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NURSING
Darius J. Candelario
“Nursing is an art & a science. It is the diagnosis and treatment of human responses to actual and
potential health problems. Earlier emphasis was on care of the sick; now promotion of health is
being stressed ”
-ANA, Alfaro,R.
“The unique function of the nurse is to assist the individual, sick or well, in the performance of
those activities contributing to health, its recovery, or to a peaceful death. The client will
perform these activities unaided if he had the necessary strength, will or knowledge. Nurses help
the client gain independence as rapidly as possible
-Virginia Henderson,ICN
THEORETICAL MODELS OF NURSING PRACTICE
A. NIGHTANGLE’S THEORY (mid-1800) : Focuses on the patient and his environment.
Developed and described the first theory of nursing. She focused on changing and manipulating the
environment in order to put the patient in the best possible conditions for nature to act. She believed that in
the nurturing environment, the body could repair itself. Client’s environment is manipulated to include
appropriate noise, nutrition, hygiene, socialization and hope.
B. PEPLAU, HILDEGARD (1951) : Introduced the Interpersonal Model
Defined nursing as a therapeutic, interpersonal process which strives to develop a nurse- patient relationship
in which the nurse serves as a resource person, counselor and surrogate.
Four Phases of the Nurse-Client Relationship:
1. Orientation: the nurse and the client initially do not know each other’s goals and testing the role each will
assume. The client attempts to identify difficulties and the amount of nursing help that is needed.
2. Identification: the client responds to help professionals or the significant others who can meet the
identified needs. Both the client and the nurse plan together an appropriate program to foster health.
3. Exploitation: the clients utilize all available resources to move toward a goal of maximum health
functionality.
4. Resolution: refers to the termination phase of the nurse-client relationship. It occurs when the client’s
needs are met and he/she can move toward a new goal. Peplau further assumed that nurse-client
relationship fosters growth in both the client and the nurse.
C. ABDELLAH, FAYE G. : Introduced Patient – Centered Approaches to Nursing Model
D. ORLANDO, IDA : Three elements–client behavior, nurse reaction & nurse actions – compose the nursing
situation
E. LEVINE, MYRA : Believes nursing intervention is a conservation activity, with conservation of energy as a
primary concern, four conservation principles of nursing includes: conservation of client energy,
conservation of structured integrity, conservation of personal integrity, conservation of social integrity.
F. JOHNSON, DOROTHY : Focuses on how the client adapts to illness; the goal of nursing is to reduce stress so
that the client can move more easily through recovery.
G. ROGERS, MARTHA : Considers man as a unitary human being co-existing with in the universe, views
nursing primarily as a science and is committed to nursing research.
H. OREM, DOROTHEA : Developed the Self-Care Deficit Theory. She defined self-care as “the practice of
activities that individuals initiate to perform on their own behalf in maintaining life, health well-being.”
I. IMOGENE KING : Nursing process is defined as dynamic interpersonal process between nurse, client and
health care system. Postulated the Goal Attainment Theory. Described nursing as a helping profession that
assists individuals and groups in society to attain, maintain, and restore health. If is this not possible, nurses
help individuals die with dignity.
J. BETTY NEUMAN: Stress reduction is a goal of system model of nursing practice. Nursing actions are in
primary, secondary or tertiary level of prevention.
K. SIS CALLISTA ROY (Adaptation Theory): Views the client as an adaptive system. The goal of nursing is to
help the person adapt to changes in physiological needs, self-concept, role function and interdependent
relations during health and illness.
L. LYDIA HALL: Introduced the model of Nursing: What Is it? It focuses on the notion that centers around three
components of CARE, CORE and CURE. Care represents nurturance and is exclusive to nursing. Core
involves the therapeutic use of self and emphasizes the use of reflection. Cure focuses on nursing related
to the physician’s orders. Core and cure are shared with the other health care providers.
M. Virginia Henderson : Introduced The Nature of Nursing Model. She identified fourteen basic needs. She
postulated that the unique function of the nurse is to assist the clients, sick or well, in the performance of
those activities contributing to health or its recovery, the clients would perform unaided if they had the
necessary strength, will or knowledge.
N. Madaleine Leininger (1978, 1984): Developed the Trans-cultural Nursing Model.
O. Ida Jean Orlando (1961) : Conceptualized the Dynamic Nurse – Patient Relationship Model.
P. Ernestine Weidanbach (1964) : Developed the Clinical Nursing – A Helping Art Model.
Q. Jean Watson (1979-1992): Introduced the theory of Human Becoming
R. Joyce Travelbee (1966,1971) : She postulated the Interpersonal Aspects of Nursing Model.
S. Josephine Peterson and Loretta Zderad (1976): Provided the Humanistic Nursing Practice Theory.
T. Helen Erickson, Evelyn Tomlin, and Mary Ann Swain (1983) :Developed Modeling and Role Modeling
Theory.
U. Margaret Newman : Focused on health as expanding consciousness. She believed that human are
unitary in whom disease is a manifestation of the pattern of health. She defined consciousness as the
information capability of the system, which is influenced by time, space movement and is ever – expanding.
Moral Theories
Freud (1961)
Believed that the mechanism for right and wrong within the individual is the superego, or conscience. He
hypnotized that a child internalizes and adopts the moral standards and character or character traits of the
model parent through the process of identification. The strength of the superego depends on the intensity of
the child’s feeling of aggression or attachment toward the model parent rather than on the actual standards of
the parent.
Erikson (1964)
Erikson’s theory on the development of virtues or unifying strengths of the “good man” suggests that moral
development continuous throughout life. He believed that if the conflicts of each psychosocial developmental
stages favorably resolved, then an ‘ego-strength” or virtue emerges.
Kohlberg
Suggested three levels of moral development. He focused on the reason for the making of a decision, not on
the morality of the decision itself. At first level called the premolar or the pre-conventional level,
children are responsive to cultural rules and labels of good and bad, right and wrong. However, children
interpret these in terms of the physical consequences of the actions, i.e., punishment or reward. At the
second level, the conventional level, the individual is concerned about maintaining the expectations of the
family, groups or nation and sees this as right. At the third level, people make post-conventional,
autonomous, or principal level. At this level, people make an effort to define valid values and principles without
regard to outside authority or to the expectations of others. These involve respect for other humans and belief
that relationships are based on mutual trust.
Spiritual Theories
Fowler (1979) : Described the development of faith. He believed that faith, or the spiritual dimension is a force
that gives meaning to a person’s life. He used the term “faith” as a form of knowing a way of being in relation
“to an ultimate environment.” To Fowler, faith is a relational phenomenon: it is “an active made-of-being-in-
relation to others in which we invest commitment, belief, love, risk and hope.”
ROLES AND FUNCTIONS OF THE NURSE
1. Caregiver 8. Decision-maker
2. Teacher 9. Protector
3. Counselor 10. Client Advocate
1. Coordinator 11. Manager
2. Leader 12. Rehabilitator
3. Role Model 13. Comforter
4. Administrator 14. Communicator
HEALTH
“A state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.A
dynamic state in which the individual adapts to changes in internal and external environment to maintain a
state of well-being” - World Health
Organization (WHO)
SECONDARY PREVENTION
Emphasizes early detection disease, prompt intervention, and health maintenance for individuals experiencing
health problems. Includes prevention of complications and disabilities.
Early Diagnosis and Prompt Treatment Disability Limitations
Case – finding measures; individual and mass; selective Adequate treatment to arrest
examinations disease process and prevent
Cure and prevention of disease process to prevent spread of further complications
communicable disease, prevent complications and shorten Provision of facilities to limit
period of disability disability and prevent death
Screening surveys and procedures any type (e.g., Denver
Developmental Screening Test, hypertension screening)
Encouraging regular medical and dental checkup
Teaching self-examination for breast and testicular cancer
Assessing the growth and development of children
Nursing assessments and care provided in home, hospital, or
other agency to prevent complications.
TERTIARY PREVENTION
Restoration and Rehabilitation
Begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible. Its focus
is to help rehabilitate individuals & restore them to an optimum level of functioning within the constraints of the
disability
Provision of hospital and community facilities for retraining and education to maximize use of remaining
capacities
Education of the public and industries to use rehabilitated persons to the fullest possible extent
Selective placement
Work therapy in hospitals
Use of sheltered colony
STRESS
“Stress refers to tension resulting from changes in the internal and external environment either: physiologic,
psychologic or social factors.”
“Stress is the nonspecific response of the body to any demand made upon it”
-Modern Stress Theory, Selye,H.
*Str ess is always a part of the fabric of life
*Str ess is not always something to be avoided
*Str ess does not always lead to distress
*Stress may lead to another stress
*A stress, whenever prolonged or intense may lead to exhaustion
*Man, whenever he encounter stress, he tends to adapt to it
ADAPTATION
The adjustments that a person makes in different situations; individuals’ reaction to and attempt to deal with
stress
Types of Adaptation
A. General Adaptation Syndrome (GAS)
Man, whenever he responds to stress, the entire body is involved
There are many similar manifestations that characterize different disease conditions; and there are
very few specific manifestations that characterize a particular disease. Fever, weakness fatigue,
headache, anorexia, pain are examples of manifestations that characterize various disease conditions.
Stages of GAS
1. Stage of Alarm (SA)
• The person becomes aware of the presence of threat or danger.
• Levels of resistance are decreased.
• Adaptive mechanisms are mobilized (fight-or-flight reaction).
• If the stress is intense enough, even at the stage of alarm, death may ensure. Example:
profuse bleeding in amputated limb due to vehicular accident.
Homeostasis
“A state of dynamic equilibrium; stability; balance; constancy; uniformity. It is now more commonly
referred to as “homeodynamics,” because it is characterized by constant change.”
It is regulated by negative feedback mechanism.
Concepts of Homeostasis (“homeodynamics”)
(Systemic Physiologic Response to Stress)
A. Symatho-Adreno-Medullary Responses (Walter Cannon)
(SAMR or Fight-or Flight Response)
Stressors:
a. physical injury
b. elevated body temperature
c. dehydration
Hypothalamus
Brain: ↑ alertness; restlessness Eyes: dilated pupils; ↑ visual perception Mouth: ↓ salivary secretion, thirst&dryness
Skin: pallor; diaphoresis; cold, clammy skin Liver: ↑ glycogenolysis, & gluconeogenesis; ↑ blood glucose level
Stressor: Hypoglycemia
(Blood glucose level = 60 mg/dl. And below)
Hypothalamus
activates
Anterior Pituitary
releases
ACTH
triggers
Adrenal Cortex
secretes
Glucocorticoid: Increases gluconeogenesis; Increases blood glucose levels
Mineralocorticoid: Retention of sodium and water; Increase ECF volume;
Increase BP.Androgen/Estrogen: (sex hormones)
C. Neurohypophyseal Response
Hypothalamus
activates
Posterior Pituitary
releases
ADH (antidiuretic)
hormone/vasopressin)acts on
Kidneys (renal)
tubules)
Retention of water in the renal
tubules
Oliguria
Inflammatory Response
1. Vascular Response
• Transitory vasoconstriction followed immediately by vasodilation (due to the
release of histamine, bradykinin, prostaglandin E)
Edema C. Exudates
• Serous
(tumor) • Serosanguinous
Pain (dolor)
• Sanguinous
• Compression of nerve endings by edema fluids
• Purulent
• Injury to nerve endings
• Mucoid/catarrhal
• Release of bradykinin
Impaired function
Purposes of Inflammation
1. To localize tissue injury 2. To protect tissue from injury 3. To prepare tissue for repair
Cellular Response
• Neutrophils. First to be launched at the site of tissue injury.
• Monocytes. Perform phagocytosis in chronic tissue injury.
• Lymphocytes. Responsible for immune response.
Processes Involved:
• Marginal/pavementation. Phagocytes line up at the peripheral walls of the blood vessels.
• Emigration/diapedesis. Phagocytes line up at the peripheral walls of the blood vessels.
• Chemotaxis. Injured tissues release substances, which exert magnet like force to the phagocytes
to bring them to the area of injury.
• Phagocytosis. Phagocytes ingest or engulf the antigens.
Healing Process (Reparative Phase)
• Regeneration. Involves replacement of damaged tissue cells by new cells which are identical in
structure or function.
• Scar Formation. Involves replacement of damaged tissue cells by fibrous tissue formation. In the
early stage, granulation tissue (pink or red, fragile gelatinous tissue) forms; later in the process, a
cicatrix or scar forms because the tissue shrinks and the collagen fibers contract.
Healing May also be classified as follows:
• First Intention: Occurs in clean-cut wound (e.g. surgical wound). The wound edges are
approximated, there is minimal or no scar tissue formation (also primary intention healing or primary
union)
• Second Intention: Occurs when the wound is extensive and there is a great amount of tissue loss
(e.g. decubitus ulcer). The repair time is longer; the scarring is greater (also, secondary intention
healing).
• Third Intention: Occurs when there is delayed surgical closure of infected wound (also, tertiary
intention healing)
The Systemic Manifestations of Inflammation:
a) Fever
endogenous pyrogens
(prostaglandins, leukotrienes, bacterial endotoxins, interleukin 1)
act on
Hypothalamus
STRESS MANAGEMENT
a. Eat a well balanced diet
b. Get sufficient amount of rest
c. Exercise regularly
d. Use relaxation methods & techniques
1. Deep breathing
2. Guided imagery
3. Progressive relaxation: various muscles groups in the body are
progressively & systematically tensed & relaxed, from head to toe
Suggested Steps:
1.Focus attention on a particular muscle group
2. Tense the muscle group upon which attention is focused
3. Maintain muscle tension for 5-7 secs.
ELIMINATION
A. Promotion of normal elimination
1. Urination
a. Adequate fluid intake
b. Normal adult urinary output=80ml/hr
2. Bowel elimination
a. Adequate fluid intake
b. Regular exercise
c. Regular fruit juices, raw fruits & vegetables as needed
d. Normal bowel evacuation: varies in healthy individuals; no more than 3 mov’ts.
/day--3X/wk.
B. Urinary Incontinence: Involuntary release of urine
Diagnosis of urinary incontinence
a. History & physical examination
b. Urinalysis-tells whether blood or infection present
c. Cystoscopy- tells whether abnormalities are present
d. Post-void residual-measures amount of urine remaining in bladder after voiding
e. Stress test-determines if urine leaks after bladder is stressed due to coughing, lifting, etc.
Treatment
a. Drug therapy
• Antispasmodic & anticholinergic-relax &increase capacity of bladder
• Alpha-adrenergic agonists-increase urethral resistance
b. Kegel exercises-strengthen weak muscles around the bladder,
*also very effective in preventing Perineal lacerations.
b. Behavioral training-client learns different way to control urge to urinate
c. Bladder retraining
d. Surgery-repair of weakened or damaged pelvic muscles or urethra
Nursing Interventions
a. Provide skin care, protective undergarments
b. Establish toileting schedule-provide easy access to bathroom & privacy
c. Teach client Kegel exercises:
• Stop & start urinary stream while voiding
• Hold contraction for 10 secs. & relax fro 10 secs.
• Work up to 25 repetitions 3X a day
d. Prevent infection
• Cleanse urethral meatus after each void
• Acidify urine
• Increase daily intake of fluids
C. Catheterization
Purposes
a. Relieve acute urinary retention
b. Relieve chronic urinary retention
c. Drain urine preoperatively & postoperatively
d. Determine amount of post-void residual
e. Accurately measure output in the critically ill
f. Obtain sterile urine specimen
g. Continuous or intermittent bladder irrigation
MOBILITY
Prevent complications
of mobility
1. Skin change-
decubitus ulcer
a. Turn client q 2 hrs.
b. Use heel/elbow protectors
c. Use alternate pressure mattress or sheepskin
2. Musculoskeletal changes
a. Start ROM exercises to affected joints
b. Provide foot board &/or foot cradle (best for gout)
c. Position & turn q 2 hrs.
3. Respiratory changes-pneumonia, atelectasis
a. Instruct client to cough & deep breathe q 2 hrs.
b. Turn q 2 hrs.
c. Suction if needed
(tracheostomy suctioning ADULT- maximum 15 seconds; therapeutic 10 seconds, INFANTS –
5 to 10 secs.)
d. Chest physiotherapy as needed
4. Cardiovascular system changes
a. Orthostatic / Postural hypotension(sign & symptoms- dizziness, headache & pallor): Instruct
client to change position slowly; especially prone to supine or standing. This is commonly seen as a
SIDE EFFECT of Vasodilators , Anti-hypertensives & Anti-cholinergics.
b. Increased cardiac workload: discourage Valsalva maneuver
c. Thrombus/embolus formation
• Apply anti-embolic stockings
• Turn q 2 hrs.
• Start anti-coagulation therapy if indicated
• Initiate exercise
5. Urinary changes: renal calculi, UTI
a. Increase fluid intake (2000-3000 cc/day)
6. Psychosocial changes: Provide stimuli to maintain orientation
B. Types of exercise
1. Passive-carried out by the nurse w/out assistance from client; purpose is to
retain joint mobility &circulation
2. Resistive-carried by the client working against resistance; purpose is to increase
muscular strength
3. Isometric-carried out by the client w/ no assistance; purpose is to increase
muscular strength
4. Range of Motion (ROM)-joint is moved through entire range; purpose is to
maintain joint mobility
5. Active-performed by the patient;purpose is to maintain mobility, muscle
strength & muscle size
C. Use of mechanical aids to promote mobility
1. Crutches
2. Cane
a. Provides stability when walking and relieves
pressure on weight-bearing joints
b. Adjust cane w/ handle @ level of greater
trochanter: elbow flexed at 30-degree angle
c. Teach client to hold cane close to body, & hold in
hand on stronger side
d. Move cane @ same time as the weaker leg
3. Walker
a. to assist in weight-bearing mobility
b. Teach client how to sit & turn
D. Prosthetic devices-used to replace a missing body part
E. Brace-support for weakened muscles
PAIN
“A feeling of distress, suffering or agony caused by stimulation of specialized nerve endings”
-Patricia Novac
Theories of Pain
a. Specificity theory proposes that pain can be initiated only by painful stimuli.
b. Pattern theory-stimulus goes to receptors in the spinal cord, which signals the brain to perceive pain
and muscles to respond
c. Gate Control Theory-pain impulses can be altered or regulated by gating mechanisms along nerve
pathways. This theory explains how past and present experiences can influence the perception of pain.
Pain Assessment
1. Influencing factors
• Past experience with pain
• Age (tolerance generally increases with age)
• Culture and religious beliefs
• Level of anxiety
• Physical state (fatigue or chronic illness may decrease tolerance)
2. Characteristics of pain
• Location • Aggravating factors
• Quality • Alleviating factors
• Intensity • Interference with Activities of Daily Living
• Timing and duration • Patterns of response
• Precipitating factors
Types of Pain
2. Use a pain intensity scale of 0 (no pain) to 10 (worst possible pain). Take careful history of prior & present
medications, response, & side effects.
3. Assess relief from medications & duration of relief. (Use the same measuring scale every time).
4. Base the initial analgesic choice on the patient’s report of pain.
5. Administer drugs orally whenever possible; avoid intramuscular injection.
6. Administer analgesia “around the clock” rather than PRN.
7. Convey the impression that the patient’s pain is understood & that the pain can be controlled.
8. Take a careful pain history. Explore pain interventions that have been used & their effectiveness. Determine if
the intensity of the pain correlates w/ the prescribed analgesic.
9. Reevaluate the pain frequently. The requirement for analgesia should decrease if other treatment is given,
including radiation/chemotherapy.
10. Use alternative measures to relieve pain such as imaging, relaxation, & biofeedback.
11. Provide ongoing support & open communication.
12. Consider referral to a pain specialist for intractable pain.
13. Provide education.
a. Method of administration of medications & importance of maintaining prescribed schedule
b. Need to call health professionals if pain has increased or occurred in another area of the body
c. Side effects of medication
(1) Constipation-best treated prophylactically
(2) Nausea-antiemetic therapy helpful
(3) Tolerance-increasing doses often required achieving the same effect. This is a normal
physiologic response to opioids. Patient reports shorter duration of effect. There is no maximum
opioid dose as long as side effects are tolerable.
(4) Addiction usually isn’t a problem to needed narcotics.
SLEEP
A state of consciousness in w/c the individual’s perception & reaction to the environment are decreased
A. Physiology
1. Reticular Activating System (RAS)-maintains a state of wakefulness & mediates some stages of sleep.
Sleep is an active process involving the RAS & a dynamic interaction of neurotransmitters.
2. Serotonin is a major neurotransmitter associated w/ sleep. It is derived from its precursor Tryptophan, a
naturally occurring amino acid. It decreases activity of RAS, thereby inducing & sustaining sleep. Other
neurotransmitters-acetylcholine & norepinephrine appear to be required for the REM sleep cycle.
B. Theories
1. Active Theory of Sleep: proposes that there are centers that cause sleep by inhibiting other brain centers.
2. Passive Theory of Sleep: states that the RAS simply fatigues & therefore becomes inactive thus, sleep
occurs.
C. Stages
1. NREM (Non-Rapid Eye Mov’t.) Stage
a. Very light sleep; drowsy, relaxed; readily awakened-Stage (St.) 1
b. Light sleep; eyes are still; HR & RR decrease slightly; body temperature falls-St. 2
c. Domination of PNS; body process slows further; difficult to arouse-St. 3
d. Deep sleep; difficult to arouse; ↓ V/S; ↓ metabolism, brain waves, muscles relaxed-St. 4
2. REM (Rapid Eye Mov’t.) Stages
a. Eyes appear to roll
b. “Paradoxical Sleep”
c. Close to wakefulness but difficult to arouse
d. Dream state of sleep
e. Sympathetic Nervous System dominates
f. Flow of gastric acid increases
g. Restores a person mentally-learning, psychological adaptation & memory
h. The sleeper reviews the day’s events & processes & restores information
D. Functions
1. NREM-body restoration
2. REM-increases synthetic processes in the brain
Physical Assessment
Use the following techniques of examination as appropriate for eliciting findings:
Inspection
a.Begins with first encounter with the patient and is the most important of all the techniques
b.Is an organized scrutiny of the patient’s behavior and body
c. With knowledge and experience, the examiner can become highly sensitive to visual clues.
d.The examiner begins each phase of the examination by inspecting the particular part with the eyes.
Palpation
a.Involves touching the region or body part just observed and noting what the various structures feel
like.
b.With experience comes the ability to distinguish variations of normal from abnormal.
c. Is performed in an organized manner from region to region.
Percussion
a.By setting underlying tissues in motion, percussion helps in determining whether the underlying
tissue is air filled, fluid filled, or solid.
b.Audible sounds and palpable vibrations are produced, which can be distinguished by the examiner.
There are five basic notes produced by percussion, which can be distinguished by
differences in the qualities of sound, pitch, duration, and intensity. These are:
Relative Relative Relative Example
Intensity Pitch Duratio Location
n
1. Flatness Soft High Short Thigh
2. Dullness Medium Medium Medium Liver
3. Resonance Loud Low Long Normal lung
4. Hyper resonance Very loud Lower Longer Emphysematous
lung
5. Tympany Tympany * * Gastric air bubble
or puffed out
cheek
*Distinguished mainly by its musical timbre.
Auscultation
a. This method uses the stethoscope to augment the sense of hearing.
b. The stethoscope must be constructed well and must fit the user. Earpieces should be
comfortable, the length of the tubing should be 25 to 38 cm (10-15 inches), and the head should
have a diaphragm and a bell.
• The bell is used for low-pitched sounds such as certain heart murmurs.
c. The diaphragm screens out low-pitched sounds and is good for hearing high-frequency sounds
such as breath sounds.
d. Extraneous sounds can be produced by clothing, hair and movement of the head of the
stethoscope.
Equipment
• Thermometer • Cotton applicator stick
• Sphygmomanometer • Stethoscope
• Oto-ophthalmoscope • Reflex Hammer
• Flashlight • Tuning Fork
• Tongue Depressor • Safety Pin
• Additional items include disposable gloves and lubricant for rectal examination
and a speculum for examination of female pelvis
VITAL SIGNS
Importance—Many major therapeutic decisions are based on the vital signs; therefore, accuracy is essential.
C. Technique D. Findings
Temperature
• Routinely, where accuracy is not crucial, an May vary with the time of day.
oral temperature will suffice. o Oral: 370C (98.60F) is considered normal. May
• A rectal temperature is the most accurate. vary from 35.80C to 37.30C (96.40-99.10F)
• Unless contraindicated (as in a patient with o Rectal: Higher than oral by 0.40C to 0.50C (0.70-
a severe cardiac arrhythmia), a rectal 0.90F).
temperature is often preferred.
Pulse
• Palpate the radial pulse and count for at Normal adult pulse is 60 to 80 beats/min; regular in
least 30 seconds. I f the pulse is irregular, rhythm. Elasticity of the arterial walls, blood
count for a full minute and note the number volume, and mechanical action of the heart muscle
of irregular beats/min. are some of the factors that affect strength of the
• Note: Whether the beat of the pulse pulse wave, which normally is full and strong.
against your finger is strong or weak,
bounding or thread.
Respiration
• Count the number of respirations taken in Normally 16 to 20 respirations/min.
15 seconds and multiply by 4.
• Note: Rhythm and depth of breathing.
Blood Pressure
• Measure the blood pressure in both arms. • Normal range:
• Palpate the systolic pressure before using Systolic—95-140 mm Hg
the stethoscope in order to detect an Diastolic—60-90 mm Hg
auscultatory gap.*
• Apply cuff firmly; if too loose, it will give a • A difference of 5 to 10 mm Hg between arms in
falsely high reading. common.
• Use cuff in appropriate size: a pediatric cuff • Systolic pressure in lower extremities is usually 10
for children; a leg cuff for obese people. mm Hg higher than reading in upper extremities.
• The cuff should be approximately 2.5 cm (1 • Going from a recumbent to a standing position can
inch) above the antecubital fossa. cause the systolic pressure to fall 10 to 15 mm Hg
and the diastolic pressure to rise slightly (by 5 mm
Hg).
Principles Practices
All objects used in a All articles are sterilized appropriately by dry or moist heat, chemicals, or
sterile field must be radiation before use.
sterile. Always check a package containing a sterile object for intactness, dryness, and
expiration date. Any package that appears already open, torn, punctured,
or wet is considered unsterile.
Storage areas should be clean, dry, off the floor, and away from sinks
Always check chemical indicators of sterilization before using a package. The
indicator is often a tape used to fasten the package or contained inside the
package. The indicator changes color during sterilization, indicating that the
contents have undergone a sterilization procedure. If the color change is not
evident, the package is considered unsterile. Commercially prepared
sterile packages may not have indicators but are marked with the word sterile.
Handle sterile objects that will touch open wounds or enter body cavities only
Sterile objects become with sterile forceps or sterile gloved hands.
unsterile when touched Discard or resterilize objects that are considered questionable, assume the
by unsterile objects. article is
unsterile.
Sterile items that are One left unattended, a sterile field is considered unsterile.
out of vision or below Sterile objects are always kept in view. Nurses do not turn their backs on a
the waist level of the sterile field.
nurse are considered Only the front part of a sterile gown (from the waists to the shoulder) and 2
unsterile. inches above the elbows to the cuff of the sleeves are considered sterile.
Always keep sterile gloved hands in sight and above waist level; touch
only objects that are sterile. Sterile draped tables in the operating
room or elsewhere are considered sterile only at surface level.
Once a sterile field becomes unsterile, it must be set up again before
proceeding.
Sterile objects can Keep doors closed and traffic to a minimum in areas where a sterile procedure is
become unsterile by being performed because moving air can carry dust and microorganisms.
prolonged exposure to Keep areas in which sterile procedures are carried out as clean as possible by
airbone micro- frequent damp cleaning with detergent germicides to minimize contaminants in
organisms. the area.
Keep hair clean and short or enclose it in a net to prevent hair from failing on
sterile objects. Microorganisms on the hair can make a sterile field unsterile.
Wear surgical caps in operating rooms, delivery rooms, and burn units.
Refrain from sneezing or coughing over a sterile field. This can make it unsterile
because droplets containing covering the mouth and the nose should be worn by
anyone working over a sterile field or an open wound.
Nurses with mild upper respiratory tract infections refrain from carrying out
sterile procedures or wear masks.
When working over a sterile field, keep talking to a minimum. Avert the head
from the field if talking is necessary.
To prevent microorganisms from failing over a sterile field, refrain from reaching
over a sterile field unless sterile gloves are worn and refrain from moving
unsterile objects over a sterile field.
Unless gloves are worn, always hold wet forceps with the tips below the handles.
When the tips are held higher than the handles, fluid can flow onto the handle
and become contaminated by the hands, When the forceps are again
pointed downward, the fluid flows back down and contaminates the
tips.
During a surgical hand wash, hold the hands higher than the elbows to
prevent contaminants from the forearms from reaching the hands.
Moisture that passes Sterile moisture-proof barriers are sued beneath sterile objects. Liquids (sterile
through a sterile object saline or antiseptics) are frequently poured into containers on a sterile field. If
draws microorganisms they are spilled onto the sterile field, the barrier keeps
from unsterile surfaces The liquid from seeping beneath it.
above or below to the Keep the sterile covers on sterile equipment dry. Damp surfaces can attract
sterile surface by capillary microorganisms in the air.
action. Replace sterile drapes that do not have a sterile barrier underneath when they
become moist.
The skin connot be Use sterile gloves or sterile forceps to handle sterile items. Prior to a surgical
sterilized and is unsterile. aseptic procedure, wash hands to reduce the number of microorganisms on
Conscientiousness, them
alterness, and honesty are When a sterile object becomes unsterile, it does not necessarily change in
essential qualities in appearance.The person who sees a sterile object become contaminated must
maintaining surgical correct or report eh situation.Don’t a set up a sterile field ahead of time for
asepsis. future use.
Nosocomial Infections
Most Common Microorganisms Causes
Urinary Tract
Escherichia coli (80%) Improper catheterization technique
Enterococcus species Contamination of closed drainage system
Surgical Sites
Staphylococcus aureus Inadequate hand washing
Enterococcus species Improper dressing change technique
Pseudomonas aeruginosa
Bloodstream
Coagulase-negative staphylococci Inadequate hand washing
Staphylococcus aureus Improper intravenous fluid, tubing, and site care technique
Enterococcus species
Preschoolers: injury from traffic, playground equipment, and other objects; choking, suffocation,
and obstruction of airway or ear card by foreign objects; poisoning; drowning fire and burns; harm from
other people or animals
Adolescents: Vehicular (automobile, bicycle) accidents, recreational accidents, firearms,
substance abuse
Older adults: Falling, burns, and pedestrian and automobile accidents
Applying Restraints
Obtain consent from the client or guardian.
Ensure that a physician’s order has been provided or, in an emergency, obtain one within 24 hours after
applying the restraint.
Assure the client and the client’s support people that the restraint is temporary and protective. A
restraint must never be applied as punishment for any behavior or merely for the nurse’s convenience.
Apply the restraint in such a way that the client can move as freely as possible without defeating the
purpose of the restraint.
Ensure that limb restraints are applied securely but not so tightly that they impede blood circulation to
any body area or extremity.
Pad bony prominences (e.g., wrists and ankles) before applying a restraint over them. The
movement of a restraint without padding over such prominences can quickly abrade the
skin.
Always tie a limb restraint with a knot (e.g., a clove hitch) that will not tighten when pulled.
Tie the ends of a body restraint to the part of the bed that moves to elevate the head. Never
tie the ends to a side rail or to the fixed frame of the bed if the bed position is to be
changed.
Assess the restraint every 30 minutes. Some facilities have specific forms to be used to
record ongoing assessment.
Release all restraints at least every 2 to 4 hours, and provide range-of-motion (ROM)
exercises and skin care.
Reassess the continued need for the restraint at least every 8 hours. Include an assessment of the
underlying cause of the behavior necessitating use of the restraints.
When a restraint is temporarily removed, do not leave the client unattended.
Immediately report to the nurse in charge and record on the client’s chart any persistent reddened or
broken skin areas under the restraint.
At the first indication of cyanosis or pallor, coldness of a skin area, or a client’s complaint of a tingling
sensation, pain, or numbness, loosen the restraint and exercise the limb.
Apply a restraint to that it can be released quickly in case of an emergency and with the body part in a
normal anatomic position.
Provide emotional support verbally and through touch.
Wash the chest and abdomen. (Omit the chest and abdomen for a partial bath. However, the areas under a
woman’s breast may require bathing if this area is irritated or if the client has significant perspiration under the
breast.)
• Place bath towel lengthwise over chest. Fold bath blanket down to the client’s public area. Keeps the
client warm while preventing unnecessary exposure of the chest.
• Lift the bath towel off the chest, and bathe the chest and abdomen with your mitted hand using long,
firm strokes . Give special attention to the skin under the breasts and any other skin folds particularly if
the client is overweight. Rinse and dry well.
• Replace the bath blanket when the areas have been dried.
Wash the legs and feet. (Omit legs and feet for a partial bath.)
• Expose the leg farthest from you by folding the bath blanket toward the other leg being careful to keep
the perineum covered. Covering the perineum promotes privacy and maintains the client’s dignity.
• Lift leg and place the bath towel lengthwise under the leg. Wash, rinse, and dry the leg using long,
smooth, firm strokes from the ankle to the knee to the thigh. Washing from the distal to proximal
areas promotes circulation by stimulating venous blood flow.
• Reverse the coverings and repeat for the other leg.
• Wash the feet by placing them in the basin of water
• Dry each foot. Pay particular attention to the spaces between the toes. If you prefer, wash one foot after
that leg before washing the other leg.
• Obtain fresh, warm bathwater now or when necessary. Water may become dirty or cold. Because surface
skin cells are removed with washing, the bathwater from dark-skinned clients may be dark, however, this
does not mean the client is dirty. Raise side rails when refilling basin. This ensures the safety of the
client.
Assist the client with grooming aids such as powder, lotion, or deodorant.
• Use powder sparingly. Release as little as possible into the atmosphere. This will avoid irritation of the
respiratory tract by powder inhalation. Excessive powder can cause caking, which leads to skin irritation.