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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
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
• 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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• 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
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