FUNDAMENTALS OF NURSING

History of nursing
1st Hospital Temple of Hygeia, Greece
1st surgery Trephining
1st physician Shaman
1st nursing law Shushurutu
1st law code of Hamurabi
1st psych nursing Linda Richards
Founder of ARC (American Red Cross) Carla Barton
1st board exam London
1st Superintendent in nursing Dorothea Dix
1st nursing School St. Thomas Hospital school ofnursing
Modernization of nursing London
Mother of modern Nursing Florence Nightingale
Grandfather of nursing HYpocrates
1st Lady with lamp St. Catherine of Sienna in Italy
1st recorded name Genesis- Deborah
1st country to record India
Angels of Battlefield Harriet Tubman (moses of the people)
1st Nursing theorist Florence Nightingale
Lady of Nursing Virginia Henderson
3 saints in Nursing
 Patroness St. Elizabeth of Hungary (statue found in
Mandaluyong)
 Lady with lamp St. Catherine of Sienna in Italy
 Founder of the order of St. Francis Assisi St. Claire Assissi

Philippines
1st Superintendent in Nursing Anastacia Giron Tupas
Founder of FNA Anastacia Giron Tupas
1st President of FNA Rosario Delgado
1st Chair BON Gufenia Gomez Tan
Editor in Chief of “The Message” Socorro Diaz
1st Magazine “The Message”
1st Dean of UP Julita Solejo
1st Chief of PGH Anastacia Giron Tupas
1st Board exam June 1920
Board Examiners Anastacia Giron Tupas and Juan
Cabanus
Florence Nightingale of Manila Julita Solejo
Florence Nightingale of Iloilo Loreto Tupaz
Florence Nightingale of Philippines Josefa Llanes Escoda
Angels of Battlefield Melchora Aquino and Gabriela
Silang
1st member of the USRN Anastacia Giron Tupas
Founder of PRG (Philippine Red Cross) Dona Hilaria de Aguinaldo

The Evolution of Nursing

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Stages
I. Intuitive (Pre-Nightingale Era)
 Shamans(White Magic) and Wakiyas (Dark Magic)
 Illness was considered caused by possession
II. Apprentice
 Nightingale at the age of 30 went to Germany and met Theodore Fliedner
and Decones Frederica Fliedner who owned the Keisserswerth Institute
where Nightingale has undergone her apprenticeship in nursing.

III. Dark
 Time of Martin Luther and the Civil war (There was no existence of practice
of art and science in nursing because it was suppressed)
IV. Educative
 On june 15, 1860, Nightingale at the age of 40 has established the first
nursing school.
 Start of the Modernization of nursing
 1st curriculum was established
 Eviidence based Practice
 Modern Technology was used in the practice of nursing
V. Contemporary
 The present time

Man
 Forms the foundation of
Nursing
Four Components or Attributes of
Man
 Capacity to think on an
Abstract Level
 Establish a family
 Establish a territory
 Ability to use verbal symbols as language
Concept:
 Animals form a family by instinct
 Via hormonal scents
Nursing Concepts of Man
Biopsychosocial Spiritual Being
 By Sister Calista Roy
 Man interacts with the environment
Open System
 By Martha Rogers
 Man interacts with the environment
 Exchanges matter with energy
 Exchanges energy with environment
Unified Whole
 By Martha Rogers

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  Man is composed of certain parts
 Total of those parts is more than the sum of all parts
 This is because man has attributes
Vital Reparative Process
 By Florence Nightingale
 Man is passive in influencing the nurse or the environment
Man is a whole. Man is complete
 By Virginia Henderson
 Man has fourteen (14) fundamental needs
Human Needs
 Needs are physiologic and psychologic
 Both these needs must be met in order to maintain wellbeing.
Key Concept:
 Basic Human Needs are equivalent to COMMON NEEDS
Characteristics of Human Needs
 Universal
 Interrelated
 One need is related to another need
 May be stimulated by internal or external factors
Maslow’s Hierarchy of Needs

A. Physiologic
1. Oxygen
2. Fluids
3. Nutrition
4. Body temperature
5. Elimination
6. Rest and sleep
7. Sex
B. Safety and Security
1. Physical safety
2. Psychological safety
3. The need for shelter and freedom from harm and danger
C. Love and Belongingness
1. The need to love and be loved
2. The need to care and to be cared for
3. The need for affection ; to associate and belong
4. The need to establish fruitful and meaningful relatinships with people, institutions, or
organizations
D. Self Esteem Needs
1. Self-worth
2. Self-identity
3. Self respect
4. Body image
E. Self Actualization Needs
1. The need to learn, create and understand or comprehend
2. The need for harmonious relationships
3. The need for beauty and aesthetics
4. The need for spiritual fulfillment

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Illness and Disease

Illness
 Is a personal state in which the person fels unhealthy
 Illness is a state in which person’s physical, emotional, intellectual, social,developmental,
or spiritual functioning is diminished or impaired compared with previous experiences
 Illness is not synonymous with disease
Disease
 An altearyion in body function resulting in reducation of capacities or a shortening of the
normal life span

Five Stages of Illness

1. Symptom experience------ Appearance of manifestations, no actions done yet to manage
2. Assumption of sick role---- The person recognizes that there is something wrong, validates
it to significant others or family members. May self medicate
3. Medical Care contact------ Consult authorities (doctor, albularyo)
4. Dependent stage------------ The person becomes dependent of the doctor's orders for
management
5. Recovery/Rehabilitation

Review on Metaparadigms of Nursing

1. Virginia Henderson
 The 14 basic needs of man
 Providing Peaceful death
 Promoting Independence
 Gave the modern definition of nursing
2. Hildegard Peplau
 Psychiatri nurse of the century
 Therapeutic communication
 Offering oneself and listening attentively to clients
 Verbalization of feelings
3. Jean Watson
 Human Care—Essence of nursing
 The 10 curative factors
 6 humanistic aspects of nursing
 The nurse role as a care giver
4. Madeline Leininger
 Transcultural nursing
 Respect and know the culture, beliefs and values
 Communicate with patient using dialect
 Two terms:
1. Aculturation--- temporary change in culture (example when you go to other
countries for a visit, you fit in to their culture and traditions.)
2. Assymilation--- Permanent change of culture (When you migrate in other
countries and you adopt to their culture)

5. Dorothy Johnson
 Human Behavioral system---- starts at home; learned and can be unlearned
 Role of the nurse: Facilitator

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6. Imogene King
 Goal Attainment Theory
 Discharge patient from hospital and assist them to maintain Optimum Level of
Function (OLOF)
7. Myra Levine
 4 consecutive Principles
1. Conservation of energy
2. Conservation of personal Integrity
(do not panic in any given situation)
3. Conservation of Social integrity
 Maintain open line of communication
 Endorse properly
 Iron out misunderstanding
 Communicate with respect
4. Conservation of structural integrity
Maintain an orderly station
Organize workplace
8. Joyce Travelbee
 Human-human relationship
 NO man is an island
 We are all interconnected and interdependent
9. Faye Glenn Abdellah
 21 nursing problem
 Old definition of nursing---- Nursing is science and art, Nursing is a profession
10. Betty Newman
 Health care system model
 Promotive and preventive type of care
 Promotion of self-reliance
 Include patient in the course of care
 Stress reduction Theory
 Get rid of stressors
 Avoid stress and manage if possible
 Planyour work and work your plan
11. Sister Calixta Roy
 Adaptation Model”
 Man is highly flexible
 Failure to adapt is the birth of illness
 Phases of adaptation takes place
 “Reconstitution”- Mastering how to adapt to situations
12. Dr. Martha Rogers
 Same birthday with Nightingale
 The only Doctor theories
 Science of Unitary Human beings- the whole is greater than the sum of its part
 Man is an energy field
 Helicy--- cyclical or constant change
 Integrated—Man and environmental integration
 Resonancy—Evolution

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  4 dimentionality Pattern
1. Biophysiological
2. Spiritual-manual
3. Familial
4. Moral Ethics
13. Dorothea Orem
 Self -Care and Self- Care Deficit
 The 4 taxonomy
1. Self care--- can do activities of daily living
2. Self care deficit—Cannot do Activities of daily living
3. Self care agent—The nurse
4. Self care Agency—Mastering the activities of daily living
 Levels of compensation
Levels Nursing role Patient

Wholy compensated Do all the activities for Dependent

the patient
Partially Compensated Interdependent( Nurse Semi dependent
helps/ assists)
Supportive educative Nurse as the consultant Independent (can do all
the activities without
Assistance)

14. Lydia Hall

 Care, Core Cure
 Care- Nurse
 Core- Patient
 Cure-intervention
 Formulated the nursing process system
 Highly Individualized
 Modified daily
 Goal Oriented
 Objective
 Systematic
 Humanistic
15. Rosemary Parse
 Theory of human becoming
 Human becoming is the optimum goal and a lifelong process
 Nurse role: Role model
16. Florence Nightingale
 Birthday- May 12, 1820 (Nurses day)
 Place of birth—Florence, Italy
 Raised at London
 Studied in Germany
 Environmental Theory (CLAW)
Cleanliness
Light

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 Air
Water
Drainage

LEVELS OF PREVENTION:
1. Primary Prevention
Emphasis on:
o Generalized health promotion and specific protection
o Recipients are
GENERALLY HEALTHY PEOPLE When given:
o Before onset of illness or before onset of disease Examples:
o Generalized health education
Prevention of accidents
Standards of nutrition o Immunizations
Specific preventions
o Risk Assessment for specific disease
o Family Planning Services and Marriage Counseling
o Environmental Sanitation
o Recreation and Housing
2. Secondary Prevention
Emphasis placed on:
o Early detection / diagnosis
o Prompt treatment
o Health maintenance of persons already having health problems
o Prevention of complications When given:
o During illness
Examples:
o Screening survey o Encouraging regular check-ups
o Complying with regular check-ups
o Teaching Breast-selfexamination
o Teaching Testicularself-examination
3. Tertiary Prevention
Emphasis placed on:
o Support of the client to achieve the following:
Successful readaptation
Optimal reconstitution
Regain high level wellness
Therefore, the purpose is more of REHABILITATION
When given:
o Begins after the illness or when a defect or disability is fixed or
irreversible
Examples:
o Referring a client to support groups
o Teaching a diabetic client how to inject
insulin
ROLES OF A NURSE
1. Caregiver / Care Provider
 To convey understanding and support

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  Activities:
o Support and comfort measures (mothering aspect of nursing / nurturance aspect
of nursing)
2. Counselor
 Involves helping patient identify and avoid stressful and psychological problems
Focuses on:
o Helping client establish capacity for successful interpersonal relations Helping
the patient develop new coping
skills
Concept:
 Do not give advice!
o This is meant to facilitate decisionmaking on the part of the client
o This is observed so that the client would not develop DEPENDENCY
3. Client Advocate
 Protects rights of patients
 Activity:
 Speaking on behalf of the patient
4. Change Agent
 Brings change or adjustments
 Nurse only influences a patient
 Nurse does not change the patient
5. Teacher
 Teaching
 Imparting of knowledge
6. Leader
 Application of interpersonal influence to bring out desired behavior (leadership)
7. Manager
 Decision-making Planning
 Giving directions
 Monitoring operations
 Facilitating staff development
 Therefore, this is done on the supervisory level of organization
8. Researcher
 After graduation, nurse cannot yet be a researcher
 He can only be a researcher after he receives his Master of Arts in Nursing
(M.A.N) degree

THE NURSING PROCESS

Concept:
 The Nursing Process was introduced by LYDIA HALL!
Definition:
 The Nursing Process is a systematic, organized, rational method of planning and
providing individualized, humanistic nursing care
Purposes of the Nursing Process:
 To identify health status
 Actual health problems
 Potential health problems

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

BENEFITS DERIVED FROM THE NURSING PROCESS

Concepts:
 Both the nurse and the patient benefit from the nursing process Patient obtains greater
benefit
 Remember:
 Nursing process is CLIENTCENTERED or PATIENTCENTERED and NOT NURSE-
CENTERED
Benefits from Nursing Process:
 Improves quality of care
 Ensures continuity and appropriate level of care
 Facilitates client participation through planning with patient
 Enables nurse to maximize resources
 Feedback allows nurse to evaluate care
 Serves as a framework for accountability through documentation
 Promotes a positive working atmosphere through collaboration
 Helps the nurse define roles to those outside the profession
 For job satisfaction
 Facilitates professional growth
 Avoidance of legal action
 Meeting standards of accredited hospitals
PARTS OR COMPONENTS OF THE NURSING PROCESS ASSESSMENT PHASE OF THE
NURSING PROCESS
Nursing Activities in the
Assessment Phase
 Data collection
 Data Organization
 Data Validation
 Data Recording

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IMPORTANT CONCEPT!
 No conclusion is developed in the assessment phase
Purposes of the Assessment Phase
 To create a data base of the client’s response to health and illness
 To determine the nursing care needs of the patient
Four (4) types of Assessment:
1. Initial Assessment
 When performed:
o At specified time after admission Where done:
o Done at the ward
 Where Admitted:
o At the ward
 Purpose of Initial Assessment:
o To create a data base for problem identification
o For reference and future comparison
2. Focus Assessment or On-going
Assessment
 When performed:
o Integrated throughout the nursing process
 Purpose of On-going Assessment:
o To identify problems overlooked earlier
o To determine the status of a health problem (i.e. hydration status every fifteen
minutes)
3. Emergency Assessment
 When done:
 During acute physiologic and psychologic crisis
 Where done:
 Emergency Room o Comfort Room
 Anywhere!!!
 On site!!!
 Purpose of Emergency Assessment
o To identify life threatening condition
 Framework or Principle in Emergency Assessment
o A – Airway
o B – Breathing
o C – Circulation o Utilize either Maslow’s Hierarchy of Needs or ABC
principle
4. Time-Lapsed Assessment When done:
o Several months after initial assessment
 Purpose of Time-Lapsed Assessment
o To compare current status of patient with base line data (initial assessment)
ASSESSMENT PROCESS
Concepts:
 Data is equivalent to information
What is the initial output of the Assessment Phase? Data or Recorded Data Never
validated data!!! Types of Data:

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1. Subjective or Covert Data Felt by the patient
 During the recording of data, this should be stated using the patient’s own words
 These are the symptoms felt by the patient
2. Objective or Overt Data
 Capable of being observed by use of senses – sight, touch, smell, taste, hearing
 These are the signs which are observable
Sources of Data:
1. Primary Source
 Patient himself except when: o He is unconscious o Patient is a baby o Patient is insane
2. Secondary Source Patient’s record
 Health care members
 Related literature or journals
 Significant others (they become primary source when patient is unconscious
 Family or relatives
 The person who brought the patient to the hospital
3. Environment of the Patient
Methods of Data Collection
 Observing
 Interviewing
 Examining
1. Observing
 It should be deliberate
 Exert effort
Two (2) aspects of observation process:
 Noticing the stimuli
 Do an interpretation of the stimuli
2. Interviewing
Two (2) types of Interview:
 Directive Type of Interview
o Structured
o Uses closed-ended questions calling for specific data
When used:
o When you need to elicit specific data
o When there is little time available
Concept:
Characteristics of Closed-ended questions:
 Yes or No questions
 Asks when or asks for the time when event happened
 Asks how many
 Point with finger when asking to provide clarity
 Therefore, they call for highly specific answers
Non-Directive Type or Rapport-
Building Interview
 Uses more open-ended questions
 Advantage is that it allows the patient to volunteer

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 information
Types of Interview Questions:
1. Open-Ended Questions
 Questions not answerable by
“yes” or “no”
 Questions that elicit information or explanation
2. Closed-Ended Questions
 Questions answerable by
“yes” or “no”
 Leading Questions
 Phrasing of question suggests what answer the interviewer is expecting
3. Neutral Questions
 Phrasing allows patient to answer with least pressure
 Usually NOT addressed to patient personally (i.e. what is your opinion about…)
 Raised as a general topic Planning the Interview Setting
Concepts:
 Before the interview, determine what information you already know or what
information is available
 An interview is a planned conversation with a purpose
 An interview is a two-way process
 When is it done?
o When patient is available
o When patient is comfortable
 Recommended distance from the patient is three (3) to four (4) feet.
Stages of the Interview 1. Opening Stage Key Concept!!!
 This is the most important part of the interview
Rationale
 What was said and done during the opening stage sets the tone all throughout the
interview
2. Body of the Interview
 Occurs when patient responds to questioning
3. Closing Stage
 How to close the interview:
o Summarizing Technique
Validation of Data
 Act of double-checking the data
 Purposes of Data Validation o To ensure the:
Correctness
Completeness
Accuracy of the data
Guidelines in Validating Data
 Compare subjective and objective data
 Be familiar with word usage
(particularly if the patient is a child)
 Reassess / double-check data which are extremely abnormal

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  Be sure that your data contains CUES and not INFERENCES
 Be sure that your data is FREE OF BIASES
 Avoid jumping to conclusions
Data Recording Concepts:
 Data Recording COMPLETES the Assessment Phase
 Initial Output of the
Assessment Phase is DATA
 Final Output of the
Assessment Phase is RECORDED DATA
DIAGNOSING PHASE OF THE NURSING PROCESS
Activities during the Diagnosing Phase:
 This involves sorting, clustering, analyzing and interpreting data
Concept:
 The final output in the Diagnosing Phase is a NURSING DIAGNOSIS!!!
Different Types of Nursing Diagnoses:
1. Actual Nursing Diagnosis
Problem present at the time the statement was made
2. High-Risk Nursing Diagnosis
A diagnosis that a patient is more vulnerable or susceptible compared with others in the
same situation
3. Possible Nursing Diagnosis
There is an evidence of a health problem but the causes are NOT fully understood
4. Wellness Nursing Diagnosis A positive statement Indicates a healthy response
Examples:
o Potential for increased compliance related to increased level of knowledge
o Potential for enhanced body image related to regular exercise
o Potential for effective coping related to adequate support systems
Domains of Nursing Diagnosis Key Concept!
It only includes health problems that a nurse is capable and licensed to treat
Parts of a Nursing Diagnosis
1. Problem Statement
Example:
 Fluid Volume Deficit
2. Presumed Etiology
Example:
 o …related to frequent loss of bowel
movement
3. Defining Characteristics
 Example:
…as manifested by decreased skin turgor
Advantages of Using Standardized Diagnostic Terminology
 Provides professional accountability and autonomy by defining and describing the
independent areas of practice
 Provides effective vehicle of communication
 Provides an organizing principle for meaningful research
 Facilitates continuity and individualized care
PLANNING PHASE OF THE NURSING PROCESS
Concept:

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Planning means:
 Determining ahead of time
 Forecasting a course of action
Key Concept!!!
 For your plans to be effective, involve the patient and the family
IMPORTANT CONCEPT!!!
 Final output of the Planning
Phase is a NURSING CARE
PLAN or a WRITTEN CARE
PLAN
Types of Planning
1. Initial Planning
 Done by the nurse When done:
o At specified time upon
or after admission of the patient
2. On-going Planning
 Who are involved:
o Done by all nurses who
worked with the patient
o The patient himself o The family o But primarily, the NURSE
 Purposes of On-going
Planning o To determine if the client’s health status has changed
o To decide which problems to focus on during the shift
o To set priorities for client care during the
shift
o To coordinate the patient care and activities so that more than one problem can
be addressed at the same time
3. Discharge Planning
 Purpose of Discharge
Planning o To ensure continuity of care
Characteristics or the Planning
Process
 S – Specific
 M – Measurable
 A – Attainable
 R – Realistic
 T – Time bound

Man
 Forms the foundation of
Nursing

Four Components or Attributes of

Man
 Capacity to think on an
Abstract Level
 Establish a family
 Establish a territory

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  Ability to use verbal symbols as language

Concept:
 Animals form a family by instinct
 Via hormonal scents

Nursing Concepts of Man

Biopsychosocial Spiritual Being
 By Sister Calista Roy
 Man interacts with the environment

Open System
 By Martha Rogers
 Man interacts with the environment
 Exchanges matter with energy
 Exchanges energy with environment

Unified Whole
 By Martha Rogers
 Man is composed of certain parts
 Total of those parts is more than the sum of all parts
 This is because man has attributes
Vital Reparative Process
 By Florence Nightingale
 Man is passive in influencing the nurse or the environment

Man is a whole. Man is complete

 By Virginia Henderson
 Man has fourteen (14) fundamental needs

Human Needs
 Needs are physiologic and psychologic
 Both these needs must be met in order to maintain wellbeing.

Key Concept:
 Basic Human Needs are equivalent to COMMON NEEDS

Characteristics of Human Needs

 Universal
 Interrelated
 One need is related to another need
 May be stimulated by internal or external factors
 May be deferred (but not indefinitely) Maslow’s Hierarchy of Needs

Why do we study this?

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  In order to prioritize nursing actions

1. Physiologic needs
 Food, maintenance of homeostasis
2. Safety and security
3. Love and belongingness
4. Self-Esteem
Feeling good about one’s self
 Two factors affecting Selfesteem
o Yourself
Sense of adequacy
Accomplishment o Others Appreciation
Recognition
Admiration
Belongingness
5. Self-Actualization
 Able to fulfill needs and ambitions
 Maximizing one’s full potential
6. Aesthetics
 Beauty

Two Additional Needs by Maslow

 Need to know
 Need to understand

Richard Kalish
 Man needs stimulation
 Needs to explore o Sex
o Activity o Novelty
Stimulator
Desire to come up with something of your own

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

Concept:

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

Illness
 Highly subjective feeling of being sick or ill

Two types of Illness:

Acute Illness
 Sudden in onset (most of the time, but not always)
 Less than six (6) months

Chronic Illness
 Gradual in onset (most of the time, but not always)
 Types of Chronic Illness o Exacerbation
Period
characterized by active signs and symptoms of the illness o Remission
Periods where no signs and symptoms are prese

Disease

 Objective pathologic process

Concepts:
 Illness without disease is possible
 Disease without illness is possible
 Illness may or may not be related to a disease
 One can have a disease without necessarily feeling ill

Deviance
 Any behavior that goes against social norms
 Shortens life span
 Results to disrupted family and community

Concept:
 Deviant behavior can be considered a disease

Rationale:
 Because it also shortens the life span like a disease

Example:
 Alcoholism o A disease rather than a
social problem

Wellness
 Feeling of being well Definitions of Health

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World Health Organization
 Health is the complete physical, mental, social (totality) well-being and not merely the
absence of disease or infirmity
 A high-level wellness!

Claude Barnard
 Ability to maintain internal milieu
Walter Cannon
 Ability to maintain homeostasis
 A dynamic equilibrium
 A state of balance of the internal environment while external environment is changing

Florence Nightingale
 Health is using one’s power to the fullest
 Being well
 Can be maintained by manipulating the environment

Virginia Henderson
 Viewed in terms of ability to perform the fourteen (14) fundamental needs or components
of nursing care UNAIDED

Martha Rogers
 Positive health symbolizes wellness
 Health is a value term defined by a certain culture

Sister Calista Roy

 A state and process of being and becoming an
INTEGRATED PERSON

Dorothea Orem
 Characterized by soundness and wholeness of DEVELOPED HUMAN
STRUCTURES and FUNCTIONS

Imogene King
 A dynamic state in the life cycle (contrasted with illness) Illness is interference in the life
cycle

Betty Neuman
 Wellness is that all parts and subparts are in harmony with each other and the whole
system

Dorothy Johnson
 Elusive dynamic state influenced by biologic,
psychologic and social factors

Models of Health and Illness

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Health-Illness Continuum
Dunn’s High Level Wellness and
Grid Model
 X-axis is HEALTH
 Y-axis is environment Quadrant 1
 High-level wellness in favorable environment
Quadrant 2
 Protected poor health in favorable environment
Quadrant 3
 Poor health in unfavorable environment
Quadrant 4
 Emergent high-level wellness in unfavorable environment

Health Belief Model

 By Rosentock
 Based on a motivational theory
 It assumed that good health is an objective common to all people
 Consider perceptions (influences individuals motivation toward
results) o Perceived susceptibility
o Perceived seriousness o Perceived threat
 Likelihood of Action influenced by: o Perceived benefit out of
the action
o Perceived barriers

Smith’s Four Levels of Health

1. Clinical Model
 Man is viewed as a
Physiologic Being
 If there are no signs and symptoms of a disease, then you are healthy
 Against WHO definition of health
 This is the NARROWEST concept of health
2. Role Performance Model
 As long as you are able to perform SOCIETAL functions and ROLES you are healthy
3. Adaptive Model
 Health is viewed in terms of capacity to ADAPT.
 Therefore, goal of treatment is to restore capacity to adapt.
 Failure to adapt is disease 4. Eudaemonistic Model
 This is the BROADEST concept of health
 Because health is viewed in terms of Actualization

Leavell and Clark’s Agent, Host,

Environment Model
 Also known as the Ecologic Model

19
  Expands to the MULTICAUSATION of a DISEASE
 Definitions of a disease as to its cause is expanded to a multi-causation of a disease (i.e.
cancer is a multi-factorial disease)
 Triad is composed of the agent, host and susceptible host
 Based on the interplay of three components of the model

Concept of Health and Illness

Stress
 By Hans Selye
 Is a non-specific response of the body to any demand placed upon it.
 General Adaptation Syndrome (GAS)
 Local Adaptation Syndrome
(LAS)

General Adaptation Syndrome Involves two (2) body systems: Nervous System
 Endocrine System

Nervous System involves:

 Sympathetic Nervous System
 Parasympathetic Nervous system

Endocrine System involves: Adrenal Glands

The Adrenal Gland is composed of:

 Adrenal Medulla
 Adrenal Cortex

Adrenal Medulla releases Adrenalins or Fight or Flight

Hormones:
 Epinephrine
 Norepinephrine
Effects of Adrenalins
 Increases Cardiac Rate
 Response to increased metabolic rate and oxygen demand
 Increases Respiratory Rate
 Response to increased metabolic rate and oxygen demand
 Bronchodilation
 Vasoconstriction
 Increased Peripheral
Resistance
 Increased Cardiac Workload
 Increased Blood Pressure
 Decreased Renal Perfusion
 Decreased Renal Output

20
  Pale, Cool, Clammy Skin

Adrenal Gland is composed of:

1. Adrenal Medulla
 Releases adrenalins
2. Adrenal Cortex Releases the following:
Mineralocorticoids o Aldosterone
Glucocorticoids
Cortisol
oA potent vasoconstrictor

Mineralocorticoids
 Increased Aldosterone levels
 Increases sodium retention and water retention
 Increases circulating blood volume
 Increases cardiac workload
(due to vasoconstriction)

Glucocorticoids
 Increased hyperglycemia
(transient)
Increased glycogenolysis Increased neogenesis Increases blood sugar
 Increases osmotic pressure
 Increases fluid retention (glucose is a colloid which attracts water and adheres to it)
 Increases cardiac workload

Concept:
Complications of Stress:
 Cerebrovascular Attack
 Increased Diabetic
Ketoacidosis (if patient is diabetic)
 Hypertension leading to cardiac arrest

Local Adaptation Syndrome

 Also known as non-specific inflammatory response
 Bradykinin o Activates inflammatory response
o Activates histamine
 Histamine
o Activates the following:
Prostaglandin
Serotonin

Concept:
 Bradykinin, Histamine,
Prostaglandin, and Serotonin all increase swelling

21
Key Concept!
 Hans Selye o Author of Physiologic Response to Stress

Lazarus
 Stress is a transaction
 Stress resulted from interaction of man with his environment and fellowman
 Therefore, Lazarus describes the SOCIAL ASPECT OF STRESS
 Also an adopted
PHYSIOLOGIC RESPONSE

Key Concept!
 The most comprehensive concept of stress is the stress concept of LAZARUS as it
combines Physiologic and
Social aspects of stress.

Statements about Stress

 Stress is NOT a nervous energy
 Man, whenever he encounters stress, tends to adopt
 Are you going around all stress? ANSWER IS NO!!! because stress is not always to be
avoided and stress is not always undesirable
 Stress may lead to another stress
 A single stress does not lead to a disease
Concepts:
 Adaptation to stress comprises of adjustments made in order to cope with a stressor

 Man is holistic in his adaptation to stress

 It involves the totality of man: o Physiologic o Psychologic o Social
Illness Behavior and Stages of
Illness

Illness Behavior
 Pertains to any activity undertaken by a person who feels ill in order to
 Define his state of health
 Discover a suitable remedy

IGUN – Eleven stages of Illness and Health-seeking Behaviors

1. Symptom Experience
 Client realizes there is a problem
 Client responds emotionally 2. Self-medication / Self-treatment (if not effective)

3. Communication to others
4. Assessment of symptoms
 Purpose is to verify the veracity of the complaint

5. Sick-Role Assumption
6. Concern Stage

22
7. Efficacy of treatment
 Assess sources of treatment
 Assess potential effectiveness of treatment
8. Selection of Treatment Stage Availability
 Cost of Treatment
9. Treatment Proper
10. Assessment of Effectiveness of
Treatment
 May go back to stage 7
(Efficacy of Treatment) if treatment is not effective
 May go to next stage if treatment is effective
11. Recovery and Rehabilitation

Compliance
 Adherence to professional’s advice
Factors Affecting Compliance
 Client motivation
 Degree of required change in lifestyle
 Perceived severity of health problem
 Difficulty of understanding instructions
 Belief about the effectiveness of the therapy
 Nature of the therapy itself o Adverse effects o Cost
 Cultural influences
 Degree of satisfaction with the relationship with health care providers

Suggested Nursing Actions in case of Non-compliance

 Assess the reasons
 Correct the misconception
 Demonstrate a caring attitude
 Encourage and provide positive reinforcement
o Focusing on the positive rather than on the negative
o Focus on things patient can still do and not on what the patient can no longer do
 Establish a therapeutic relationship of freedom and mutual responsibility
o Make patient realize he is also responsible for his recovery
o He is a partner with the health care team
o He is an active participant

Guidelines to Enhance
Compliance
Be sure patient understand procedure by giving
information
 Make sure patient is capable of performing activity
o Set realistic goals
 Ensure that he is a WILLING participant
o Look for buying signals

23
 Looking at wound
Looking at materials needed

LEVELS OF PREVENTION:

1. Primary Prevention Emphasis on:

o Generalized health promotion and specific protection
o Recipients are
GENERALLY HEALTHY PEOPLE When given:
o Before onset of illness or before onset of disease Examples:
o Generalized health education
 Prevention of accidents
 Standards of nutrition o Immunizations
 Specific preventions
o Risk Assessment for specific disease
o Family Planning
Services and Marriage
Counseling
Environmental Sanitation
o Recreation and
Housing

2. Secondary Prevention
 Emphasis placed on:
o Early detection / diagnosis
o Prompt treatment o Health maintenance of persons already having health
problems
o Prevention of complications When given:
o During illness
 Examples:
o Screening survey o Encouraging regular check-ups
o Complying with regular check-ups
o Teaching Breast-selfexamination
o Teaching Testicularself-examination

 Concept:
o Most effective method of teaching is
DEMONSTRATION

 Additional Examples of
Secondary Prevention o Assessment of growth and development
o General nursing assessment and care at the hospital, community and the home

3. Tertiary Prevention
 Emphasis placed on:
o Support of the client to achieve the following:
 Successful readaptation

24
  Optimal
reconstitution
 Regain highlevel wellness
 Therefore, the purpose is more of REHABILITATION When given:
o Begins after the illness or when a defect or disability is fixed or
irreversible
 Examples:
o Referring a client to support groups
o Teaching a diabetic client how to inject
insulin

ROLES OF A NURSE

1. Caregiver / Care Provider

 To convey understanding and support
 Activities:
o Support and comfort measures (mothering aspect of nursing / nurturance aspect
of nursing)

2. Counselor
 Involves helping patient identify and avoid stressful and psychological problems Focuses
on:
o Helping client establish capacity for successful interpersonal relations Helping the
patient develop new coping
skills

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

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

4. Change Agent
 Brings change or adjustments
 Nurse only influences a patient
 Nurse does not change the patient

5. Teacher
 Teaching

25
  Imparting of knowledge

6. Leader
 Application of interpersonal influence to bring out desired behavior (leadership)

7. Manager
 Decision-making Planning
 Giving directions
 Monitoring operations
 Facilitating staff developmentTherefore, this is done on the supervisory level of
organization

8. Researcher
 After graduation, nurse cannot yet be a researcher
 He can only be a researcher after he receives his Master of
Arts in Nursing (M.A.N) degree

TEACHING AND LEARNING

STRATEGIES

Basic Guidelines
 Develop a well-defined objective
 Assess client’s readiness to learn
 Start with what the client is concerned about
 Assess and start with what the client already knows; proceed from the known to the
unknown
 Start with the simple proceeding to the complex
 Schedule a review of the content

Concept:
 Areas of Learning Domain o Knowledge – cognitive o Skills – motor o Attitude – emotional

TEACHING STRATEGIES

1. Explanation and Description

 Address cognitive aspect of learning

2. One-to-one Discussion
 Addresses affective and cognitive learning

3. Answering Questions
 Cognitive

4. Demonstration
 Motor

26
5. Discovery
 Cognitive and Affective

Concept:
 Learning is more effective if the learner discovers the content for himself. (That is, through
experience!)

6. Group Discussion
 Affective and Cognitive
 Sharing feelings during group dynamics

7. Practice
 Motor

8.Printed and Audiovisual Material

9. Role-playing
 For pediatric and psychiatric nursing settings

10. Modeling
 What you say is what you do

11. Computer Assisted Learning

Programs
 Online review THE NURSING PROCESS

Concept:
 The Nursing Process was introduced by LYDIA HALL!

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

Purposes of the Nursing Process:

 To identify health status o Actual health problems
o Potential health problems
 To establish plans
 To deliver specific nursing care

Characteristics of Nursing
Process (MEMORIZE THIS!!!)
1. Goal-oriented and clientcentered
2. Cyclical (no absolute beginning and end), dynamic (moving) rather than static
3. Plan of care organized according to client problems rather than nursing goals
4. Basis of prioritizing nursing activities would be the problems and not the goals
5. Follows a logical sequence

27
 6. Universally applicable (to any type of patient)
7. Interpersonal and collaborative
Work with patients and relatives
Work with colleagues and other members of the health team
8. Adaptation of problem-solving techniques and principles
9. Problem-oriented, flexible, open to new information
10.Allows creativity of nurse and patient
BENEFITS DERIVED FROM THE NURSING PROCESS

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

Benefits from Nursing Process: Improves quality of care

 Ensures continuity and appropriate level of care
 Facilitates client participation through planning with patient
 Enables nurse to maximize resources
 Feedback allows nurse to evaluate care
 Serves as a framework for accountability through documentation
 Promotes a positive working atmosphere through
collaboration
 Helps the nurse define roles to those outside the profession
 For job satisfaction
 Facilitates professional growth
 Avoidance of legal action
 Meeting standards of accredited hospitals

COMMUNICATION TECHNIQUES IN NURSING

Communication
 Exchange of ideas, information, feelings, data between two communicators

Concept:
 Communication is the basic component of Human
Relationships

Elements of Communication
1. Message
 Data
2. Sender
 Encoder
3. Receiver
 Decoder

28
4. Feedback5. Context
 Setting
 Overall environment where the communication takes place

Modes of Communication
1. Verbal
Oral
 Spoken
 Written communication
 Texted communication
 Cable communication
 Telex communication
 Facsimile communication

2. Non-verbal communication Facial expression

 Grimacing
 Posture
 Gait
 Adornment
 Make-up
 Gestures

Factors Affecting Communication

 Ability of the communicator
 Perceptions
 Proxemics
o Distances between communicators
Intimate Distance
 Actual physical contact to 1.5 feet
Personal Distance
 1.5 feet to 4 feet
 3 feet to 4 feet for interview

Social Distance
 4 feet to 12 feet
Public Distance
 12 feet and beyond
 Territoriality
o One person believes that the space and all the things in that space belongs to him
o Do not enter abruptly; this may result in breach of privacy
 Roles and relationships

Therapeutic Communication in
Nursing
 Using Silence

29
  Supplement with non-verbal communication
 Provide General Leads o
o Examples:
o “…go on”
o “…tell me more”
 Open-ended questions
 Use Touch
o But assess the culture of the patient
o If the patient is a child, touch the patient on the top of the head
o If the patient is an elderly, touch the
patient on the hand
o If the patient is of the same age level, touch the patient on the shoulder
 Offering yourself o For autistic child
Stay nearby or stay beside the patient
 Presenting Reality o Example:
“You are in the hospital”
 Reflecting o Example:
“What do you think will make you happy”
o Never agree nor disagree
o Reflect it back or throw it back

Non-therapeutic Communication
 Stumbling blocks to effective communication
 Stereotyping
 Generalizing
 Agreeing and Disagreeing
 No confrontation
 No argument
 Being defensive
 Moralizing or Passing Judgment
 Giving Common Advise Examples:
 “If I were you…”
 “You should have done it…”

PROMOTING REST AND SLEEP

Circadian Rhythm
 A biological rhythm
 A biological clock
 Regulated from outside the person’s body

Types of Sleep
1. Rapid Eye Movement Sleep
(REM sleep)
 Increased brain metabolism and activity

30
  Also called PARADOXICAL SLEEP
 Characterized by: o Vivid dreams o Easily recalled upon awakening

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

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

2. Non-Rapid Eye Movement Sleep (Non-REM Sleep)

 Deep restful sleep
 Benefit is that it restores the body physically and psychologically (especially for post-
operative patients)

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

Wellness Teachings to Enhance or

Promote Sleep
 Establish a regular routine
 Have adequate exercise at daytime
o Avoid stimulating activity by bedtime
 Avoid all types of stimulants
o Caffeine-containing foods
Coffee
Cocoa
Chocolate
Tea
Cola
o Nicotine
o Alcohol
 Prolongs the REM stage of sleep
 It excites the patient like an anesthetic
 Not a stimulant Avoid shabu
 Use the bed mainly for sleep
 If unable to sleep, get up and pursue satisfying activity
 Drink something warm or hot
(except stimulants)
o Milk contains L-tryptophan

31
 o L-tryptophan is an amino acid with a natural sedative effect that induces one to
sleep
 Side-to-side turning every two hours with back tapping
 Support bedtime rituals
 Remove all music in order to sleep

PROMOTING NUTRITION

Proteins
 Macromolecules composed of o Carbon o Hydrogen
o Oxygen o Nitrogen

Basic Body Needs:

 Carbohydrates
 Proteins
 Fats

Concepts:
 Glucose is a ready source of energy for metabolic
processes

Carbohydrates
 When eaten are metabolized to glucose for energy
 Excess carbohydrates are converted to glycogen and
stored in the liver
 Other excess carbohydrates go to the fat cells

Key Concept!
 During starvation, stored glycogen is converted to glucose via a process called
glycogenolysis

 If glycogen is used up, fat resources are converted to glucose via a process called
gluconeogenesis

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

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

Gluconeogenesis
 Production of glucose out of non-carbohydrate products

Lipoproteins
 Substances composed of fats and proteins

32
Types of Lipoproteins
1. High Density Lipoproteins (HDL)
 High-grade lipoprotein
 Good grade lipoprotein
 Good cholesterol
 Function of HDLs o Transports the bad cholesterol from systemic
circulation to the liver for metabolism and eventual
elimination

2. Low Density Lipoproteins (LDL)

 Low-grade lipoprotein
 Bad cholesterol
 Function of LDLs
 They clog the blood vessels

3. Very Low Density Lipoproteins (VLDL)

 Very bad cholesterol

Functions of Fats
 Insulation
 Heat Conservation
 Source of Energy

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

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

33
Concepts!!!
 If protein levels are decreased, sodium and glucose will not be enough to hold plasma
inside blood vessel resulting into edema

 In liver cirrhosis, hypoalbuminemia results to edema

Review on Vitamins
Taxonomy Medical Name Sources Deficiency
A Retinol (animal) All yellow orange Xerophthalmia-
Carotene (Plants) fruits and Nightblindness
vegetables
B1 Thiamine Rice, chicken, Wernicke’s-
fish, nuts encephalopathy
Decreased level of
consciousness
due to increased
intracranial
pressure

Korsakoff
Psychosis-
confabulation

Severe Body
fatigue

B2 Riboflavin Eggs, eggplant, Ariboflavinosis

coconut Cheilosis—
Cracking at the
side of the lips

B3 Niacin/ Nicotinic Legumes, Pelagra

Acid/ Nicotinamide rootcrops,
cassava, 3 signs of pellagra
avocado 1. Dementia
2. Dermatitis
3. Diarrhea
B5 Pathotenic Malunggay, all Poor mental
meat performance
Stanted growth
No energy or body
malaise
Liver failure (if
severe)
B6 Pyridoxine Same as B2 Microcytic anemia

Peripheral neuritis
 Paresthesia
 Paralysis

34
 B7 Biotin Corn, aubergine, Burning feet
pork syndrome
B9 Folic acid/ Folate Milk Megaloblastic
anemia

Neural tube defect

B12 Cyanocobalamin All vegetable, all Pernicious Anemia

(Only absorbed in meat
the intestines) Diagnosis:
Schillings test (24
hour urine
specimen)

Results: If >40% of
B12 is present in
urine—positive
pernicious anemia

Causes:
1. No intrinsic
factor (parietal
cells)
2. Decreased
B12
3. Removal of
ileum (Cancer
patients
undergoing
surgery)

C Ascorbic Citrus Weak immune

system
Scurvy, poor
wound healing
D Calciferol Daing, Milk, Osteomalacia,
NAchoves, rickets
sardines
E Tocoferol Vegetable oil, Dry skin,
nuts, atis comedones,
sagged skin
K Phytomenadione/ Liver, passion Bleeding
Aquamenadione fruit
H Inactivated Biotin Same as b7 Burning feet
syndrome

MICRONUTRIENTS
Ferrous sulfate (FeSO4)
 Forms:

35
 o Tablet
o Liquid
o Injectable
 Oral (tablet and liquid forms)
o Take on an empty stomach
o If there is GI distress
(i.e. diarrhea), take with food
o If GI distress subsides, take on an empty stomach Toxic effects:
o Constipation (first option)
o Oral Liquid Iron o Use dropper and apply at the back of the tongue or use a straw
▪ Rationale:
To avoid staining the teeth
 Health Teaching!!!
o To enhance iron absorption, advice
taking orange juice
o Vitamin C in orange juice enhances iron absorption
o Do not take milk o Milk inhibits absorption of iron
o Too much fiber prevents absorption of iron
o Thus, do not take oats when taking iron.
 Injectable Iron
o Route is deep I.M.
o Use Z-track technique
Gauge of Needle is at least 18
o Length of Needle is 1.5” to 2.0”
o Site of administration is the GLUTEAL MUSCLE ONLY!!!
o Rationale:
o To avoid staining the skin
 Concept:
o Use an airlock
o Place 0.5 ml of air in syringe so that medication would not leak into
the subcutaneous tissues
 Nursing Alert!
o Apply firm pressure for at least five (5) minutes after injection
 Do NOT massage

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

2. Soft Diet
 For people with difficulty with swallowing and chewing Generally low residue diet
 Nursing Alert!

36
 o Avoid the following:
Nuts
Seeds (tomato, guava, berry)
Raw fruits and vegetables
Fried Foods
Whole grains and cereals

3. Pureed Diet
 Osteorized diet

4. Full Liquid Diet

 Foods that melt or liquefy at body temperature

5. Clear Liquid Diet

 Given to surgical patients Limited to:
o Water
o Coffee o Tea o Cola
o Clear stained broth o Gelatin o Hard candies
 Nursing Alert!
o Dairy products are avoided

6. High Fiber Diet

 For patients at risk for constipation

7. Candidiasis Diet
 Free of the following: o Fruits o Sugar o Yeast o Fermented foods

8. Low Residue Diet

 Reduced fiber
 To decrease GI irritation
 For patients with bowel inflammatory diseases: o Chron’s disease o Ulcerative colitis

Acid-Ash Diet
 To alkalinize urine
 To soothe an irritated bladder and urethra
 Give citrus fruits Give vegetables
 Exceptions are: o Prune Juice o Cranberry Juice o Both produce ACIDIC URINE

Ash-Acid Diet
 Given to acidify urine
 To minimize or help control Urinary Tract Infections Give the following: o Protein o Meat
o Poultry

ASSESSMENT OF NUTRITIONAL STATUS

37
Anthropometric Measurements

Skin Fold Test

 Derived from reserved fat of the body

Mid-upper arm Circumference

Measurement
 Obtains the muscle mass of the body
 This reflects the protein reserves of the body
 Laboratory diagnostic procedure for albumin

SUPPORTING NUTRITION OF
PATIENT: ENTERAL AND PARENTERAL FEEDING

ENTERAL FEEDING
1. NASOGASTRIC TUBE FEEDING (NGT)
 Purpose of NGT insertion o For gastric gavage and lavage
o For administration of food and medication
o To keep the stomach empty
o To prevent aspiration from regurgitation of gastric contents
o For gastric decompression
 How to Insert NGT
o Depth of Insertion
Measure length from the tip of the nose to the ears to the tip of the xiphoid process
o Insertion:
o Position the patient in semi-Fowler’s or Fowler’s position
o While inserting to NASOPHARYNX Position the head in a hyperextended manner
o When glottis, epiglottis are approached, Flex the head to prevent entry of the tube
into the trachea
 Nursing Alert!
o Watch for signs and symptoms of RESPIRATORY DIFFICULTY
If there are signs, WITHDRAW TUBE
o While inserting tube, observe for coughing or difficulty of breathing
 After inserting, ascertain proper placement on the stomach
 Concept!
o Most accurate method to test for proper placement of the NGT is via X-RAY
 Other ways to test proper placement:
1. Let patient hum
 If positive for humming, tube is in the esophagus and stomach
 If negative for humming, tube is in the trachea
 Nursing Alert!
o Small-bore tube allows patient to hum
o Therefore, this method is NOT RELIABLE
2. Determine the pH of the aspirate
 Use litmus paper

38
  Change of color from BLUE to RED indicates that the aspirate is acidic
and, therefore, from stomach contents
 Change of color from RED to
BLUE indicates that the aspirate is basic and, therefore, from lung
contents
 IMPORTANT CONCEPTS!!!
o To insure safety of the patient prior to feeding, CHECK THE FOLLOWING:
1. Placement of the tube

•
For patient safety
•To prevent LUNG aspiration of food
2. Patency of the tube

• To insure successful introduction or administration of food

3. By auscultating the epigastric region while insufflating 50 ml of air
• Hear gurgling sound
TUBE FEEDING
 Never try to submerge the free end of the NGT to water
o This is potentially dangerous
o If in trachea and submerging of free end to water coincides with inspiration, it will
suck the water and lead to pulmonary aspiration
 Position during feeding:
o Fowler’s Position
 Measure gastric residual volume
Subtract this from total feeding to introduce
o If aspirate is greater than 50 ml for adult or 10 ml for infant, then WITHHOLD
FEEDING for 2 – 3 hours.
o Rationale:
 Patient is not yet ready for next feeding. o If same occurs after 2 – 3
hours, NOTIFY DOCTOR.
 There is a problem with gastric emptying
 Watch out for COUGHING o Leakage to trachea
 If with DIFFICULTY OF BREATHING
o Stop the procedure
 Flush with water after feeding to avoid clogging of the tube
 After the procedure
o Do not place the patient on bed before 30 minutes have lapsed
o Rationale: To prevent aspiration and regurgitation
 Average volume of feeding: o 300 ml to 400 ml

TOTAL PARENTERAL NUTRITION

 Introduced directly to the bloodstream
 Tube is inserted via the: o Subclavian vein o Internal jugular vein of the neck
o External jugular vein of the neck
 Important Concept!!!

39
 Tube must reach two (2) centimeters before or above the RIGHT ATRIUM
 Nursing Responsibilities:
Watch out for signs and symptoms of embolism
 Care of Insertion Site

 Application of sterile dressing with antibacterial ointment as ordered by doctor (prn)

GASTROSTOMY TUBE FEEDING

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

PROMOTING OXYGENATION

DEEP BREATHING
Two (2) types of Deep Breathing:
1. APICAL DEEP BREATHING
 Done to expand the upper portion of the lungs
 Let the patient place palms on the upper chest
 Concentrate on that area
 Take a slow deep breath at a count of 1,2,3
 Release it slowly through the nose or a pursed lip at a count of 4,5,6,7
 Therefore, expiration is longer than inspiration Rationale:
o To prevent respiratory alkalosis
 Taught to patients who will undergo:
o Upper abdominal surgery
Cholecystectomy
 Incision site on diaphragm
 Patient does not want to breathe
 Predisposed to hypostatic pneumonia

2. BASAL DEEP BREATHING Same procedure

 Area of concentration is the lower ribcage
 When to teach patient: o Before surgery o Before pain is present
 Rationale:
o If pain is already present, it would be difficult for patient to
follow
When done:
o Done q2 hours together with turning
COUGHING EXERCISES
 Purpose
o To expand the lungs
o To facilitate expectoration of secretions
 How often done:

40
 o At least every two (2)
hours
 Procedure o Teach the patient to inhale and exhale
o Tell the patient to inhale and exhale a second time
o Tell the patient to inhale and cough out
 NURSING ALERT!!!
o Coughing is contraindicated in the following patients:
 With increased intracranial pressure (ICP)
 With increased intraoptical pressure (IOP)
 With cardiac arrhythmias (but are allowed to do deep breathing)
Concepts!!!
 Deep Breathing and Coughing o Purpose is to stimulate surfactant production
 Yawning and sneezing also stimulate surfactant production

OXYGEN INHALATION AND ADMINISTRATION

Practical Application Concept!

 When administering oxygen, be sure to open the valve of the oxygen tank first.
 Be certain that the valve on the regulator is closed so that the flow meter would not break!

Concept!
 Humidifier moistens the oxygen administered
 Purpose o To avoid drying and irritation of the mucosal lining
o Also traps particulates from the tank
 Iron oxide may be present in the tank (iron plus oxygen produces iron
oxide or rust)
Concept!
 Fire Precaution o Place ‘NO SMOKING’ sign at the door or at the head part of the patient
 Tank and oxygen do not explode
 They merely support combustion

Other Concepts!
 Do not use volatile substances
 Acetone and alcohol can react with oxygen and lead to toxicity of patient
 Do not use oil based or grease on any part of the oxygen set
 Do not allow the patient to use an electric razor as sparks may trigger combustion

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

Modes of Administration
1. Low Flow Administration
 Utilizes nasal cannula or nasal prongs or nasal catheters

41
  Given to COPD patients
2. High Flow Administration
 Uses a venturi mask

NEBULIZATION
 With sodium chloride and salbutamol
 A physiologic solution
 Water liquefies secretions
 Sodium chloride stimulates coughing
 Salbutamol is a bronchodilator
 Purpose:
o For expectoration of secretions

Nursing Pre-therapy Assessment Prior to Nebulization

 Have baseline data of patient’s breath sounds
 Assess again after nebulization to assess effectiveness of the procedure

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

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

Three components of Chest Physiotherapy

 Vibration
 Percussion
 Postural Drainage

Vibration

42
  Palms of your hand are placed on chest or back of patient giving quivering motions
 Palms remain in contact with the chest or back
Percussion
 Use cupped hands
 Hands alternate in rising and coming into contact with chest or back of patient

Postural Drainage
 Drain secretions by gravity
 Change positions
 IMPORTANT CONCEPT!!!
o Rule out contraindications before performing chest physiotherapy
Pre-therapy Assessment for Vibration and Percussion
 Assess breath sounds to know which lung fields have secretions
 Then assess again after procedure to check effectiveness of the procedure.

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

Postural Drainage When done: o Before meals o Two (2) hours after meals
 Before doing the procedure, the following baseline data are needed: o Breath sounds o
Vital signs
o Continuous ECG monitoring
 During the procedure:
o Ensure the comfort of the patient
o Provide a kidney basin and tissue paper
 Nursing Alert!
o Watch out for signs of symptoms which may require stopping of the procedure:
 Sudden dyspnea
 Cyanosis
 Extreme diaphoresis
 Sudden alteration of blood pressure, respiratory rate, pulse rate
 Appearance of arrhythmias
 Hemoptysis
 General intolerance of the procedure

Important Concept!
 If any of the above occurs, STOP THE PROCEDURE and inform the physician

Concepts!
 After the procedure assess the following:
o Breath sounds o Vital signs o Quantity and quality of sputum
o Overall response of the patient to the procedure

43
  Give oral hygiene o Rationale:
To eliminate phlegm from the mouth

Important Concept!!!
 Patients with cystic fibrosis benefit much from postural drainage

TYPES OF SUCTIONING SUCTIONING

Type of Suctioning Position of the Depth Duration Interval Total
Patient while with Time
Suctioning each
Pass of
Suction

Oropharyngeal

 Purpose is to seek out secretions

Concepts!!!
 Question:
o If you have only one (1) suction catheter, which will you suction first, the nose or the
mouth?
 Answer:
If the patient is an infant or a newborn:
Start on the mouththen proceed to the nose
Rationale:
If you start on the nose, you will trigger the sneezing reflex and this would result into
aspiration
 Answer:
o If the patient is an adult, suction the mouth first, then proceed to the nose
Rationale:
This is done for aesthetic reasons

44
Suctioning 10 – 15 Not more 20 – 30 Not more
If patient is conscious centimeters than 10 – seconds than 5
15 minutes
seconds

Fowler’s (high or
moderate); Head
turned to one side
(towards the
nurse)

If the patient is
unconscious 10 – 15 20 – 30 Not more
centimeters Not more seconds than 5
than 10 – minutes
Place on one side 15
(facing the nurse); seconds
Tilt neck to move
head slightly
forward towards
the basin to avoid
aspiration during
suctioning
Nasopharyngeal 20 – 30 Not more
Suctioning seconds than 5
From tip of Not more minutes
the nose to tip than 10 –
If the patient is of the earlobe 15
conscious Neck should be seconds
hyperextended;
Fowler’s position
Flat on bed with
head turned to the
nurse

From tip of
the nose to
the tip of the Not more
earlobe Not more 20 – 30 than 5
If the patient is Lateral position than 10 – seconds minutes
unconscious may be 15
assumed seconds

TYPES OF SUCTIONING

45
If patient is Measure from Not more 20 – 30 Not more than
conscious mouth than 10 seconds 5
to mid- seconds minutes
sternum
Low to
semifowler’s
position
If the patient Measure from Not more 20 – 30 Not more than
is mouth than 10 seconds 5
to mid- seconds minutes
unconscious Flat on sternum
bed;
Suction
trachea
through the
mouth
Nasotracheal Low to From tip of Not more 20 – 30 Not more than
Suctioning semifowler’s the nose to than 10 seconds 5
position earlobe to seconds minutes
If the patient is dominating
conscious side
of
neck to the
thyroid
cartilage

Flat on From tip of Not more than

If the patient 20 – 30
bed; the nose to Not more than 5
is seconds
Suction earlobe to 10 – Minutes
unconscious
dominating 15 seconds
trachea
side
through the
of
nose
neck to the
thyroid
cartilage

TYPES OF Position of the Depth Duration Interval Total

SUCTIONING Type Patient while with Time
of Suctioning Suctioning each
Pass of
Suction

46
Endotracheal Semi-Fowler’s 12.5 5 – 10 2–3 Not more
Tube if not centimeters or seconds minutes than 5
Suctioning contraindicated 6 inches; minutes
Insert as far
as it goes until
you meet
resistance
or until
patient coughs

Tracheostomy Semi-Fowler’s Insert as far 5 – 10 2–3 Not more

Tube if not as it gets until seconds minutes than 5
Suctioning contraindicated you meet minutes
resistance or
until the
patient coughs

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

47
 o Orotracheal Suctioning: Oral approach
o Nasotracheal Suctioning: Nasal approach
General Conditions for Suctioning
For Endotracheal and Tracheostomy (Naso and Oral and Tube)
o Before suctioning, HYPEROXYGENATE the patient
o During intervals, HYPEROXYGENATE the patient
For ET, Tracheostomy, ET Tube
o Nursing Alert!
During insertion, if you encounter resistance, withdraw the catheter about one
centimeter (1 cm) before applying suction
o Rationale: To avoid trauma on the mucous membrane
Do suctioning intermittently
Suctioning should not be continuous
Rotate the catheter (between the thumb and the index finger) as you withdraw
Apply suction only when you are ready to withdraw (i.e. keep finger away from
suction port if you are still not ready)

How to Hyperoxygenate the Patient

 Give two (2) to three (3) blows by ambubag
 Increase flow rate and concentration of oxygen
 Nursing Alert!
o If the patient has thick, tenacious secretions,
DO NOT USE AN AMBUBAG Use an OXYGEN INSUFFLATION SUCTION CATHETER
instead!!!
o This is a two-lumen catheter (one lumen brings oxygen to the patient, the other
lumen brings out secretions from the patient)
 In the event of encrustations, PERFORM TRACHEAL LAVAGE
o Instill 2.5 ml to 5.0 ml Normal Saline Solution for adults to liquefy the mucous plug
o Instill 2.0 ml Normal Saline Solution for children to liquefy the mucous plug
 Instill 0.5 ml to 1.0 ml Normal Saline Solution for infants to liquefy the mucous plug

VITAL SIGNS

TEMPERATURE
o Oral
 Axillary
 Rectal

Oral Method
 Most convenient Most accessible
 Nursing Alert!
o Applicability is for children aged six (6) years and above
o Not applicable for children below six (6) years old
 Contraindicated in patients with:
o Oral surgery o Mouth breathers
o History of convulsive seizures
o Unconscious

48
 o Incoherent
o Irrational
o Mentally disrupted
o Insane
 Procedure o Nothing Per Orem for about thirty (30) minutes before taking temperature
o No food intake o No drinks o No smoking o No chewing gum o No whistling
o No gargling
 Rationale:
o Any of the above would alter the result
 Placement:
o Under the tongue, beside the frenulum (right or left)
 Total Time:
o Two (2) to three (3) minutes
Axillary Method
 Least realiable Safest method
 Nursing Alert!
o During application, be sure that axilla is dry
o Dry using a patting motion Nursing Alert!
o Do NOT RUB!!!
 Rationale:
o This increases heat due to friction
o Rubbing increases blood supply to the area
o Therefore, there will be increase in temperature reading
o Rubbing provides a false-positive elevation of temperature reading Duration:
o In adults – nine (9) minutes
o In children – five (5) minutes
Rectal Method
 Most reliable (except for tympanic thermometer)
 Most accurate (except for tympanic thermometer)
 Concept!
o If tympanic method is used using a tympanic thermometer, the rectal method is
only second most reliable and second most accurate Disadvantage:
o Placement on a different site yields a different reading
o Therefore, ensure that the bulb of the rectal thermometer rests on the mucous
membrane
 Contraindications:
o Hemorrhoids
o Rectal Surgery
o Certain Cardiac ailments due to stimulation of the vagus nerve;
valsalva maneuver leads to arrhythmias
 Position of Patient when taking the reading:
o Sim’s left position
o Sim’s right position
o For Newborn, lift up ankles to keep buttocks up
o In Toddlers, set on prone position on adult’s lap
 Duration: Two (2) minutes
Conversion of Centigrade to Fahrenheit

49
  Centigrade = (5/9)F – 32
 Centigrade = (F/1.8) – 32

Conversion of Fahrenheit to Centigrade

 Fahrenheit = (9/5)C + 32
 Fahrenheit = (1.8)C + 32

Concepts!!!
 Peak body temperature occurs at 12NN to 3PM or 4PM
 Lowest body temperature occurs in the early morning hours of the day

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

First Stage of Fever

 Typical signs and symptoms indicate the body’s compliance mechanism to increase and
conserve heat:
o Chills
o Shivering
o Gooseflesh
o Vasoconstriction
Decreases blood supply to the skin
Pallid Skin o Cyanotic nail beds
 Key Concept!!!
o Patient complains of feeling cold
o Sweating will stop because body will minimizes heat loss Also called: o Onset Stage
o Chill Stage o Cold Stage
o This stage is characterized by low febrile temperatures
 Nursing Management o Key Concept
Aim is to minimize heat loss
o Key Concept
o Do NOT apply TEPID SPONGE BATH because this would make patient
progress to SHOCK
o Provide additional clothing as necessary
o Provide additional blankets as necessary
o Provide something warm to drink
o These measures would result to a gradual increase in body temperature Question:
o When will you start application of TSB?
Answer:
o If there is a 1°C to 2°C increase in body temperature
Second Stage of Fever

50
  Also called Coarse Stage of Fever o Peak Stage of Fever
 Key Concept!
o Patient does not feel hot or cold
o Skin is warm to touch
o Skin is flushed
o Fever blisters are present
Herpetic lesions o Absence of shivering o Possible dehydration
 Important Concept!!!
o For every increase of temperature, there is a corresponding increase in pulse rate
Rationale:
o Increase in temperature results in an increase in pulse rate due to increased
metabolic rate
o Increased metabolic rate increases oxygen demand
o Due to increased oxygen demand of susceptible brain cells,
CONVULSIVE
SEIZURES may occur. These may also be due to irritation of nerve cells –
FEBRILE CONVULSIONS
 Increased oxygen demand also leads to an increase in respiratory rate
 Patient complains of:
o Loss of appetite
o Myalgia or muscle pains due to increased catabolism
 Nursing Management

Tepid Sponge Bath

 Temperature of water is 32°C
o This temperature is maintained throughout the procedure
o How to apply:
o Done by patting
 Rationale:
o To avoid friction, which increases temperature
 Important Concept!
o Do NOT use ALCOHOL when applying TSB
o Rationale:Alcohol dries the skin and leads to irritation
 Key Concept!
o TSB should not be done hurriedly Rationale:
o When done hurriedly, TSB will stimulate shivering
o Shivering would lead to increased muscle activity
o Increased muscle activity would lead to increased temperature
Cooling Bed Bath
 Water temperature will start at 32°C
 Procedure will go on with gradual decrease in water temperature until it is maintained at
18°C
 Therefore, to achieve this drop in temperature, utilize ice
 Same procedure of application as in Tepid Sponge Bath
Types of Fever
1. Intermittent Fever

51
  A fever that is alternated at regular intervals by periods of normal and subnormal
temperature

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

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

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

5. Staircase or Spiking Fever

 Common in patients with TYPHOID FEVER PULSE ASSESSMENT

Concepts!
 If pulse is regular, count or monitor pulse for thirty (30) seconds and multiply by
two (2). This is legal!

 If pulse is irregular, count or monitor the pulse for one (1) FULL minute

Assessment of the Pulse Deficit

 This is the most accurate method
 Involves two nurses using one watch
 Starts at the same time
 Ends at the same time
 Comparison of results ensues
 Count is done for one (1) full minute

Scale in Pulse Assessment

 0 - Absent or cannot be felt
 1+ - Weak or thready
 2+ - Normal
 3+ - Grounding

BLOOD PRESURE

Systolic
 Produced by ventricular contraction
 Pressure on blood vessels during depolarization or ventricular contraction
Diastolic
 Pressure that remains in the walls of the blood vessels during relaxation
or repolarization or resting
Broadly two (2) types:

52
  Direct o By insertion of a catheter
Indirect Method o Auscultatory method o Palpatory method o Flush Method

Auscultatory Method
 Uses Korotkoff sound o A popping sound o NOT the heart beat
o It is a phenomenon – an unknown phenomenon!

Determining Amount of Inflation

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

Tripartite Blood Pressure Done if patient is an adult.

 Example:
 140 mmHg systolic – first loudest sound
 100 mmHg 1st diastolic – muffling
 70 mmHg 2nd diastolic – last sound
o Therefore, the tripartite blood pressure is 140 / 100 / 70
 If there is no muffling, an example would be:
o 160 / no muffling / 110

Concepts!!!
 Take systolic on loudest sound if patient is an adult
 If patient is pediatric or up to ten (10) years old, take the first sound, whether it is faint or
loud
 If, for example, first sound is at 190 mmHg and there is silence up to 140 mmHg and then
there is a sound at 130 mmHg down to 80 mmHg then…
 Use the PALPATORY
METHOD in combination with the AUSCULTATORY
METHOD because there is an auscultatory gap

Repeat using:
 Auscultatory method
 Palpatory method

How to do the Palpatory Method

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

Flush Method

53
  Represents the mean blood pressure
 Represents the average of the systolic and diastolic pressures
When done:
o When you have a BP
apparatus without a stethoscope
o Used for pediatric patients
 How done:
o Inflate up to the point where extremity
becomes pale
o Deflate slowly and look for a REBOUND FLUSH – when extremity becomes red
again
 This is the true reading!!
 Note that there is only ONE reading!!!

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

Stages of Decubitus Ulcer

Formation
Stage 1
 Involves the epidermis
 Manifestation o Non-blanchable
erythema of INTACT
SKIN o This is the first heralding sign of
decubitus ulceration

Stage 2
 Partial Thickness Skin Loss
 Involves epidermis and dermis
 Manifestation o Blister formation o Shallow craters
o Shallow abrasion and ulceration

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

54
 fascia

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

Tools to Assess Risk of Ulceration

 Norton’s Pressure Area Risk
Assessment Form
Shannon’s Scoring System
Branden Scale of Predicting
Ulceration
 Waterlow Risk Assessment
Cards o Most important tool o Most common tool o Most often used tool

EDEMA
 Caused by shifting of fluid into the interstitial tissues

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

Concept!
 If edema is due to prolonged standing, DO THE ELEVATION
2. Wear elastic stockings

3. Use warm compress alternated with cold compress

Rationale:
 Vasoconstriction and vasodilation causes re-circulation of fluid
Concept!
 This is contraindicated if there is inflammation

Assessment of Edema
Induration
 1+ - 1 cm induration
 2+ - 2 cm induration
 3+ - 3 cm induration 4+ - 4 cm induration
 5+ - 5 cm induration

PAIN MANAGEMENT

Pain

55
  A noxious stimulation of actual or threatened / potential tissue
damage

Categories of Pain according to

Origin
 Cutaneous o Skin
 Deep Somatic o Tendons, ligaments o Bones
o Blood Vessels
 Visceral Pain o Organs of the body

Categories of Pain based on Cause

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

Categories of Pain according to Where It Is Experienced

 Radiating Pain o Felt on the source and is extending to nearby tissues
 Referred Pain
Felt on other parts detached from the source
o Example:
o Pain on a lacerated liver may be felt on the right shoulder and not on the right
upper quadrant
 Intractable Pain
o Highly resistant to pain-relief methods
 Phantom Pain
o Pain that is felt on a MISSING BODY PART or a PART THAT IS
PARALYZED by SPINAL CORD INJURY.
Pain Threshold
 Amount of pain stimulation that is required in order to feel pain

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

Gate Control Theory Concept!

 This is the most widely used theory in pain management

Concepts!
 At the dorsal horn of the spinal cord is a gate.
 This gate is called the SUBSTANCIA GELATINOSA
 A series of nerves pass through this gate
 Small diameter nerve fibers pass through the substancia gelatinosa
o Pain signals are carried to the spinal cord by the small diameter nerve
fibers

56
  Large diameter nerve fibers also pass through the substancia gelatinosa
o Large diameter nerve fibers close the gate – prevents the transmission of impulses
through the spinal cord
o Therefore, when LARGE DIAMETER NERVE FIBERS ARE
STIMULATED, THE GATE IS CLOSED
 Pain management operates on the principle of how to stimulate the Large Diameter Nerve
Fibers to close the gate.

Pain Management Strategies

Pharmacologic Methods
Narcotics
 NSAIDs
 Adjuvants or Co-analgesics

Non-Pharmacologic Methods
 Physical Interventions
 Cognitive/ Behavioral Interventions
Non-Pharmacologic Physical Interventions
1. Cutaneous Stimulation
Massage
o Effleurage o Soft massage o Gentle stroking Petrissage
o Hard massage
Large and quick pinches
o Also done by striking
 Application of Counter-Irritant o Bengay o Menthol o Omega Pain Killer o Flax Seeds o
Poultices
 Heat and Cold Application o Nursing Alert!
o Rebound Phenomenon
 When you apply heat (usually done for 20
minutes), vasodilation is produced
 If heat is applied for more than 20
minutes, there is vasoconstriction
 This is an inherent defense mechanism from burning of tissues
 Cold Application o Maximum
vasoconstriction is reached when skin reaches 15°C
o If there is further drom in temperature, there is vasodilation (skin becomes reddish)
o This is the inherent defense mechanism from being frozen
 Accupressure o Pressure on certain points of the body
o Stimulates release of endorphins, which have natural analgesic
effects
o This started in Ancient China
 Accupuncture
o Insertion of long slender needles on certain chemical pathways
o Origin is also Ancient china
 Contralateral Stimulation
o Example: Injury on left side and massage is done on the right side

57
 Useful when patient cannot be accessed:
 For patients in a cast
 For patients with burns
 For patients with phantom pain

2. Immobilization
 Application of splints

3.Transcutaneous Electrical Nerve Stimulation

 Composed of electrodes
 Operated by battery
 Electrodes are applied on painful site or over the spinal cord

4.Administration of a Placebo
 Relieves pain because of its intent and not because of physical or chemical
properties

Cognitive or Behavioral Non-Pharmacologic Interventions Purpose:

o To alter pain perception
To alter pain behavior
To provide client with a greater sense of control over the pain
Specific Interventions
1.Distraction
 Purpose is to divert attention from pain
 Slow Rhythmic Breathing o Stare at a certain object
o Take deep breath slowly
o Release or exhale slowly
o Concentrate on breathing
o Picture a peaceful scene
o Establish a rhythmic pattern

2.Massage and Slow Rhythmic

Breathing

3.Rhythmic Singing and Tapping

 Key Concept!
o Faster beat music is
more preferable

4.Guided Imagery
 Imagine that you are walking along a peaceful shore
 Eyes are closed and suggestions are given

5.Hypnosis
 The success of hypnosis depends on the ability of the patient to concentrate and the
capacity of the hypnotist to suggest
 Based on suggestion

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  Progressive relaxation

URINARY ELIMINATION

Oliguria
 Renal output of less than 500 ml per day

Anuria
 Renal output of less than 100 ml per day

Retention
 Positive for distended bladder
 May also occur in the absence of bladder distention

Altered Urinary Elimination

Enuresis
 Common among pediatric patients
 Age 4 – 5 years old child has adequate bladder control
 Primary Enuresis o Never had a dry period
 Secondary Enuresis o Acquired enuresis
o At age 7, bladder control is present for at least one year
o Then, enuresis comes back
o Urinating could NOT be controlled again
Incontinence
 Involuntary passage of urine

Types of Incontinence

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

3.Stress Incontinence
 Loss of urine is less than 50 ml occurring with increased intra-abdominal pressure o Occurs
when laughing o Occurs when sneezing o Occurs when smiling
4. Total Incontinence
 Continuous flow of urine
 No bladder distention

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  No bladder spasm
 No awareness of bladder filling

5. Urge Incontinence
 Urine flows as soon as a strong sense of feeling to void occurs
 Strong bladder spasm

Management of Incontinence

1.Kegel’s Exercises
Also called:
o Pubococcygeal Muscle Exercises
o Pelvic Floor Muscle Exercises
Applicable for:
o Functional Incontinence
o Stress Incontinence
How done:
o Advise patient to stand with legs slightly apart
o Concentrate on perineum
o Draw perineum upward slowly
 Alternative way:
o When urinating, try to stop in the middle of flow or try to stop diarrhea from flowing
o Advantage of Kegel’s Exercises o Increases muscle tone of the pelvis
o Increases muscle control

2.Clean Intermittent Self Catheterization

 Applicable for Reflex Incontinence
 How done:
o Use a mirror for:
o Obese male patients
o Female patients
3.Crede’s Maneuver
 Application of a steady but gentle pressure on the suprapubic region to force urine out of
the bladder
 Nursing Alert!
o Do not use if there is OBSTRUCTION (i.e. renal obstruction in the form of renal
stones)
o This is done only for patients who are no longer expected to regain control (Reflex
incontinence and retention)

4.Prompted Voiding or Scheduled Toileting

 For Reflex Incontinence

5.Application of Adult Catheter and External Condom Catheter

 For elderly with Total Incontinence
6.Catheterization

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MIDSTREAM CLEAN CATCH
URINE SPECIMEN
How is this done?
 If patient is a MalE, Clean the penis
o Do this from the meatus down to the shaft
o Let the patient urinate
o Discard the first or the initial urine
o Collect midstream urine o Purpose is to attain sterile specimen for urine culture
and sensitivity testing
 If patient is a Female…
o Let patient wash genitals
o Dry the genitals o Get to bed
 Place patient in semi-Fowler’s position when she is ready to void
 Clean and spread labia with two fingers
 Remain holding labia
 Then let patient urinate
 Let go of first flow
 Collect next flow

CATHETERIZATION

 Coude Catheter -Elbowed catheter for Benign Prostatic Hypertrophy patients

 Robinson Catheter o Straight catheter
 Multi-Lumen Retention Catheter/Foley catheter
o One lumen is for inflation
o One lumen is for drainage of urine
o One lumen is for irrigation
 A three-way catheter
 Aspirate using syringe and needle
 This is made with a self-sealing rubber

Concepts!!!
 See to it that penis is perpendicular to body to straighten up the urethra to bladder
 While inserting the catheter, ask the patient to breathe through the mouth
 Cleanse the penis before insertion
 Grasp penis firmly to avoid stimulating erections
 Where to tape catheter? Tape it upward on the abdomen
 Rationale:
o To avoid scrotal excoriation
o Tape on the inner thigh (with penis sideways either on left or right and follow the
normal contour of the penis
 Length of Catheter -40 centimeters
 Depth of Insertion
o While inserting, the point at which urine starts to flow, insert further by five (5)
centimeters and then inflate the balloon –

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 o Insert up to a the Y point, retract after inflating (this method is more prone
to infection
 For females
o Insert at female Urethra
o Length of Catheter - 22 centimeters
o Depth of Insertion - Point at which urine starts to flow, insert further by five
(5) centimeter before inflating balloon

GIT – FECAL ELIMINATION

Wellness Teachings
 Fluid intake of at least 2,000 ml per day
 Regular exercise
 High fiber diet
 Avoid ignoring the urge to defecate
 Do not abuse laxatives

Concepts!
 For Flatulence
o Avoid carbonated drinks
o Do not use straw
o Avoid chewing gum
o Avoid gas-forming foods:
Camote, Cabbage,Cauliflower, Onions
For Constipation:
 Increase fluid intake
 Prune juice
 Papaya
 Increase fiber in the diet
 Use METAMUCIL (natural fiber) instead of laxatives

Special Laboratory Procedures

1.Guiac Test
 To determine the presence of occult blood
 Concepts!!!
o Have a meat-less diet three (3) days before examination
o Withhold oral iron supplements
o Injectible iron is allowed
o Avoid any food that discolors the stool.

2.GI SERIES Upper GI Series – Barium Swallow Nursing Considerations:

o Elimination of contrast medium How:
o Increase fluid intake
o Increase fiber in the diet
 Rationale:

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 o To offset the risk of constipation
o Inform patient that the color of the stool will be WHITE
Lower GI Series – Barium Enema
 Done at the radiology department
 Nursing Concern:
o Elimination of Barium
 How:
o Cleansing enema may be needed after barium enema

Different Types of Enema

1. Cleansing Enema
 Soap suds enema Alkaline solution
 Nursing Alert!
o Contraindicated in patients with liver cirrhosis and with increased ammonia in the
blood
o Rationale:
• Alkaline solution facilitates transfer of ammonia from the GI tract to the
bloodstream, Therefore, use lemon juice or dilute vinegar instead!!!
 Nursing Alert!
o Also contraindicated in possible appendicitis or appendicitis patients
 Rationale:
o Can lead to rupture of he appendix
2. Carminative Enema
 Used to expel out flatus
 Burned sugar
 Now commercially available

3. Oil Retention Enema Purpose:

o To lubricate the colon and to soften the feces
o Retention time is one
(1) to three (3) hours

4. Retention Flow Enema

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

Positions in Enema
 Cleansing Enema
 High Cleansing Enema o Clean as much of the colon as possible
o On introduction, Sim’s Left position facilitates flow of enema to sigmoid
colon
o Then, assume Dorsal Recumbent position to facilitate flow of enema to transverse
colon
o Then, Right Side-Lying position to facilitate flow of enema to the descending colon
 Low Cleansing Enema o For cleaning of rectum and colon only

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