FUNDAMENTALS OF NURSING PRACTICE - Protection, Promotion, and optimization of health and abilities, prevention of

illness and injury, alleviation of suffering through the diagnosis and treatment
of human response, and advocacy in the care of the individuals, families,
4 Central Concepts/Fundamentals in Nursing Practice: communities and populations (ANA, 2003)
1. Person/Patient: Recepient of nursing care
2. Health: Maximum wellness of being
Historical Development of Nursing
3. Environment: Internal and External surroundings
1. Intuitive Period
4. Nursing: attributes, chracteristics and actions performed
to the person to promote his well-being • Practice during the pre-historic times among the primitive tribes
• Nursing practice is by intuition > Mothers/Females (Nursing)
• Illness: Evil spirit (Black magic/voodoo)
Concepts of Man and His Basic Human Needs • Healing: Shaman/Witch Doctor (White Magic)
• Man is a… 2. Apprentice Period
• Biopsychosocial and Spritual being who is in constant contact with the - “On the Job” period of nursing
environment - No formal education in nursing > training or OJT with “more experienced”
- To be able to understand man well and to provide care to them
- Bio: Man is like “all” other man; we are all composed the same nurses
- Crusades (Men): Knights of St. Lazarus, Alexian Brothers Hospital
- Spiritual: We all believe in a supreme higher being - The Rise of the Secular Orders (Females): St. Elizabeth of Hungary, St.
- Social: Man is like “some” other man; we all have different values
- Psych: Man is like no other man Catherine of Siena
- The Dark Period of Nursing: Sairy Gamp and Betsy Prog
• Open system in constant w/ a changing environment - Nursing in America: Clara Barton (Started American Red Cross)
- There is an input and output
- Man is affected by the internal and external environment/systems 3. Educated Period
- 1860: F. Nightingale opened first nursing school with criteria for admissions
• Unified whole composed of parts which are interdependent and interrelated w/ - Florence Nightingale: Mother of Modern Nursing, The Lady with the Lamp,
each other First Nurse-Epidemiologist
• Composed of parts which are greater than and different from the sum of all his 4. Contemporary Period
parts - Began after WWII up to present
- Systems are interrelated, when giving care to px it must be holistic - Establishment of WHO
• Composed of subsystems and suprasystems - Health is a fundamental right of every individual
- Subsystems: Within; Physiologic, Biologic, Psychological, etc. Sytems - Acknowledged Health Promotion and Disease Prevention
- Suprasystems: Systems beyond or outside of man such as family, - Community Based Nursing
community, population and society - Sophisticated technology + equipments
Characteristics of Basic Human Needs Current Trends in Nursing
• Universal Evidence-based practice
•
• Met in different ways Community-Based nursing
•
• Stimulated by external and internal factors Decreased length of hospital stay
•
• Priorities may be altered Aging population
•
• May be deferred Increase in chronic care conditions
•
• May be interrelated Independent nursing Practice
•
• Unmet human need results in disruptoion of normal body activities and frequently Culturally Competent care
•
leads to eventual illness
Nursing Theories (JOHHN PARROLL *WKNB)
Abraham Maslow’s Hierarchy of Human Needs J: Johnson, Dorothy > Behavioral Systems Model
• Self Actualization O: Orem, Dorothea > Self Care/Self Care Deficit
• Self Esteem H: Hall, Lydia > Core, Care, Cure
- Being well thought of oneself and others
- Improve px self esteem by giving them indepence H: Henderson, Virginia > 14 Fundamental Needs
N: Nightingale, Florence > Environmental
• Love and Belongingness
• Safety and Security P: Peplau, Hildegard > Interpersonal Relations Model/ Psychodynamic Nsg Model
- Physical and Psychological Safety
- Physical: Raise Side Rails, Care of suicidal px, etc. A: Abdellah, Faye > 21 Nursing Problems
- Psychological: Explain procedure R: Roy, Callista > Adaptation Model
R: Rogers, Martha > Science of Unitary Human Being
• Physiologic O: Orlando, Ida Jean > Nursing Process Theory/ Dynamic Nurse-Px Relations
* if all problems fall under Physiologic Level: L: Leininger, Madeleine > Transcultural Care
* High Priority: Life Threatening Problems (ABCDE) L: Levine, Myra > 4 Conservations Principles
* Medium Priority: Health Threatening Problems (Nutrition, etc.)
* Low Priority : Developmental Needs *W: Watson, Jean > Human Caring Theory
*K: King, Imogene > Goal Attainment Theory
Concepts of Nursing *N: Newman, Betty > Total Person Model
• Nursing: *B: Benner, Patricia > Novice to Expert Theory
- Act of utilizing the environment of the px to assist him in his recovery
(Nightingale) 1. Johnson, Dorothy
- Theoretical system of knowledge that prescribes a process of analysis and
• Behavioral System Model
action related to the care of the ill person (Roy) • Each person as a behavioral system is composed of 7 substems
- Humanistic science dedicated to compassionate concern with maintaining
• In a normal condition, the 7 subsystems are stable as well as the behaviour of
and promoting health and preventing illness and caring for and rehabilitating the person.
the sick and disabled (Rogers) • If there is stress in one of the systems, there is an expected erratic behaviour
Action > Levels of Prevention > of the px.
- Helping or assisting service to persons who are wholly or partly dependent,
when they, their parents or their guardians, or other adults responsible for 2. Orem, Dorothea
their care are no longer able to give or supervise their care (Orem) • Self Care and Self Care Deficit Theory of Nursing
• Self Care Agency: Independent or Dependent

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 • Indepent Agent: I am capable of providing my own self care • Goal must be px- Centered
• Dependent Agent: I am dependent on others for my self-care demands
• Based on the concepts of: 15. Newman, Betty
- Self Care • Total Person Model
- Self Care Agency • nursing is concerned with the whole person
- Self Care Requisites • The goal of nursing is to assist IFGC in attaining and maintaining a maximal
- Therapeutic Self Care Demand level of total wellness by purposeful interventions.

3. Hall, Lydia 16. Benner, Patricia

• Core, care, cure • Novice to Expert Theory
• three aspects of nursing: therapeutic use of self, bodily care, cure - Novice
- Advanced Beginner
4. Henderson, Virginia - Competent
• The nature of nursing model - Proficient
• 14 fundamental needs - Expert

5. Nightingale, Florence Health, Disease, Illness

• Environmental Theory • Health:
• 5 Environmental Factors (Air, Water, Drainage, Cleanliness and Light) - Prescence or abscence of a disease
- A state of complete physical, mental and social, well-being and not merely
6. Peplau, Hildegard the absence of disease or infirmity (WHO, 1948)
• Interpersonal Relations Model/ Psychodynamic Model • Illness:
• 4 Phases of Nurse-client Relationship - Personal State
- Orientation - Highly Subjective
- Identification - Not synonymous to a disease and may or may not be related to a disease
- Exploitation • Disease:
- Resolution - Alteration in body functions resulting in a reduction of capacities or a
shortening of the normal life span
7. Abdellah, Faye
• Px-Centered Approaches to Nursing Model Models of Health and Illness
• 21 Nursing Problems 1. Smith’s 4 Models of Health
A. Clinical Model
8. Roy, Sister Callista • Narrowest definition of health
• Adaptation Model • A person is considered to be healthy if he is without any s/sx
• Humas as biopsychosocial beings who constantly interact with their B. Role Perfomance Model
environment through biopsychosocial adaptation mechanisms • All of us are healthy if we are able to perform our societal roles
C. Adaptive Model of Health
9. Rogers, Martha • Health is a creative process and a person is considered to be healthy if
• Science of Unitary Human Beings he is able to adapt
• Unitary Man is an energy field in constant interaction with the enrvironment D. Eudaemonistic Model of Health
• Human beings are more than and different from the sum of their parts • A healthy person is a self-actualized person
• Most comprehensive view of health
10. Orlando, Ida Jean
• Dynamic Nurse- Px Relationship Model 2. Leavell and Clark Model
• Nurse Process Theory A. Agent- Host- Environment Model (Ecologic Model)
• Nursing as a process involved in interacting with an ill individual to meet an • Agent: Factors
immediate need. • Host: Person
• ADPIE • Environment
11. Leininger, Madeleine 3. Dunn’s High Level Wellness Grid
• Transcultural Nursing Model A. Health- Illness Continua
• Cultural Care Diversity and Universality Theory
• Nursing is a humanistic and scientific mode of helping a client through specific
cultural caring process to preserve or maintin a health condition.

12. Levine, Myra

• Described the Four Conservation Principles
- Conservation of Energy
- Conservation of Structural Integrity of the Body
- Conservation of Personal Integrity
- Conservation of Social Integrity

13. Watson, Jean

• Human Caring Theory
• 10 Carative Factors
• As nurses, it is intrinsic in us to be caring

14. King, Imogene

• Goal Attainment Theory
• Described the nature and standards for nurse-px interactions that lead to goal
attainment- nurses purposefully interact and mutually set, explore and agree to
means to achieve goals

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4. Travis’ Illness/Wellness Continuum 5. Recovery or Rehabilitation
A. Travis’ Model * not all undergo these stages

Stages of Health Behaviour Change

• Precontemplation
• Contemplation
- Desire to change
- This may take several months to years
• Preparation
- Taking steps to begin the change
• Action
- Engages in an observable change
• Maintenance
• Termination

Nursing Process
• Characteristics:
- Cyclic and dynaminc nature
5. Rosenstoch-Becker Model - Critical thinking skills
- Decision Making
- Client centered
- Interpersonal and collaborative
- Universally applicable

1. Assessment
• Systematic collection, validation, organization, recording and reporting of data
A. Initial Assessment
• When: Upon Admission
• Why: Baseline Data
B. Problem-Focused Assessment
• When: Ongoing assessment
• Why: New or overlooked problem
C. Emergency Assessment
• When: during physiological or psychological crisis
• Why: Determine any life threatening problems
D. Time-Lapsed Assessment
• When: After a period of time
• Why: for evaluation
• Sources of Data (Primary or Secondary)
- Client
- Family
Health Status, Beliefs and Practices - Health Care Professional
• Health Status: state of wellbeing at a certain period in time • Types of Data (Covert or Overt)
• Beliefs: Not all factual, affected by culture - Subjective: Covert (Symptoms)
• Practices - Objective: Overt (Signs)
• Steps in Assessment
Factors Affecting Health Status, Beliefs, and Practices A. Collection of Data
• Factors in the human dimensions that influence health-illness status • Principal Methods:
- Physical Dimension: genetic inheritance, age, developmental level, race and - Observing: use of senses (both of the patient and the
gender environment);
- Emotional Dimension: how the mind affects body function and responds to First thing to observe in the px is physiological or
body conditions psychological crisis!
- Intellectual Dimension: Cognitive abilities, educational background, and past Second thing to observe is if there is any threat to the
experiences patient’s safety
- Environmental Dimension: housing, sanitation, climate, pollution of air, food Third is to check the functioning of assistive devices (IV,
and water IC, Colostomy, O2, NGT, Etc.)
- Sociocultural Dimension: economic level, lifestyles, family and culture Fourth is to observe the patient and the environment
- Spiritual Dimension: Spiritual beliefs and values - Interviewing: Purposeful communication with the patient
• Risk Factors for Illness Social Phase: 2-5 mins to establish rapport
- Etiological Factors Professional Phase: Data Collection
- Predisposing Factors Keep in mind the patient’s privacy and personal space
- Contributory Factors - Examining:
- Precipitating Factors IPPA
• Beliefs and practices Flatness: extremely dull
• Basic human needs Dullness: thudlike
• Self-concept Resonance: hollow
Hyperresonance: Bomming
5 Stages of Illness by Suchman Tympany: Musical
1. Symptoms Experience B. Validation of Data
2. Assumption of the Sick Role C. Organizing Data
3. Medical Care Contact (Validation, Explanation, Reassurance) D. Categorizing or Identifying patterns of data
4. Dependent Client Role E. Making influencers or impressions

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 F. Recording/ Reporting of Data • Guidelines for Evaluation
- systematic process
- ongoing basis
Nursing Diagnosis - revision of the plan of care when needed
• Medical Diagnosis - involve the client, significant others and other members of the health team
- focuses on illness, injury & disease process - must be documented
- remains constant
- identifies cindition that practitioner is licensed & qualified to treat Documenting and Reporting
• Nursing Diagnosis • Medical Record or Chart
- focuses on response to actual or potential health problems - account of the client’s history, current health status, treatment and progress
- changes as the client’s response or health problems change - written communication that permanently documents information relecant to
- identifies situation oon which the nurse is licensed & qualified to interview his or her health care management
• Reports
- oral or written exchange of communicatiom

Categories of Nursing Diagnosis • Purposes of Clients Records

1. Actual Nursing Diagnosis - Communication
• indicates that a problem exists & is composed of the diagnostic label, related - Planning client care
factors, signs & symptoms - Audit
- Research
2. Risk Nursing Diagnosis (Potential Problem) - Education
• indicates that a prolem does not yet exist but special risk factor are present - Reimbursement
- Legal documentation
3. Wellness diagnosis
• describes human responses to levels of wellness in an individual, family or Documentation System
community that have a readiness for enhancement • Source-Oriented Medical Record (SOMR)
- data are arranged according to source of information ex. nurse - nurses’
Components of Nursing Diagnosis notes, physician - physician’s order sheet
• Basic Two Part Statement - there is redundancy
- Problem-Etiology • Problem-Oriented Medical Record (POMR)
- Ex. Constipation related to prolonged laxative use - data are arranged according to the problems of the patient
• Basic Components:
• Basic Three Part Statement - Database
- Problem-Etiology-Defining Characteristics - Problem list
- Ex. Situational low self esteem related to rejection by husband as - Plan of care
manifested by hypersensitivity to critisism - Progress notes
• Methods of Charting
Planning 1. Narrative Charting - narrates sequence of events
• 3 Phases of Planning Nursing Care 3 2. Focus Charting (FDAR) - recirds changes or response of client to the
1. Initial Planning treatment
2. Ongoing Planning 3. SOAP, SOAPIE, SOAPIER, APIE- usually used in CHN
3. Discharge Planning 4. Charting by Exception (CBE)
• Steps
- significant changes or abnormal manifestations
- Setting priorities - makes us of checkilst (standardized checklist, unique checklist) ex. ICU
- Establishing client goals
- Selecting nursing interventions Reports
- Writing nursing orders • Change of shift report
- Types of nursing order • Telephone report
1. Observation order • Telephone orders - signed within 24hrs
2. Prevention order Ex. Comatose px, bedsore prec - turn to sides • Transfer reports
3. Treatment order • Incident reports
4. Health promotion order
Vital Signs
Implementation • Body Temperature
• Requirements of Effective Implementation - Heat Produced = Heat Lost
1. Cognitive Skills (Intellectual) Core Temperature
2. Proficiency with Psyhomotor Skills Surface Temperature
3. Interpersonal Skills - Thermoregulation Process (36.5-37.5)
• Process of Implementing Heat Production
- Reassess client - to make sure that intervention is still appropriate Heat Loss
- Determine nurse’s needs for assistance - Factors affecting Body Temp
- Implementing nursing interventions Age Exercise
- Supervising the delegated care Hormones (Progesterone: Up Temp)
- Documenting nursing activities Stress
Environmental Temperature
Evaluation Meds
• Purposes of Evaluation Diurnal Variation/Circadian Rhythm
• Determine:
- Alterations in Body Temp
- client’s progress or lack of progress Average: 36-38
- effectiveness of nursing care Hypothermia: 34-35
- overall quality of care provided - Accidental
• Promote nursing accountability - Induced
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 Pyrexia/Fever: 38-40 - Disturbing or distruptive characteristics w/i the environment
- Onset/Chill Phase: Up RR, HR, shivering, cold skin, cessation of • Response Based (Selye)
sweat - Non-Specfic response of the body to any demand made upon it
- Course/Plateau Phase: No Chills, Warmth, Up HR RR, Thirst • Transaction Based (Lazarus)
- Abatement Phase: flushed skin, sweating, less Shivering • Individual perceptual response rooted in psychological and cognitive
Hyperpyrexia: 41-42 process
- Common Types of Fever • Adaptation Model
Intermittent: fluctuation from febrile to afebrile - an anxiety provoking stimuli
Remittent: temp is above normal but fluctuation is wide (more than - People experience anxiety and increased stress when they are
2CO unprepared to cope with stressful situations
Constant: temp is above normal • Sources of Stress
Relapsing - Intrinsic/Internal Stressor
- Nursing Interventions (Fever) - Extrinsic/External Stressor
Feels Chilled: Provide extra blankets - Developmental Stressor
Feels Warm: Remove Excess Blankets - Situational Stressor
Adequate nutrition and fluids
Reduce physical activity • Characteristics of Stress
Oral Hygiene - Fabric of Life
TSB: Up Heat loss - Organism reacts as a unifid whole
Dry clothing and linen - Not a nervous energy
VS - Not always results to feeling of distress
I&O - not always due to tissue injury
Monitor CBC, Hct - Not always something to be avoided
• Pulse Rate - Whenever prolonged or intense may lead to exhaustion
- Pulse Strength • Factors influencing manifestations of stress
0: absent - Nature and intensity of stressor
1+: pulse is diminished, barely palpable, easy to obliterate - Perception of the stressor
2+: easily palpable, normal pulse - Duration of exposure to stressor
3+: full pulse, increased - Number of stressors experienced at the same time
4+: strong, bounding pulse, cannot be obliterated - Previous experience with a stressor
- Pulse deficit: difference of apical pulse and radial pulse - Age
• Respirations - Support People
- Three processes
Ventilation: inflow and outflow of gas going in and out of lungs Homeostasis
Diffusion: Movement or exchange of gases (O2 and CO2) between • Tendency of the body to maintain a state of balance or equilibrium while
Alveoli and Blood; Higher to Lower Concentration constantly changing
Perfusion: • Classification of Homeostasis
Inhalation/Inspiration: 1 to 1.5 secs • Physiologic - internal environment of body is stable & constant
Exhalation/Expiration: 2 to 3 secs • Psychologic - refers to emotional, psychological, mental balance or state of
- Assessing Ventilation well being
RR • Characteristics of Homeostatic Mechanisms
Depth 1. Self-regulatory (come automatically)
Rhythm 2. Compensatory (counterbalancing)
Volume 3. Regulated by feedback mechanism - positive and negative feedback
Ease and Effort mechanisms - homeostasis
- Alteration in Breathing Patterm 4. Require several feedback mechanism to correct one physiologic
- Rate: Tachypnea, Bradypnea, Apnea, Eupnea imbalance
- Rhythm: • 2 Major Homeostatis Regulators
Biot’s: shallow apnea (CNS depression) 1. Autonomic nervous System - sympathetic & parasympathetic
Cheyne-Stokes: waxing and weaning, slow, deep, apnea (Inc ICP) 2. Endocrine system - pituitary, thyroid, parathyroif, pancreas & adrenal
Kussmaul’s: Rapid, deep (Lung fields are Hyperventilated > glandsa
Hypercapnea > Respi Alkalosis) 3. Plus organ systems as respiratory, cardiovascular, GI & renal
- Volume: Hyperventilation, Hypoventilation
- Ease of Effort: Dyspnea, Orthopnea Adaptation
• Arterial Blood Pressure • Adjustments that a person make in different situations
- < 120/80 mmHg • Modes of Adaptation
- Systolic Pressure • Physiologic
- Diastolic Pressure - GAS & LAS
- Pulse Pressure: 40 mmHg - Compensatory physical change
- Physiology of Arterial BP
BP = CO x R • Psychologic
Pumping action of the heart - involves a change in attitudes or behavior
Peripheral Vascular Resistance
Blood Volume • Sociocultural
Blood Viscosity - changes in the prson’s behavior in accordance with norms, conventions &
beliefs of various groups
Stress
• Stress: condition in which the person experiences changes in the normal • Technological
balanced state - involves the use of modern technology
• Stressor: any event or stimulus that causes an individual to experience stress
• Models of Stress
• Stimulus Based (Holmes and Rahe)

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General Adaptation Syndrome
STAGES: Local Adaptation Syndrome
1. Alarm
- awareness of stressor • Inflammatory response
- SNS - increase vital signs 1. Pain (Dolor)
- mobilization of defenses 2. Redness (Rubor)
- increase hormone level 3. Heat/ Warmth (Calor)
4. Swelling/ Edema (Tumor)
2. Resistance 5. Loss of function (Functiolaesa)
- repel of stressor
- repel > adaptation
- normalization of hormone levels
- normalization of vital signs
- increase in body resistance 3. Reparative Phase
- Regeneration
3. Exhaustion - Fibrous Tissue (Scar or “Cicatrix”) Formation
- decrease energy level
- breakdown in the feedback mechanisms
- results to positive feedback mechanism Types of Wound Healing
- Primary Intention: If the wound edges are well approximated (Surgical Wound),
- organ or tissue damage
- decrease physiological function minimal tissue damage
- Secondary Intention: Longer repair time, higher risk of infection compred to
- exaggerated manifestation of illness
Primary Intention
- Third Intention: Delayed Primary Intention
General physiological Adaptive Mechanisms
Anterior pituitary gland - secrete ACTH - stimulate adrenal cortex - ac secetes 3S
(glucocortecoids-salt, mineralocortecoids -sugar, androgen- sex)
Physiologic Effects of Heat and Cold
Posterior pituitary gland - ADH - kidneys - sodium and water retention/reabsorption
- decreased urine output - increased blood volume - increased BP , oxytocin -
uterine contraction HEAT COLD

• Adrenal medulla - epinephrine, norepineohrine

Vasodilation Vasoconstriction
• Sympathoadreno-medullary Response (SAMR)
- prepares body for fight or flight mechanism Inc. capillary permeability Dec. Capillary permeability

• Sympathettic nervous system - epi, norepi - increase in physiological activitie Inc. Cellular metabolism Dec. Cellular metabolism
(except gi)
• Physiologic Indicators of Stress Inc. Inflammation Dec. Inflammation
- Increased mental alertness, restlessness
- Dilated pupils, increased visual perception
- Dryness of the mouth, decreased salivary secretion, thirst Sedative effect Local anesthetic effect
- Tachycardia, increased cardiac output
- Bronchodilation, hyperventilation
- Peripheral vasoconstriction, increased BP
- Pallor, cold clammy skin, diaphoresis Heat and Cold Application
- Hyperglycemia due to glycogenolysis & gluconeogenesis • Done for 30 min. average of 15-20 mins or else there will be a rebound effect.
- Decrease peristalsis, constipation or flatus • Dry Heat:
- Urinary output decreases - Hot Water Bags: temp 98-106FO
- Muscle tension increases ready for defense - Disposable hot packs
- Floor Lamp/Gooseneck Lamp/Heat Cradle
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 Bulb: 25 watts • Adventitious Breath Sounds
Distance 18-24 inches D. Crackles (Rales)
• Dry Cold Application: - Fine, short, interrupted crackling sounds
- Ice Collar E. Gurgles (Rhonchi)
- Ice cap - continouous, low-pitched, coarse, gurgling, harsh sound with
- Disposable cold packs moaning/snoring quality
• Moist Heat Application F. Friction Rub
- Warm moist compress - Superficial grating or creaking sounds
- Hot Sitz Bath/Hip Bath G. Wheeze
Used to soak the client’s pelvic area - Continous, High-Pitched, Squeaky musical sounds
Immersed from the midthings to the iliac crests or umbilicus • Vocal (Tactile) Fremitus
Water temp: 40-43CO - Faintly perceptible vibration felt through the chest wall when the client
Duration: 15-20 mins speaks
Take px VS especially BP and RR - Tres tres
Side Effects: Lightheadedness due to pooling of blood in the pelvic area
> Stop the procedure Sputum
• Temperature ranges for Hot and Cold Application • Diagnostic Studies
- C&S
Temp Centigrade Fahrenheit - AFB (for TB)
Range Range - Cytology
Hot 37-41 98-106 • Specimen Collection
- Morning, upon awakening
- Mouth care prior to collection
Warm 34-37 93-98 - 1-2 tbsp (15-30 ml)
Tepid 26-34 80-93 Thoracentesis
• specimen collection, removal of pleural fluid, instill medication
Cool 18-26 65-80 • Pretest:
- Consent
Cold 10-18 50-65 - Do not cough or talk during procedure
- At the side of the bed with upper torso supported on overbed table
• Intratest:
Oxygenation - Assistance
- Specimen Collection
• Three Processes
1. Pulmonary Ventilation • Posttest:
- Clear Airways - Auscultate breath sounds
- Intact CNS and respiratory center - Observe for s/sx of pneumothorax
Medulla Oblongata and pons
- Shock, Leakage at puncture site
Carotid and Aortic bodies • Position after Thoracentesis: Lie down at Unaffected Side to allow Maximum
- Intact thoracic cavity Lung Expansion
- Adequate pulmonary compliance and recoil
2. Diffusion Bronchoscopy
- Concentration of the gases • Diagnosis, Biopsy, Specimen Collection, Examination of stucture/tissues, removal
- Thickness of the membrane of foreign bodies
3. Perfusion • Pretest:
- Cardiac Output - Consent
- Nurmer of erythrocytes and blood hct - Remove Denture
• Hypoxia vs. Hypoxemia
- Oral Hygiene
- Hypoxemia: dec O2 in blood - NPO: 6-12 hours
- Hypoxia: dec O2 in tissues and cells • Posttest:
• Signs of Hypoxia
- NPO until return of gag reflex
- Increased restlessness or light-headedness (Earliest Manifestation!) - on side or in semi-fowlers
- Rapid Pulse - Ice bags on throat
- Rapid, shallow respirations and dyspnea - Discourage talking or coughing
- Elevated BP
- Flaring of Nares Respiratory Modalities
- Substernal or Intercostal Retractions • Abdominal (Diaphragmatic) and Pursed Lip-Breathing
- Cyanosis - Semi/High Fowlers position
- Clubbing of Fingers (Sign of Chronic Hypoxia) - Slow deep breath, hold for a count of 3 then slowly exhale through mouth
• Normal Breath Sounds and pursed lip
A. Vesicular - 5-10 slow deep breaths every 2 hours on waking hours
- Soft intensity, low Pitched • Coughing Exercise
- T5 onward - Upright position
- Peripheral lung, base of the lung - Contraindicated: s/p brain, spinal, or eye surgery
B. Bronchovesicular - Take 2 slow deep breaths; on the third breath, hold for a few seconds, cough
- Moderate intensity, moderate pitch twice without inhaling in between
- T3-T5 - May splint surgical incisions: put a pillow or folded towel on top of incision
- Between scapulae lateral to the sternum site
C. Bronchial - Every 2 hours while awake
- High Pitch, loud harsh sounds • Incentive Spirometry/SMI Sustained Maximal Inspiratory Device
- T1-T3 - a breathing device that provides visual feedback that encourages px to
- Anteriorly over the trachea sustain deep voluntary breathingand maximum inspiration

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 - 10 times every 1-2 hours Epistaxis noted with continous suctioning > Notify MD and anticipate
• Postural Drainage the need for nasal trumpet
- Purposes: Aids in airway clearance of mucus in patient’s with retained
tracheobronchial secretions Oxygen Therapy
- Facilitated movement of secretions from smaller peripheral airways into • Special Considerations
larger central airways - Given with MD’s orders
- Contraindication: Inc. ICP, Inc. IOP, With active hemorrhage, With - careful and continous assesssment to evaluate the need for and its effect on
hemoptysis, Weak or uncooperative px the px
- When: Morning, at bedtime, 30 mins-1hr before or 1-2 hrs after meal • Safety Precaution
- Each position: assumed for 10-15 mins - Drying effect > Need for humidifier
- Entire treatment: should last only for 30 minutes - “No Smoking” and “O2 in Use” signs at the door
- Disconnect grounded electrical equipment
- Avoid use of oil, grease, alcohol and wool (easily ignited)
- Use of a hand bell instead of an electric one
• Delivery
- Cannula
Check frequently that both prongs are in the px’s nares
encourage the px the nose, with mouth closed
May be limited to no more than 2-3 lpm to px’s with chronic lung DSE
- Face Mask
Simple Face Mask: 40-60% O2 delivered
Partial Rebreather Mask: 60-80% O2 delivered
Nonrebreather Mask: 80-95% O2 delivered
Venturi Mask: Most precise O2 concentration O2 delivered
• Unexpected Situations and Associated Interventions
- NC was attached but px is cyanotic > check if tubing is still connected to flow
meter and if flow meter is still on previous setting
- Areas over ear or back of the head are irritated > Pad areas and tubing is not
pulled too tight
- When dozing, px begins to breathe through the mouth > temporarily place
the NC near the mouth > notify MD to switch to mask while sleeping
• Nursing Interventions for Simple Face Mask
- Monitor px frequently and check the placement of the mask
- Support px if claustrophobia is a concern
- Secure MD’s order to replace mask with NC during meal time
- Remove mask and dry the skin every 2-3 hours if the O2 is running
• Chest Physiotherapy continously. Do not use powder around the mask.
- Percussion: Rhythmical force provided by clapping the nurse’s cupped • Nursing Interventions for Partial Rebreathing Mask
hands against the px’s thorax; over affected segment for 1-2 mins - Set Flow rate so that mask remains two-thirds full during inspiration
- Vibration: Perform by contracting all the muscles in the nurse’s upper - Keep reservoir bag free of kinks
extremities to cause vibration while applying pressure to the px’s chest wall; • Nursing Interventions for Non Rebreathing Mask
one hand over the other; 3-5 vibrations - Maintain flow rate so reservoir bag collapses only slightly during inspiration
(Nubulization/Steam Inhalation 20 mins before > Positioning > Percussion > • Nursing Interventions for Venturi Mask
Vibration > Removal of secretions by coughing or suctioning > Expectoration ) - requires careful monitoring to verify FiO2 at flow rate ordered
• Suctioning - Check that air intake valves are not blocked
- Purposes: • Oxygen Hood
- Maintain patent airway • Oxygen Tent
- Promote adequate exchange of O2 and CO2 • Allows freedom of movement (Pedia Px)
- Substiture for effective coughing • Unexpected Situations and Associated Interventions
- Specimen Collection - Child refuses to stay in the tent > Parent may play games in tent with
- Size: child
Adult: Fr 12-18 - Difficult to maintain an O2 level above 40% in the tent > Ensure that flap
Child: Fr 8-10 is closed and edges are tucked properly
Infant: Fr 5-8
- Length: From tip of nose to earlobe (5in) Inhalation Therapy
Nasopharyngeal: 5-6 inches • Moist Inhalation: Steam Inhalation; 12 -18 inches for 15-20 mins
Oropharyngeal: 3-4 inches • Dry Inhalation: Metered Dose Inhaler; Use of Inhaler; Use of spacer hold breather
Nasotracheal: 8-9 inches for 10 secs, 5 mins interval
ET: length of ET + 1 inch
Trach: length of Trach + 1cm Chest Tube and Drainage Systems
- Duration: 5-10 secs; max is 15 secs • Used to drain fluid and air out of the mediastinum or pleural space into a
intermittent suctioning upon withdrawal using rotating motion collection chamber to reestablish normal negative pressure for lung reexpansion
If to repeat 1-2 mins interval • Insertion: 2nd-3rd ICS (Air) 4th ICS (fluid)
Limit suctioning in a total of 5 mins • One Bottle System:
- Hyperventilate/Hyperoxygenate the client before and after suctioning! - Drainage and Water Seal
ask to deep breath 3-5 times - With air vent open to air
- Unexpected Situation and Associated Interventions - Water Seal: Immersed Tip 2-3 cm at sterile water
Vomits suring suctioning > Remove cath, change cath, Turn px to side - Bottle: Keep 2-3 feet below chest level to prevent backflow; never raise
and elevate head to prevent aspiration above level of heart
Secretions appear to be stomach contents > ask px to extend neck - Check for patency
slightly - Fluctuations should synchronize with Respiration
- Intermittent bubbling (Normal)
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 - Continous Bubbling (Leak) Reposition atleast every 24-48 hrs
- No Fluctuations Depth and length during insertion should be maintained
- Obstruction: Chest px first before tubing Level of tube: Gumline/Biteline (Level at which ET Tube can
- Lungs has re-expanded: Validate (X-Ray) expand both lungs)
• Two Bottle System: Maintain Cuff pressure of 20-25mmHg
- Drainage and Water Seal Check lips for cracks and irritation
- W/o Suction • Unexpected Situations and Associated Interventions (ET tube)
1st Bottle: Drainage; 2nd: Water Seal - px accidentaly extubated during suctioning > remain with px > notify MD >
Intermittent Bubbling @ 2nd Bottle - O2 sat dec after suctioning > Hyperoxygenate px > Auscultate lung sounds >
- W/ suction lung sounds over 1 lobe? Notify MD > remain with px, Pnuemothorax
1st Bottle: Drainage and Water Seal; 2nd: Bottle: Suction Control possible
Normal: Intermittent Bubbling in Water Seal, gentle Bubbling in Suction • Tracheostomy Tube
Control Bottle • To maintaine patent airway and prevent infection of respi tract
- 2nd Bottle: Immerse tube 10-20 cm of sterile NSS • Care of px with trache
• Three Bottle System: - Sterile: acute phase
- Drainage - Clean: home care
- Water Seal - 1st 24 hrs: trache cate every 4 hrs
- Suction Control (if pressure increases, injury is prevented at lung tissues) - prevent aspiration
- 20-30 cm of water @ Suction Control Bottle
- 1st bottle: Drainage; 2nd: water seal; 3rd: Suction Nutrition
- 2nd Bottle: normal intermittent bubbling/fluctuations • Sum of all interactions between an organism and the food it consumes
- 3rd Bottle: normal gentle bubbling only • Combination of process by which a living organism receives and utilizes
- Cont/Vigorous Bubbling=Leak materials or substances
• Care of Client with Chest Tube • Essential Nutrients
- Occlusive dressing around the chest tube insertion • Water
- No dependent loops or kinks in the drainage tubing • Macronutrients
- Drainage bottle below client’s chest • Carbohydrates: 4 cal
- Available at bedside: • Proteins: 4 cal
Sterile Gauze (occlusive Dressing) for accidental pulling of CTT • Fats: 9 cal
Extra Sterile Bottle with Sterile NSS • Micronutrients
Forcep/Clamp (if there is no extra bottle, clamp the tube) - Fat Soluble Vitamins: Vit ADEK
- Gentle bubbling and tidaling is normal - Water Soluble Vitamins: Vit C, B1-12, Biotin; Whatever your body doesn’t
- I&O per shift need the body excretes
• Unexpected Situations and Associated Interventions • Types of Diet
- CTT separates from drainage device > Gloves > Open Sterile NSS and • Regular/Full Diet/DAT
insert the chest tube into the bottle while not contaminating the tube > - Has all essentials, no restrictions
Assess for signs of Respi Distress > Notify MD > Do not leave px > - no special diet needed
Anticipate need for a new drainage System • Clear Liquid
- CTT becomes dislodged > gloves > apply occlusive dressing> assess signs - See-Through food like broth, tea, strained juices, gelatin
for Respi Distress > Notify MD - Recover from surgery or very ill
- Lack of Drainage when there had been drainge previously > check for any - To prevent dehydration
kinks or tubes or clot in the tubing > Do not Milk (squeezing and releasing • Full Liquid/GLEMCD
small segments of the tubing between the fingers) or Strip (squeezing the - Clear liquids plus milk products, eggs
length of the tube without relasing it) the tubing! > adjust suction - Transition from clear to regular diet
appropriately, keep the tube horizontal across the bed or chair before • Soft
dropping horizontally - soft Consistency and mild spice
- Drainage exceeds 100ml per hr or becomes bright red > Notify MD ASAP - difficulty swallowing
- CTT drainage suddenly decreases with not Tidaling > Notify MD ASAP • Mechanically Soft
- Regular diet but chopped or ground
Artificial Airways - Difficulty Chewing
• Oropharyngeal Airway/Oral Airway • Bland
- prevents falling back of the tongue in px who are unconscious - Chemically and Mechanically non stimulating, no spicy foof
- Stimulates gag reflex - Ulcers and Colitis
- Prevents tongue from falling back against the posterior pharynx • Low Residue
- Measurement: opening of the mouth to the ear or back angle of the jaw - No bulky food, apples or nuts, fiber, foods with skins and seed
- Check for loose teeth, food and dentures - Rectal disease
• Unexpected Situations and Associated Interventions (Oropharyngeal Airway/Oral • High calorie
Airway) - High CHON, Vit and Fat
• Px Awakens > Remove - Malnourished
• Tongue is sliding back into posterior pharynx causing respi difficulties > gloves • Low Calorie
and remove > make sure the size is right - Dec fat, no whole milk, cream, eggs, complex CHO
• Vomits while inserting > position to side to prevent aspiration > Remove > - obese
suction PRN • Diabetic
• Nasopharyngeal Airway/Nasal trumpet - Balance of CHON, CHO and fat
• Indications: Clenched teeth, enlarged tongue, need for frequent nasal - Insulin-food imbalance
suctioning • High CHON
• Measurement: from the tragus of the ear to the nostril + 1 inch - Meat, fish, milk, cheese, poultry, eggs
• Proper lubrication for easy insertion - Tissue Repaie and underweight
• Endotracheal Tube • Low Fat
• Indication: route for mech vent, easy access for secretion removal, artificial - Little butter, cream, whole milk or eggs
airway to relieve mech airways obstruction - Gallbladder, liver or heart disease
• Care of px with ET: • Low Cholesterol

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 - Little meat or cheese - Posttest
- Need to Dec Fat intake Laxatives to enhance elimination of barium and prevent
• Low Na obstruction or impaction due to constipation
- No salt added during cooking • Diagnostic Examination - Lower GI Series
- Heart or renal DSE • Barium Enema
• Tube Feeding - Pretest
• 1kcal = 1ml NPO 8 hrs pretest
Enema the morning of test
Enteral Nutrition Laxative or suppository
• Indications: cancer, Neurological muscular disorder, GI disorder, Respiratory Cramping may be experienced during introduction of barium
failure with prolonged intubation - Post test
• Nasogastric Tube Feeding Laxative and fluid to assist in expelling barium
- Purpose: Gavage, Lavage, Aspirate Specimen and Decompression • Endoscopy
- Position: Hyperextend the neck then flex - Pretest:
- Measurement: Nose - Ear - Xyphoid Process NPO 6-8 hrs
- Placement: Auscultate, Aspirate, pH (1-4) , XRay Consent
- Position after feeding: High Fowlers 30 mins after Local anesthetic will be used
• Gastrostomy & Jejunostomy Tube Feeding Hoarseness and sore throat for several days
- 6 weeks or more - Posttest:
- No need to check for placement, Check for patency NPO until with gag reflex
- High Fowlers after feeding Warm Normal saline gargles
Gastric Lavage • Colonoscopy
Irrigant (NSS) usually 1000-1500 cc for adult 500cc for pedia - Pretest
Gastric Decompression NPO 8 hrs
intermittent or continous Laxatives and Enemas
low pressure: 20-40mmHg Consent
Instrument will be inserted into the Rectum
Parenteral Nutrition Check platelet count before test
• Indications: nonfunctional GIT, Extended bowel rest, Preoperative TPN, severe - Posttest
burns, bowel DSE, acute Renal Failure, Hepatic Failure, Metastatic CA or Major Observe for rectal bleeding and signs of perforation
Surgery wherein px will be NPO for more than 5 days • Liver Biopsy
• Hyperalimentation - Pretest
• Site of insertion: NPO 6-8 Hrs
- Infraclavicular: R or L subclavian vein, allows freedom of movement or Consent
ambulation Hold Breathe during Biopsy
- Supraclavicular: R or L jugular vein, hinders head and neck movements - Posttest
• Preparation/Procedure: VS Q1 for 8-12 hrs
- Explain Right side lying with pillow against the abdomen
- Valsalva Maneuver as catheter being inserted with head down in the Observe site for bleeding
opposite direction of insertion • Alteration on Stool Charateristics
- Cover area with streile dressing - Acholic Stool
- Regulate at ordered rate, Never catch up - Hematochezia
- WOF for air embolism, etc. - Melena
- VS Q4 - Steatorrhea
- CBG (hyperglycemia) and urine specific gravity (hyperosmolar diuresis) • Constipation
- Change tubing Q24 - Passage of Dry hard Stool, fewer than 3 bowel movements per week
- Monito I&O • Fecal Impaction
- Weigh once a day - Mass or Collection of Dry Hard Stool
- Prevent constipation
Bowel Elimination • Types of Laxatives
• Assessment Type Action Examples
- IAPP Approach
- Bowel Sounds (4 quadrants)
Active: every 5-20 seconds Bulk-Forming Inc Fluid, Gaseous or Metamucil, Citrucel
Hypoactive: one per minute (s/p abdominal surgery, Paralytic Ileus) Solid Bulk
Hyperactive: every 3 secs (Diarrhea, Laxatives, Early Bowel Emollient/Stool Softens, Delays Colace
Obstruction) Softener Drying of feces
Absent: none heard in 3-5 mins
• Fecalysis Stimulant/Irritant Irritates, Stimulates Dulcolax, Senokot,
- An inch of formed stool, 15-30 ml of liquid stool Castor Oil
• Fecal Occult Blood Testing/Guaiac Test
- False-Positive: no hidden blood but positive test Lubricant Lubricates Mineral Oil
- False-Negative: with hidden blood pero di nakita
- No Dark Colored Foods 3 days before test Saline/Osmotic Draws water into Epsom Salts, Milk of
- Do not take Vit C for more than 1000 mg intestine Magnesia, Mg Citrate
• Diagnostic Examination - Upper GI Series
• Barium Swallow
- Flouroscopic Exam of the Upper GI
- Pretest:
NPO from midnight or 6-8 hrs pretest
Barium will taste chalky

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• Enema • 600cc of urine will make you urinate
• Types • Urine Tests
1. Cleansing Enema - Routine Urinalysis
- Prior to Dx Test or Surgery - Urine C&S
- In cases of constipation and impaction - Timed Urine Specimens
- Either be: - Renal function Tests
High enema: 12-18 inches Blood Urea Nitrogen
Low Enema: 12 inches Creatinine Clearance
2. Carminative Enema • IVP: Intravenous Pyelogram
60-80 ml of fluid - Flouroscopic visualization of the tract
To expel flatus - Pretest:
3. Retention Enema Assess for Iodine sensitivity
Solution retained for 1-3 hrs Enema the night before
Oil Enema, Antibiotic Enema, Antihelmintic Enema, Nutritive Consent
Enema NPO for 8 hrs
4. Return-Flow Enema - Posttest
To expel flatus Force Fluids
Alternating flow of 100-200 ml of fluid in and out of the rectum • Cystoscopy
• Appropriate Size of Rectal Tube in Enema - Pretest
- Adult: Fr 22-30 General or Local Anesthesia
- Child: Fr 12-18 Consent
• Length of Insertion NPO
- Adult: 3-4 inches Enema as ordered
- Child: 2-3 inches - Posttest
- Infant: 1-1 1/2 inches Force Fluids
- “Enemas until clear”: when no solid fecal Material exists, but solution maybe Pink tinged urine 24-48 hours
colored Warm Sitz bath and analgesics
• Enema Solutions • Managing Urinary incontinence
- Bladder Training
Solution Constituents Actions
inhibiting the urge to void sensation
Tape Drainage Hole for 4 hours, release for 30 mins then clamp again
Hypertonic e.g. Sodium, Draws water into - Pelvic muscle exercise/ Kegel’s Exercise
(Fleet Enema) Phosphate Solution the colon Contracting for 3-5 seconds, 10 contractions/session; 5 times daily
• Types of Catheterization
Hypotonic Tap Water Distends colon, - Intermittent/Single Catheterization
Stimulates, Softens - Indwelling/Retention Cathterization
- CBI
Isotonic Normal Saline Distends colon,
Stimulates, Softens • Indications of Catheterization
- Decompression
- Instillation
Soapsuds 3-5 ml soap to 1L Irritated mucosa, - Irrigation
water Distends Colon - Specimen Collection
Oil Mineral, Olive, Lubricates Feces
- Urine Measurement
Cottonseed Residual urine (single cath)
Hourly Urine Output (retention cath)
• Diarrhea - Promotion of healing of GUT
• Flatulence • Cath Size
• Fecal Incontinence - Children: Fr 8-10
• Hemorrhoids - Female Adult: Fr 14-16
• Guidelines for Ostomy Care - Male Adult: Fr 16-18
- Keep px as free of odors as possible. Empty Ostomy appliance frequently • Position
- Inspect Stoma Frequently - Female: Dorsal Recumbent
- Male: Supine with thighs slightly abducted
Bladder Elimination • Length of Insertion
• Types of Urinary Alterations - Female: 2-3 inches
- Urgency - Male: 7-9 inches
- Dysuria • Anchor
- Frequency - Female: inner thigh
- Hesitancy - Male: Lower Part of Abdomen or Upper Thigh
- Nocturia
- Retention Pain
- Residual Urine • Sensation of physical or mental suffering or hurt that usually causes distress or
- Polyuria agony to the one experiencing it
- Oliguria • Theories on Pain
- Anuria - Specificity Theory: certain nerve fibers in the skin or body that when
- Incontinence: Involuntary passage of urine stimulated will produce pain
Functional: bladder cannot hold a specific amount of urine - Pattern Theory: Stimulation should be intense for th epain to be perceived
Overflow: overdistended bladder - Affect Theory: The more painful one senses, the part affected is of more
Reflex: at a certain amount of urine the bladder will empty itself value to you
Stress: increase in abd pressure - Gate Control Theory: Gate @ Spinal Cord that when it is open there is
Urge transmission of pain and when closed it will impede the transmission of pain
• 200 cc of urine in bladder will make you experience the initial urge to urinate

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• Physiology of Pain
- Transduction: Pain receptors can be excited by mechanical, thermal or
chemical stimuli
- Transmission: Pain impulse travels from the peripheral nerve fibers to the
spinal cord
- Modulation: When neurons in the thalamus and brain stem send signals
back down to the dorsal horn of the spinal cord
- Perception: when client becomes conscious of the pain
• Pain Assessment
• 5th Vital Sign
• Mnemonic for Pain Assessment
• COLDERR
• PQRST
• Wong-Baker Scale
• Nonpharmacologic Interventions for Pain Control
- Target domain of Pain Control
Body
Mind
Spirit
Social Interactions

Comfort, Rest and Sleep

• Rest: State of calmness; relaxation w/o emotional stress or freedom from anxiety
• Sleep: State of consciousness in which the individual’s perception and reaction to
the environment are decreased
• Physiology of Sleep
- RAS: Reticular Activating System
- State of wakefullness
- BSR: Bulbar Synchronizing Region
- State of serotonin (asleep)
• Theories of Sleep
- Passive Theory
- Active Theory
• Types of Sleep
- NREM (Deep, restful sleep/ Slow-wave sleep)
- Stages:
I: very light, drowsy, relaxed, eyes roll from side-to side, lasting a few
minutes
II: light sleep, body process slow further, eyes are still, lasts about
10-20 mins
III: difficult to arouse, domination of the PNS, not disturbed by sensory
stimuli, 15-30 mins
IV: delta sleep, important in growing up children, 15-30 mins
- REM
Where most dreams take place
Brain is highly active, hence “paradoxical sleep” (EEG is active)
Increase in Brain activity > Inc in Cortical Activity > Important in
Memory Retention

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