2. Diurnal variations (circadian rhythm): A cycle of 1 to 1.5 degrees F
▪ For diagnostic purpose
occurring in the morning hours and the peak occurring in the late
▪ For therapeutic purpose
afternoon to early evening.
Equipment: 3. Exercise: Moderate to hard exercise increases body temperature.
4. Hormones: The menstruation cycle in women. Progesterone
• Stethoscope secretion, occurring with ovulation at midcycle, causes a 0.5 degree
• Sphygmomanometer to 1 degree F rise in temperature that continues until menses.
• Thermometer
Sites to measure body temperature:
• Second hand watch
• Red and blue pen • Oral
• Pencil • Rectal
• Vital sign sheet • Axillary
• Cotton swab in bowl • Tympanic
• Disposable gloves if available
-Thermometer is an instrument used to measure body temperature.
• Dirty receiver kidney basin

Times to assess vital signs

Temperature measurements are obtained by several methods
✓ On admission – to obtain baseline data
✓ When a client has a change in health status or reports symptoms • Heat-sensitive patches
such as chest pain or fainting
-patch placed on the skin; color changes on the patch indicate temperature
✓ According to a nursing or medical order
readings.
✓ Before and after the administration of certain medications that
could affect RR or BP (Respiratory and CVS) • Electronic thermometers
✓ Before and after surgery or an invasive diagnostic procedure - Consist of a rechargeable battery-powered display unit, a thin wire
✓ Before and after any nursing intervention that could affect the vital cord, and a temperature processing probe.
signs. (e.g. ambulation) • Tympanic thermometer
✓ According to hospital/ other health institution policy.
-Special form of electronic thermometer; inserted into auditory canal
Temperature
The procedure: Oral Temperature
- Is the hotness or coldness of the body. It is the balance between ▪ Obtained by putting the thermometer under the tongue.
heat production & heat loss of the body. ▪ Its measurement is 0.65 less than rectal temperature and 0.65
- Normal body temperature using oral 37 Celsius or 98.0 F greater than axillary temperature.
Two kinds of body temperature ▪ Leave 3-5 minutes in place.
▪ Is the most common site for temperature measurement
1. Core Temperature ▪ This site is inconvenient for:
- Is the temperature of internal organs and it remains constant most - Unconscious patients,
of the time (37c); with a range of 36.5-37.5c. - Infants and children
- Is the temperature of the deep tissues of the body - Patients with ulcer or sore of the mouth,
- Remains relatively constant - Patients with persistent cough
- Measure with thermometer
2. Surface temperature Advantage – easy access and patient comfort

-Surface body temperature is the temperature of the skin; subcutaneous Disadvantage – it can lead to a false reading if a person has taken hot or
tissue & fat cells and it rises & falls in response to the environment. cold food/drink by mouth, & has smoked so we have to wait for at least
10-15min, after meal or smoking.
-Ranges between 20-40c
Contraindication
-It doesn't indicate internal physiology
▪ Px who cannot follow instruction to keep their mouth closed
 ▪ Child below 7 yrs. old Route Normal Sites
▪ Epileptic, or mentally ill patients Range F/C
▪ Unconscious Oral 98.6 F/37.0 Mouth
▪ Clients receiving O2 C
▪ Clients with persistent cough Tympanic 99.6 F/ 37.6 Ear
▪ Uncooperative or in severe pain C
▪ Surgery of the mouth Rectal 99.6 F/ 37.6 Rectum
▪ Nasal obstruction C
Axillary 97.6 F/ 36.6 Axilla
▪ If px has nasal or gastric tubs in place
C
Alterations in body temperature
▪ Normal body temperature is 37 C or 98.6 F Pulse
▪ Range is 36-38 C (96.8-100 F)
▪ Body temperature may be abnormal due to fever (high - pulse is a wave of blood created by the contraction of left ventricle.
temperature) or hypothermia (low temperature) - pulse reflects the heart beat
▪ Pyrexia, fever: a body temperature above the normal ranges 38 C –
41 C (100.4 - 105.8 F) -stroke volume and the compliance of arterial wall are the two important
▪ Hyperpyrexia: a very high fever, such as 41 C > 42 C leads to death. factors influencing pulse rate.
▪ Hypothermia: body temperature between 34 C – 35 C, < 34 C is -pulse rate is regulated by autonomic nervous system.
death.
- the normal pulse for healthy adult ranges from 60 to 100 beats per
Common types of fever minute.
1. Intermittent fever: The body temperature alternates at regular ▪ Peripheral pulse: is a pulse located in the periphery of the body
intervals between periods of fever and periods of normal or subnormal (e.g. in the foot, and or neck)
temperature. ▪ Apical pulse (central pulse): it is located at the apex of the heart
2. Remittent fever: a wide range of temperature fluctuation (more ▪ The PR is expressed in beats/minute (BPM)
than 2 C) occurs over the 24-hour period, all of which are above normal ▪ The difference between peripheral and apical pulse is called pulse
deficit, and it is usually zero.
3. Relapsing fever: short febrile periods of a few days are interspersed
with periods of 1 or 2 days of normal temperature. Pulse is assessed for

4. Constant fever: the body temperature fluctuates minimally but • Rate (60-100bpm)
always remains above normal. • Rhythm (regularity or irregularity)
• Volume
The Procedure: Rectal Temperature • Elasticity of arterial wall
▪ Obtained by inserting the thermometer into the rectum or anus. *The pulse is commonly assessed by palpation (feeling) and auscultation
▪ It gives reliable measurement & reflects the core body (hearing using a stethoscope)
temperature.
▪ Hold the thermometer in place for 3 to 5 minutes. Factors affecting the Pulse Rate
▪ More accurate, most reliable, is >0.65C (1 C) higher than the oral ▪ Age
temperature because few factors can influence the reading.
▪ Disadvantages are: The average pulse rate of an infant ranges from 100 to 160 BPM.
-injure the rectum, it needs privacy The normal range of the pulse in an adult is 60 to 100 BPM
-it is inappropriate for patients with diarrhea and anal fissure.
▪ Sex
The Procedure: Axillary Temperature
After puberty, the average male’s PR is slightly lower than female.
▪ It is safe and non-invasive
▪ Is recommended for infants and children *The pulse rate may fluctuate and increase with exercise, illness,
▪ Disadvantage: injury, and emotions. Girls ages 12 and older women, tend to have
faster heart rates than do boys and men.
-long-time: 5-10 mins
Autonomic Nervous System Activity
-less accurate as it is not close to major vessels
-Stimulation of the parasympathetic nervous system results in decrease in
-is considered the least accurate & least reliable of all the sites because the PR.
the temp obtained using this route can be influenced by a number of
factors (e.g. bathing & friction during cleaning -Stimulation of sympathetic nervous system results in an increased pulse
rate.
-is the route of choice in patients that cannot have their temp
measured by other routes. -Sympathetic nervous system activation occurs on response to a variety of
stimuli including
The Procedure: Tympanic membrane Temperature
▪ Pain, anxiety, exercise, fever
▪ Placed into the client’s ear canal ▪ Ingestion of caffeinated beverages
▪ It reflects the core body temperature ▪ Change in intravascular volume
▪ Is readily accessible and permits rapid temp readings in pediatric,
or unconscious patients *Position changes:
▪ It is very fast method 1 to 2 seconds. A sitting or standing position blood usually pools in dependent vessels of
▪ Disadvantages: the venous system
-it may be uncomfortable involves risk of injuring the membrane Because of decrease in the venous blood return to heart and subsequent
-presence of cerumen (wax) can affect the reading decrease in BP increases heart rate.

-right & left measurements may differ.

Medication ✓ Observed by the movement of the chest upward and downward.
✓ Commonly used for adults
- Cardiac medication such as digoxin decrease heart rate
- Medications that decrease intravascular volume such as diuretics 2. Diaphragmatic (abdominal)
may increase pulse rate
✓ Involves the contraction and relaxation of the diaphragm,
- Atropine inhibits impulses to the heart from the parasympathetic
observed by the movement of abdomen.
nervous system, causing increased pulse rate
✓ Commonly used for children.
- Propanolol blocks sympathetic nervous system action resulting in
decreased heart rate sites used for measuring pulse rate. Factors Affecting Respiration
Pulse Sites ▪ Age: Normal growth from infancy to adulthood results in a larger
lung capacity. As lung capacity increases, lower respiratory rates
▪ Carotid: at the side of the neck below tube of the ear (where the
are sufficient to exchange.
carotid artery runs between the trachea and the
▪ Medications: Narcotics decrease respiratory rate & depth
sternocleidomastoid muscle)
▪ Stress or strong emotions increases the rate & depth of respirations
▪ Temporal: the pulse is taken at temporal bone area.
▪ Exercise: increases the rate & depth of respirations
▪ Apical: at the apex of the heart: routinely used for infant and
▪ Altitude: The rate & depth of respirations at higher elevations
children < 3 years
(altitude) increase to improve the supply of oxygen available to the
▪ In adults – Left mid-clavicular line under the 4th, 5th, 6th intercostal
body tissues.
space.
▪ Gender: men may have a lower respirations rate than women
▪ Brachial: at the inner aspect of the biceps muscle of the arm or
because men normally have a larger lung capacity than women
medially in the antecubital space (elbow crease)
▪ Fever increases respiratory rate
▪ Radial: on the thumb side of the inner aspect of the wrist- readily
available and routinely used. Assessment
▪ Femoral: along the inguinal ligament. Used for infants and children
✓ The client should be at rest
▪ Popliteal: behind the knee. By flexing the knee slightly.
✓ Assessed by watching the movement of the chest of abdomen
▪ Posterior tibia: on the medial surface of the ankle.
- Rate
▪ Pedal (Dorsal Pedis): palpated by feeling the dorsum (upper
- Rhythm
surface) of foot.
- Depth
Pulse rate - Special characteristics of respiration are assessed
• Normal 60-100 b/min (80/min)
• Adult PR > 100 BPM is called tachycardia
Respiratory Rate
• Adult PR < 60 BPM is called bradychardia
-Try to do this as surreptitiously as possible. Observing the rise and fall of
-if the pulse is regular, measure (count) for 30 seconds and multiply by
the patient’s hospital gown while you appear to be taking their pulse.
2.
-Respiration rates may increase with fever, illness,.. When checking
- if it is irregular count for 1 full minute.
respiration, also note whether a person has any difficulty breathing.
- Each heart beat consists of two sounds
Rate:
- S1 – is caused by closure of the mitral and tricuspid valves separating
▪ Is described in rate per minute (RPM)
the atria from the ventricles
▪ Healthy adult RR= 15-20/min. is measured for full minute, if regular
- S2 – is caused by the closure of the plutonic and aortic values for 30 seconds.
▪ As the age decreases, the respiratory rate increases.
- The sounds are often described as a muffled “lub-dub” ▪ Eupnea- normal breathing rate and depth.
Pulse: Quantity ▪ Bradypnea- slow respiration
▪ Tachypnea- fast breathing
-if the rate is particularly slow or fast, it is probably best to measure for a ▪ Apnea- temporary cessation of breathing
full 60 seconds in order to minimize error.
Age Average range/min
Pulse: Regularity Newbon 30/80
-is the time between beats constant. Irregular rhythms, are quite common. Early childhood 20-40
Late childhood 15-25
Pulse: Volume Adulhood-male 14-18
-does the pulse volume feel normal? This reflects changes in stroke Female 16-20
volume. In hypovolemia, the pulse volume is relatively low.
Apical Pulse represents the actual beating of the heart. Rhythm:

Pulse deficit: difference between the radial and apical rates; signifies that ▪ Is the regularity of expiration and inspiration.
the pumping action of the heart is faulty. ▪ Normal breathing is automatic & effortless.
Depth:
Respiration
▪ Described as normal, deep or shallow.
▪ Respiration rate (RR): respiration is the act of breathing and
▪ Deep: a large volume of air inhaled & exhaled, inflates most of the
includes the intake of oxygen and removal of carbon-dioxide.
lungs.
▪ Ventilation is also another word, which refers to movement of air in
▪ Shallow: exchange of a small volume of air minimal use of lung
and out of the lung.
tissue,
▪ Hyperventilation: is a very deep, rapid respiration.
▪ Hypoventilation: is a very shallow respiration. Abnormal Respiratory Rate

Two types of breathing: -Respiration rates over 25 or under 12 breathes per minute (when at rest)
1. Costal (thoracic) may be considered abnormal.
Blood Pressure ✓ Explain the procedure to the patient & remove any light cloth from
patient’s arm
▪ It is the force exerted by the blood against the walls of the arteries ✓ Make sure that the client has not smoked or ingested caffeine,
in which it is flowing. within 30 minutes prior to measurement.
▪ It is expressed in terms of millimeters of mercury (mmHg) ✓ Position the patient on lying, sitting or standing position, but
Two types of Blood Pressure always ensure that the sphygmomanometer is at the level of the
heart with the arm supported & the pal facing upwards.
1. Systolic Pressure is the maximum of the pressure against the wall of the
vessel following the ventricular contraction. Position of the Patient

2. Diastolic pressure is the minimum pressure of the blood against the ▪ Sitting position
walls of the vessels following closure of aortic valve (ventricular relaxation) ▪ Arm and back are supported
▪ Feet should be resting firmly on the floor
✓ BP is measured by using an instrument called BP cuff ▪ Feet not dangling
(sphygmomanometer) & stethoscope
✓ The average normal value is 120/80 mmHg for adults. Position of the arm
✓ Brachial artery and popliteal artery are most commonly used. ▪ Raise patient arm so that the brachial artery is roughly at the same
✓ It is measured by securing the BP cuff to the upper arm and thigh height as the heart. If the arm is held too high, the reading will be
placing the stethoscope on brachial artery in the antecubital space artificially lowered, and vice versa.
& popliteal artery at the back of the knee.
✓ Pulse pressure: is the difference between the systolic and diastolic Points to remember when taking BP from client
pressure. Remember the following for accuracy of your readings:
Factors affecting Blood Pressure - Instruct your patients to avoid coffee, smoking or any other
▪ Fever unprescribed drug with sympathomimetic activity on the day of the
▪ Stress measurement
▪ Arteriosclerosis Blood pressure cuff:
▪ Exposure to cold
▪ Obesity - If it is too small , the readings will be artificially elevated.
▪ Hemorrhage - The opposite occurs if the cuff is too large.
▪ Low hematocrit
▪ External heat
Sites for measuring blood pressure
▪ Upper arm (using brachial artery)
-most common
▪ Thigh around popliteal artery
▪ Forearm using radial artery
▪ Leg using posterior tibial or dorsal pedis
-A persistently high BP, measured for greater than three times is called
hypertension & that persistently less than normal range is called
hypotension.
-Because of many factors influencing Bp a single measurement is not
necessarily significant to confirm hypertension.
-When the cause of hypertension is known it is called seconary
hypertension and when the cause is unknown is called primary/essential
hypertension.
Assessing blood pressure
Purpose:
▪ To obtain base line measure of arterial blood pressure for
subsequent evaluation
▪ To determine the clients homdynamic status
▪ To identify and monitor changer in blood pressure.
Equipment
▪ Stethoscope
▪ Blood pressure cuff of the appropriate size
▪ Sphygmomanometer
Parts of stethoscope
➢ Earpieces
➢ Binaurals
➢ Rubber or plastic tubing
➢ Bell
➢ Chestpiece
➢ Diaphragm
Procedure to measure blood pressure