Fundamentals of Nursing

Professor Darius J. Candelario

RM,RN, MAN, MSN,
US-RN #026-0031609 Vermont &
Florida
 NURSING
“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. OR/LAN/DO, 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
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
humans 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
2. Teacher
3. Counselor
4. Coordinator
5. Leader
6. Role Model
7. Administrator
8. Decision-maker
9. Protector
10. Client Advocate
11. Manager
12. Rehabilitator
13. Comforter
14. Communicator
CONCEPTS OF HEALTH AND
ILLNESS
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)
VARIABLES INFLUENCING HEALTH
BELIEFS AND PRACTICES
INTERNAL VARIABLES
1. Developmental Stage
2. Intellectual Background
3. Perception of functioning
4. Emotional and Spiritual Factors

EXTERNAL VARIABLES
1. Family practices
2. Socioeconomic Factors
3. Cultural Background
MODELS OF HEALTH AND ILLNESS
1. HEALTH-ILLNESS CONTINUUM (NEUMAN)
- Degree of client wellness that exist at any
point in time--ranging from an optimal wellness
condition, with available energy at its
maximum--to death, which represents total
energy depletion.
- Dynamic state that continuously alters as a
person adapts to changes in the internal &
external environment to maintain a state of
physical, emotional, intellectual, social,
developmental & spiritual well- being.
2. HIGH-LEVEL WELLNESS MODEL
(HALBERT DUNN)
- The high-level wellness model is oriented
toward maximizing the health potential of an
individual. This model requires the individual
to maintain a continuum of balance and
purposely direction within the environment.
It involves progress toward a higher level of
functioning, an open-ended and ever-
expanding challenge to live at the fullest
potential. Last, there is continued integration
of health practices by the individual at
increasingly, higher levels throughout life.
3. AGENT-HOST-ENVIRONMENT MODEL
(LEAVELL)
The level of health of an individual or group
depends on the dynamic relationship of the
agent, host and environment.
a. AGENT – is any internal or external factor that
by its presence or absence can lead to disease or
illness.
b. HOST – is the person or persons who may be
susceptible to a particular illness or disease. Host
factors are physical or psychosocial situations or
conditions putting an individual or group at risk
for becoming ill.
c. ENVIRONMENT – consists of all
factors outside of the host, physical
environment includes economic level,
climate, living conditions, and elements
such as light and sound levels. Social
environment consists of factors
involving a person’s or group’s
interaction with others, including stress
conflicts with others, economic
hardships and life crises such as the
death of a spouse.
4. HEALTH-BELIEF MODEL (HBM)
- Addresses the relationships between a
person’s belief and behaviors. It provides a way
of understanding and predicting how clients
will behave in relation to their health and how
they will comply with health care therapies.
FOUR COMPONENTS:
a. The individual’s perception of susceptibility to an
illness.For example, a client’s needs to recognize
the familial link for coronary artery disease.
After this link is recognize, particularly when
one parent and two siblings have died in their
fourth decade from myocardial infarction, the
client may perceive the personal risk of heart
disease.
b. The individual’s perception of the seriousness of
the illness.
- this perception is influenced and modified by
demographic and sociophysiological variables,
perceived threats of the illness and cues to action
(for example, mass media campaigns and advice
from family, friends, and medial professionals)
c. The perceived threat of a disease.
- this perception refers to beliefs a person holds
about whether or not a disease poses a real threat
to him. Perceived threat is influenced by certain
cues to action in relation to health (e.g. mass-media
campaigns, advice from others or a reminder a
postcard from a dentist or physician).
d. The perceived benefits of taking preventive action.
- This perception refers to beliefs a person holds
about the effectiveness of preventive action he might
take to prevent illness. Perceived barriers to taking
preventive action may relate, for example, to
whatever the person believes stands in his way. For
example, a barrier to seeing a dentist regularly to
prevent tooth decay may be a person’s intense fear
that the procedure is very painful.
5. EVOLUTIONARY-BASED MODEL
- illness and death serves as an evolutionary function.
- Evolutionary viability reflects the extent to which
individual’s function to promote survival and well-
being.
6. HEALTH PROMOTION MODEL
- A “complimentary counterpart to models of health
protection”
- Directed at increasing a client’s level of well-being.
- Explains the reasons for client’s participation in
health-promotion behaviors.
The model focuses on three functions:
– It identifies factors (demographic and social) that
enhance or decrease the participation in health
promotion.
– It organizes cues into a pattern to explain the
likelihood of a client’s participation in health-
promotion behaviors.
– It explains the reasons that individuals engage in
health activities.
 THE THREE LEVELS OF
PREVENTION

PRIMARY PREVENTION
-Generalized health promotion
specific protection against disease.
It precedes disease or dysfunction
and is applied to generally healthy
individuals or groups.
 Health Promotion
• Health Education
• Good standard of nutrition adjusted to
developmental phases of life
• Provision of adequate housing &
recreation
• Marriage counseling and sex education
• Genetic screening
• Periodic selective exams
• Health education about accident and poisoning
prevention, standards of nutrition and of growth
and development for each stage or life, exercises
requirements, stress management protection
against occupational hazards, and so on
• Immunizations
• Risk assessment for specific disease
• Family planning services and marriage
counseling
• Environmental sanitation and provision of
adequate housing recreation, and work conditions
 Specific Protection

• Use of specific immunizations

• Attention to personal hygiene
• Use of environmental sanitation
• Protection against occupational hazards
• Protection from accidents
• Use of specific nutrients
• Protection from carcinogens
• Avoidance of allergens
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
 Case – finding measures; individual and mass;
selective examinations
 Cure and prevention of disease process to prevent
spread of communicable disease, prevent
complications and shorten period of disability
 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.
 Disability Limitations
Adequate treatment to arrest
disease process and prevent further
complications
Provision of facilities to limit
disability and prevent death
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
 Referring a client who has had a colostomy to a
support group
 Teaching a client who has diabetes to identify and
prevent complications
 Referring a client with a spinal cord injury to a
rehabilitation center to receive training that will
maximize use for remaining abilities
Difference between Health Promotion
and Health Protection
Health Promotion
 Not disease oriented
 Motivated by personal, positive “approach”
to wellness
 Seeks to expand positive potential for health
Health Protection
 Illness or injury specific
 Motivated by “ avoidance” of illness
 Seeks to thwart the occurrence of insults to
health and well-being
Factors Affecting the Nursing Shortage
 Aging Nurse Workforce
– Number of Nurses under 30 decreasing
– Number of nurses age 40-49 increasing with 40%
older than 50 by 2010
– New graduates entering workforce at an older age
and will have fewer years to work
 Aging of Nurses Faculty
As nursing faculty retire, nursing programs may have
fewer faculty to educate future nurses
 Aging Population
- Individuals 65 and older to double between 2000 and
2030
- Increasing health care needs of aging population
 Increased Demand for Nurses
- Increased acuity of hospital clients requiring
skilled and specialized nurses.
- Shorter hospital stays resulting in transfer of
clients to long term care and community
settings, creating increased demand for nurses
in the community
 Workplace Issue
- Inadequate staffing
- Heavy workloads
- Increased use of overtime
- Lack of sufficient support staff
- Inadequate recruiting and retaining nurses
 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.
*Stress is always a part of the fabric of life
*Stress is not always something to be avoided
*Stress 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.
2. Stage of Resistance (SR)
- Characterized by adaptation &
parasympathetic nervous system activity.
- Levels of resistance are increased &
hormonal levels return to normal.
- The person moves back to homeostasis &
stabilization.
3. Stage of Exhaustion
- Results from prolonged exposure to
stress and adaptive mechanisms can no
longer persist.
- Unless other adaptive mechanism will be
mobilized, death may ensue.
Local Adaptation Syndrome (LAS)
- Man may respond to stress through a
particular body part or body organ (e.g.
inflammation, backache, headache, diarrhea).
Modes of Adaptation
Physiologic/Biologic Adaptive Mode
- e.g. enlargement of arm and chest muscles
among men whose jobs include heavy lifting;
people who live in countries with very
hot/warm climate develop dark skin. This is
due to overproduction of melanin to protect
inner layers of the skin.
Psychologic Adaptive Mode
- e.g. use of ego defense mechanism
like denial, rationalization.
Sociocultural Adaptive Mode
- e.g. talking, acting, dressing like
to people in a particular place
Technologic Adaptive Mode
-e.g. nurses learn how to use
electronic devices and computers.
 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 temp.
c. Dehydration

SNS Adrenal Medulla

(norepinephrine) (Epinephrine & norepinephrine)

hypothalamus
Brain:  alertness; restlessness
Eyes: dilated pupils;  visual perception
Mouth:  salivary secretion, thirst & dryness
Heart: tachycardia; coronary vasodilation;  force of
cardiac contractility;  cardiac output
Lungs: hyperventilation, bronchodilation
Blood vessels: peripheral vasoconstriction; BP
Skin: pallor; diaphoresis; cold, clammy skin
Liver:  glycogenolysis, & gluconeogenesis;  blood glucose
level
Muscles:  glycogenolysis;  muscle tension
G.I. Tract:gastric motility;HCl secretion; peristalsis;
constipation; flatulence
Spleen: contraction;  hemolysis
Pancreas:  secretion. of insulin and pancreatic enzymes
Urinary Bladder: relaxation of the detrusor muscles
B. Adreno – Cortical Response
Stressor: Hypoglycemia
(Blood glucose level = 60 mg/dl. And below)

Hypothalamus
Anterior Pituitary

ACTH

Adrenal Cortex

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
Stressors: Blood loss (hemorrhage, excess loss of body

Hypothalamus

Posterior Pituitary
ADH (antidiuretic)
Kidneys (renal) tubules

Retention of water in the renal

Oliguria

Conservation of Prevention of
Circulating Volume Hypovolemic Shock
 Local Physiologic
Responses to Stress
Inflammation involves mobilization of specific
and nonspecific defense mechanism in
response to tissue injury or infection.
 Inflammants: Prevention of Hypovolemic Shock
Mechanical
Chemical
Microbial
Electrical

1. Vascular Response
-Transitory vasoconstriction followed immediately by vasodilation
(due to the release of histamine, bradykinin, prostaglandin E)

Increased Capillary Permeability

Hyperemia: Fluid / Cellular

Redness (rubor)
Heat (calor)

Cont ‘d
 Exudates
Edema Serous
Serosanguinous
Sanguinous
Pain (dolor) Purulent
Compression of nerve endings Mucoid/catarrhal
by edema fluids
Injury to nerve endings
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
A. Fever
Inflammation:
endogenous pyrogens
(prostaglandins, leukotrienes, bacterial endotoxins, interleukin 1)

Hypothalamus

Resetting of the body temperature set-point at a higher level

Increasing heat production/decreasing heat loss

(shivering; sweating is inhibited; vasoconstriction)

Increased production of interferon

(protects the cell from viral invasion)

Increased phagocytic activity

b. Leukocytosis (elevated WBC)
c. Elevated ESR (erythrocyte sedimentation
rate)
d. Lymphadenopathy
e. Anorexia
f. Headache
g. Body Weakness/Fatigue
h. Body Malaise
 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.
4. Slowly relax the muscle group while continuing
the focus
5. Repeat these steps for each muscle group in the
body, from head to toe
4. Meditation: contemplative reflection &
thought, & communication w/ self
5. Yoga: system of meditation & mental to
attain a balance in the continuum of mend &
body
6. Biofeedback: providing information to a
subject about current status of some body
function; goal-gain & maintain control in
real-life circumstances
E. Engage in social support system
 Nursing Responsibilities in
Stress Management
I. To assist client & his family to adapt to stress
& manage it wisely
II. Recommended four guideposts when the
nurse helps the client to manage stress
A. Eliminate as many stressors as possible
B. Teach about both the beneficial and
detrimental effects of stress
C. Teach how to cope & adjust with stress
 NURSING PROCESS
-“A deliberate, problem-solving approach to
meeting the health care & nursing needs of
patients” -Sandra Nettina
- The most efficient way to accomplish
personalized care in a time of exploding
knowledge and rapid social change. It assists in
solving or alleviating both simple and complex
nursing problems. Changing, expanding, more
responsible role demands knowledgeably
planned, purposeful, and accountable action
by nurses
Reasons for documentation of
nursing care:
1. Provide evidence of comprehensive
and systematic nursing care
2. Satisfy requirements of regulatory
agencies
3. Provide a legal document that reflects
the care given to and the progress of the
patient
4. Provide a data base for continuous
quality improvement programs
Steps in the Nursing Process (ADPIE)
1. Assessment : Collection of personal, social, medical,
and general data
a. Sources: Primary (client and diagnostic test results)
and secondary (family, colleagues, Kardex,
literature)
b. Methods
b.1 Interviewing formally (nursing health history)
and informally during various nurse-client
interactions
b.2 Observation
b.3 Review of records
b.4 Performing a physical assessment
 Types of Assessment
1. Initial Assessment
- Performed within specified time
after admission to health care agency
- To establish a complete database for
problem identification, reference, and
future comparison
- example: Nursing admission
assessment
2. Problem-focused assessment
- Ongoing process integrated with care
- To determine the status of a specific
problem identified in an earlier assessment
- To identify new or overlooked problems
- example: Hourly assessment of client’s fluid
intake and urinary in an ICU.
Assessment of client’s ability to perform self-
care while assisting a client to bathe
3. Emergency assessment
- During a physiologic or psychologic
crises of the client
- To identify life-threatening problems
- example: Rapid assessment of a
person airway, breathing status, and
circulation during a cardiac arrest
Assessment of suicidal for violence
4. Time-lapsed reassessment
- Several month after initial assessment
- To compare the client’s current status
to baselines data previously obtained
- example: Reassessment of a client’s
functionally health patterns in a home
care or outpatient setting or, in a
hospital, at shift change
 Example of subjective data:
“I feel weak all over when I exert myself.”

Client states he has a cramping pain in his

abdomen. States “I feel sick to my stomach.”

“I’m short or breath.”

Wife states: “He doesn’t seem so sad today”
“I would like to see the chaplain before
surgery.”
Examples of objective data:

• Blood pressure 90/50

• Apical pulse 104
• Skin pale and diaphoretic
• Vomited 100 mL green-tinged fluid
• Abdomen firm and slightly distended
• Active bowel sounds auscultated in all four
quadrants
• Lung sounds clear bilaterally; diminished in right
lobe
• Client cried during interview
• Holding open Bible
• Has small silver cross on bedside table.
2. Nursing Diagnosis : Definition of client's
problem: making a nursing diagnosis
“A nursing diagnosis is a definitive statement of
the client's actual or potential difficulties,
concerns, or deficits that are amenable to
nursing interventions .This step is to organize,
analyze and summarize the collected data.
There are two components to the statement of a
nursing diagnosis joined together by the phrase
"related to"”
Part I: a determination of the problem
(unhealthful response of client)
Part II: identification of the etiology
(contributing factors)
3. Planning: the nursing care plan, a
blueprint for action remembering
client is the center of the health team;
client, family, and nurse collaborate
with appropriate health team
members to formulate the plan
 Guidelines:
a. Planned intervention may include independent,
interdependent,and dependent functions of the
nurse; prescriptions made by physician or allied
health professionals may be included
b. New diagnoses should be noted on the nursing care
plan and progress notes as they are identified
c. Client outcomes (goals of nursing intervention) are
reflected in expected changes in the client
c.1 Expected client outcome is written next to each
nursing diagnosis on nursing care plan
c.2 These outcomes must be objective, realistic,
measurable alterations in the client's behavior,
activity, or physical state; a time period should be
set for achievement of the outcome
c.3 The outcome provides a standard of measure
that can be used to determine if the goal toward
which the client and nurse are working has been
achieved
d. Nursing interventions (nursing orders) are
written for each nursing diagnosis and should be
specific to the stated outcome or goal; each goal
may have one or more applicable interventions

4. Implementation: the actual administration of the

planned nursing care
5. Evaluation: Outcome and revision of
nursing care plan
a. Process is ongoing throughout client's
treatment/hospitalization
b. If outcome/goal is not reached in
specified time, the client is reassessed to
discover the reason
c. Reordering of priorities and new goal
setting may be necessary
d. When diagnosis/problem is resolved,
the date should be noted on care plan
Examples of Critical Thinking in the
Nursing Process
Nursing Process Critical Thinking Activities
Phase
Assessing Making reliable observations
Distinguishing relevant from
irrelevant data
Distinguishing important from
unimportant data
Validating & Organizing data
Categorizing data according to
a framework
Recognizing assumptions
Diagnosing Findings patterns and relationships
among cues
Identifying gaps in the data & Making
Inferences
Suspending judgment when lacking
data
Making interdisciplinary connections
Stating the problems
Examining assumptions
Comparing patterns with norms
Identifying factors contributing to the
problem
Planning Forming valid generalizations
Transferring knowledge from one
situation to another
Developing evaluative criteria
Hypothesizing & Making
interdisciplinary connections
Prioritizing client problems
Generalizing principles from other
sciences
Implementing Applying knowledge to perform
interventions
Testing hypothesis
Evaluating Deciding whether hypotheses
are correct
Making criterion-based
evaluation
Advantages of nursing process
1. Encourages thorough individual client assessment
by nurse
2. Determines priority of care
3. Provides comprehensive and systematic nursing
care planning and delivery
4. Permits independent, creative, and flexible nursing
intervention
5. Facilitates team cooperation by promoting:
a. Contributions from all team members
b. Communication among team members
c. Coordination & Continuity of care
6. Provides for continuous involvement and
input from client
7. Facilitates the "costing-out" of nursing
services and care
8. Facilitates nursing research
9. Provides accurate legal document of
client care
 COMMUNICATION
“Refers to reciprocal exchange of
information, ideas, beliefs, feelings and
attitudes between 2 persons or among a
group. The need to communicate is universal.
People communicate to satisfy needs. Clear
and accurate communication among
members of the health team, including the
client, is vital to support the client's welfare”
-Dolores Saxton
Signs of Lack of Communication
a. Efforts to change the subject-the client
may not understand what the nurse is
saying
b. Lack of questions
c. Non-Verbal Clues : Blank expression,
lack of eye contact, etc.
MAINTENANCE OF EFFECTIVE
COMMUNICATION:
THE NURSE'S ROLE
A. Be aware that effective communication
requires skill in both sending and receiving
messages
1. Verbal: for example, words and tone of
voice
2. Written
3. Nonverbal: for example, facial expression,
eye contact, and body language
B. Recognize the high stress-anxiety potential of
most health settings created in part by:
1. Health problem itself, treatments and
procedures
2. Exclusive behavior of personnel
3. Foreign environment
4. Change in lifestyle, body image, and self
concept
5. Inability to use normal coping skills such as
exercise or talking with friends
C. Recognize the intrinsic worth of each person
1. Listen, consider wishes when possible, and explain
when necessary
2. Avoid stereotyping, snap judgments, and unjustified
comparisons
3. Be nonjudgmental and non-punitive in response and
behavior
D. Be aware that each individual must be treated as a
whole person
E. Recognize that all behavior has meaning and usually
results from the attempt to cope with stress
1. Be aware of importance of value systems &
significance of cultural differences
2. Be sensitive to personal meaning of experiences to
clients
 3. Recognize that giving information may not
alter the client's behavior
4. Recognize the defense mechanisms that the
individual is using
5. Recognize own anxiety and cope with it
F. Maintain an accepting, open environment
1. Accept the client but set limits on
inappropriate behavior
2. Identify and face problems honestly
3. Value the expression of feelings & be
nonjudgmental
G. Recognize the client as a unique person
1. Use names rather than labels such as room
numbers or diagnoses & maintain the client's
dignity
2. Be courteous toward the client, family, and
visitors
3. Permit personal possessions where practical
(e.g., own nightclothes, pictures, and toys)
4. Explain at the client's level of understanding
and tolerance & encourage expression of
feelings
H. Support a social environment that
focuses on client needs
1. Use problem-solving techniques that
focus on the client
2. Be flexible in carrying out routines
and policies
 Special Considerations in
Communication
Clients with Hearing Loss
Signs of hearing Loss
a. speech deterioration
b. indifference
c. social withdrawal
d. suspicion
e. tendency to dominate conversation
 Nursing Interventions:
a. Face client directly, make sure your face is clearly
visible
b. Before discussion, tell the client the topic you are
going to discuss
c. Ensure that the client has access to hearing aid and
that it is functional
d. Speak slowly and distinctly; do not shout ; keep
sentences short and simple
e. Use written information to enhance spoken word ;
resort to writing if unable to understand
f. Pay attention when the person speaks;facial &
physical gestures helps understand what the person is
saying
Clients with Aphasia
Aphasia Syndromes
a. Wernicke’s Aphasia : patient speaks readily but
speech lacks clear content, information and direction
b. Anomic or Amnesic Aphasia : speech is almost
normal but marred by word-finding difficulty
c. Conduction Aphasia : comprehension of language
is good but has difficulty repeating spoken material
d. Non-fluent Aphasia : speech is sparse and
produced slowly and with effort and poor articulation
e. Global Aphasia: severe disruption of all aspects of
communication (verbal, written, reading,
understanding)
 Nursing Interventions:
a. Face client & establish eye contact
b. Use gestures, pictures and communication boards
c. Limit conversations to practical matters
d. Keep background noise to a minimum; keep
environment simple and relaxed
e. Do not shout or speak loudly; speak at normal rate
and volume (patient not hearing impaired!)
f. Give client time to understand and respond; allow
plenty of time to answer
g. If clients has problems speaking, ask “yes” or “no”
questions
Client with Stroke
“Refers to onset and persistence of neurologic
dysfunction lasting for longer than 24 hours
and resulting from disruption of blood supply
to the brain”
Nursing Interventions
a. Approach the client from the side of intact
vision
b. Remind the client to turn head in the
direction of visual loss to compensate for loss of
visual field
c. Explain location of object when placing it
near the client
d. Always put client care items in same places
e. Put objects within client’s reach and on
unaffected side
f. Encourage client to repeat sounds of the
alphabet
g. Speak slowly and clearly
h. Use simple sentences with questions or pictures
i. Reorient client to time, place and situation
j. Provide familiar objects & minimize
distractions
k. Repeat & reinforce instructions
Clients with Dementia
“Dementia is a disturbance involving multiple cognitive
deficits including memory impairment.Primary
dementias are degenerative disorders that are
progressive, irreversible and not due to any other
conditions.”
Nursing Interventions
a. Be calm & unhurried; identify yourself & address the
person by name each meeting
b. Keep conversations short & focused ; use simple
words and phrases
c. Do not ask the client to make decisions
d. Be consistent
e. Avoid distractions
f. Use reality oriented techniques
 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.
c. Behavioral training-client learns different way
to control urge to urinate
d. Bladder retraining
e. 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
 Relieve acute urinary retention
 Relieve chronic urinary retention
 Drain urine preoperatively & postoperatively
 Determine amount of post-void residual
 Accurately measure output in the critically ill
 Obtain sterile urine specimen
 Continuous or intermittent bladder
irrigation
Types of Catheter & General Guidelines
a. Indwelling Catheter
 Use a closed drainage system
 Advance catheter almost to bifurcation of catheter, esp.
in male patients
 Inflate balloon w/in guidelines of manufacturer only
after urine is draining properly, then slightly w/draw
catheter
 Secure catheter to patient’s thigh, allowing for some
slack to accommodate movement & to lessen drag on
patient
 Ensure tubing is over patient’s leg
Care of indwelling catheter
 Cleanse around area where catheter enters urethral
meatus
 Do this w/ soap & water during the daily bathing
routine & after defecation
 Don’t pull on catheter while cleansing
 Don’t use powder or spray around perineal area
 Don’t open the drainage system
 Avoid raising the drainage bag above the level of the
bladder
 Avoid clamping the drainage tubing
 Catheter is only irrigated when an obstruction, usu.
Following prostate or bladder surgery (e.g., potential
blood clots) is anticipated
b. Suprapubic Catheter
– Placed to drain the bladder
– Achieved via a percutaneous catheter or by way
of an incision through the abdominal wall
c. Intermittent Self-catheterization
 Purpose: to drain the bladder
 Employed by the client w/ Spina Bifida & other
neuromuscular diseases; can be taught to children 7-8
yrs.
Procedure:
– Gather equipment: catheter, water-soluble lubricant,
soap, water, urine collection container
– Wash hands
– Cleanse urethral meatus & surrounding area
– Lubricate tip of catheter
– Insert catheter until urine flows
– W/draw catheter when urine flow stops
– Clean off residual lubricant from meatus
– Dispose of urine
– Wash hands
 D. Ostomies
Types of ostomies
a. Ileostomy
• Liquid to semi-formed stool, dependent upon amount of
bowel removed
• May skew fluid & electrolyte balance, especially
potassium & sodium
• Digestive enzymes in stool irritate skinDo NOT give
laxatives
• Ileostomy lavage may be done if needed to clear food
blockage
• May not require appliance set; if continent ileal
reservoir or Koch pouch
b.Colostomy
 Ascending-must wear appliance--semi-liquid stool
 Transverse-wear appliance--semi-formed stool
 Loop stoma
o Proximal end-functioning stoma
o Distal end-drains mucous
o Plastic rod used to keep loop out
o Usually temporary
 Double barrel
• Two stomas
• Similar to loop but bowel is surgically severed
  Sigmoid
• Formed stool
• Bowel can be regulated so appliance not needed
• May be irrigated
Stoma assessment
a. Color-should be same color as mucous membranes
(normal stoma color- Red not dusky or pale: sign of
infection)
b. Edema-common after surgery. Bleeding-slight
bleeding common after surgery
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
a. Support feet and legs during walking
b. Adjust hand bars to allow 15-20 degrees of
elbow flexion
c. Use well-fitting shoes with non-slip soles
d. Use rubber suction tips on crutches
e. May be used temporarily or permanently
f. Teach client crutch walking
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
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)
 Characteristics of pain
• Location
• Quality
• Intensity
• Timing and duration
• Precipitating factors
• Aggravating factors
• Alleviating factors
• Interference with Activities of Daily Living
• Patterns of response
Types of Pain
1. Acute: Self-Limited, has a beginning and an end
lasting up to 6 mos.
2. Chronic: Persistent or episodic pain lasting >6 mos.
Medical Treatment
– Pharmacologic
– Nonpharmacologic Intervention
a. Acupuncture
• Oriental method: insert fine needles at
specified body sites
• How acupuncture works physiologically:
Unknown
b. Relaxation Techniques-biofeedback, visualization,
meditation, hypnosis-to help client control anxiety
c. Electronic Stimulation such as Transcutaneous Electric
Nerve Stimulation (TENS)-electrodes applied over the
painful area or along nerve pathway
d. Distraction-focusing client’s attention on something
other than pain
e. Massage-generalized cutaneous stimulation of the body;
makes the client more comfortable due to muscle
relaxation
f. Ice and Heat Therapies-effective in some circumstances;
ice may decrease the prostaglandins which intensify the
sensitivity of pain receptors
g. Guided Imagery-using one’s imagination in a guided
manner to achieve a specific positive effect
 Patient-Controlled Analgesia
(PCA)
Type of intravenous pump that allows the client to
administer his own narcotic analgesic (e.g., morphine)
on demand within preset dose and frequency limits.

Goal: To achieve more constant level of analgesia as

compared to PRN IM injection. In general, causes less
sedation and lower risk of pulmonary depression.
Used most often for postoperative pain management; also
used for intractable pain in terminal illness.
PCA pump may be used solely on PCA mode or may be
combined with a continuous basal mode where client is
receiving continuous infusion of narcotic in addition to
self-administered bolus injections.
 Nursing Interventions
1. Instruct client in use of PCA pump
a. Demonstrate how to push control
button.
b. Explain concept of patient-
controlled analgesia.
2. Frequently assess client’s level of
consciousness (LOC), RR, and degree
of pain relief.
Electrical Stimulation Technique for Pain
Control Transcutaneous Electrical
Nerve Stimulator (TENS)
Noninvasive alternative to traditional methods of
pain relief
Used in treating acute pain (e.g., post-op pain)
and chronic pain (e.g., chronic low back pain
chronic)
1. Consists of impulse generator connected by
wires to electrodes on skin ; produces
tingling, buzzing sensation in the area
2. Mechanism based on gate-control theory: electrical
impulse stimulates large diameter nerve fibers to
“close the gate”
a. Don’t place electrodes over incision site, broken skin,
carotid sinus, eyes, laryngeal or pharyngeal muscles.
b. Don’t use in client with cardiac pacemaker.
c. Provide skin care.
 remove electrodes once a day; wash area with
soap & water, & air dry
 wipe area with skin prep pad before reapplying
electrode
 assess area for signs of redness; reposition
electrodes if redness persists for more than 30
mins.
 Nursing Assessment &
Interventions for Pain
1. Evaluate objectively the nature of the patient’s pain:
location, duration, quality, & impact on daily activities.
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
– Constipation-best treated prophylactically
– Nausea-antiemetic therapy helpful
– 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.
– 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
E. Sleep-promoting Nursing Interventions
1. Warm bath- relaxes muscles, which induces sleep.
2. Drink Milk – rich in tryptophan, which induces sleep.
3. Attend to individual’s bedtime rituals that promote
sleep
4. Emphasize adequate exercise.
*Exercise at least 2 hrs. Before sleep to enhance
NREM, not immediately before sleep.
5. Give or advise high protein food; they contain
tryptophan, w/c is a CNS depressant.
6. Assess habits of sleep rhythm & wake-up time.
7. Avoid caffeine & alcohol in the evening.
8. Make sure client goes to bed when sleepy.
9. Use the bed mainly for sleep.
10. Be judicious in using minor tranquilizers.
F. Common Sleep Disorders
1. Insomnia: *difficulty in falling asleep *intermittent
sleep *premature awakening
2. Hypersomnia: *excessive sleep (daytime or night time)
*r/t psychologic problems, CNS damage, metabolic
disorders
3. Narcolepsy/Sleep Attack: *overwhelming sleepiness
*REM uncontrolled
4. Sleep Apnea: periodic cessation of breathing during
asleep; characterized by snoring
5. Parasomnias
a. Somnambolism/Sleep Walking
b. Night Terrors: After having slept for few hrs., the
child bolts upright in bed, shakes & screams, appears
pale & terrified.
c. Nocturnal Enuresis/Bedwetting
d. Soliloquy/Sleep-talking
e. Bruxism: clenching & grinding of teeth during sleep; may
erode & diminish the height of dental crowns & may
cause the teeth to become loose

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
• Involves touching the region or body part just observed
and noting what the various structures feel like.
• With experience comes the ability to distinguish
variations of normal from abnormal.
• Is performed in an organized manner from region to
region.
Percussion
• By setting underlying tissues in motion, percussion
helps in determining whether the underlying tissue is
air filled, fluid filled, or solid.
• 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 Duration Location
1. Flatness Soft High Short Thigh
2. Dullness Medium Medium Medium Liver
3. Resonance Loud Low Long Normal lung
4. Hyper Very loud Lower Longer Emphysemat
resonance ous lung
5. Tympany 5. Gastric air
Tympany bubble or
puffed out
cheek
c. The technique for percussion may be described as
follows:
1 .Hyperextend the middle finger of your left hand,
pressing the distal portion and joint firmly against
the surface to be percussed.
– Other fingers touching the surface will damp the
sound.
– Be consistent in the degree of firmness exerted by
the hyper extended finger as you move it from
area to area or the sound will vary.
2. Cock the right hand at the wrist, flex the middle
finger upward, and place the forearm close to the
surface to be percussed. The right hand and forearm
should be as relaxed as possible.
• With a quick, sharp, relaxed wrist motion,
strike the extended left middle finger with the
flexed right middle finger, using the tip of the
finger, not the pad. (A very short fingernail is
a must!) Aim at the end of the extended left
middle finger (just behind the nail bed) where
the greatest pressure is exerted on the surface
to be percussed.
• Lift the right middle finger rapidly to avoid
damping the vibrations. The movement is at
the wrist, not at the finger, elbow, or
shoulder; the examiner should use the lightest
touch capable of producing a clear sound.
 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.

Vital Signs or Cardinal Signs are:

• Body temperature
• Pulse
• Respiration
• Blood pressure
• Pain
 Body Temperature
Types of Body Temperature
a. Core temperature –temperature of the deep
tissues of the body.
b. Surface body temperature

Normal Adult Temperature Ranges

1. Oral 36.5 –37.5 ºC
2. Axillary 35.8 – 37.0 ºC
3. Rectal 37.0 – 38.1 ºC
4. Tympanic 36.8 – 37.9ºC
 Methods of Temperature-
1. Taking
Oral – most accessible and convenient method.
 Wash thermometer before use.
 Take oral temp 2-3 minutes.
 Allow 15 min to elapse between client’s food intake
of hot or cold food, smoke
Contraindications
• Young children an infants
• Patients who are unconscious or disoriented
• Who must breath through the mouth
• Seizure prone
• Patient with oral lesions ,post oral surgery, and
with nasal contraptions
 2. Rectal- most accurate measurement of temperature
• Position- lateral position with his top legs flexed and
drape him to provide privacy.
• Insert thermometer by 0.5 – 1.5 inches
• Hold in place in 2 minutes
• Do not force to insert the thermometer

Contraindications
• Patient with diarrhea
• Recent rectal or prostatic surgery or injury because it
may injure inflamed tissue
• Recent myocardial infarction
 3. Axillary – safest and non-invasive
• Pat the axilla dry
• Hold it in place for 9 minutes because the
thermometer isn’t close in a body cavity
Note:
1. Use the same thermometer for repeat temperature
taking to ensure more consistent result
2. Store chemical-dot thermometer in a cool area
because exposure to heat activates the dye dots.
Temperature
Routinely, where May vary with the
accuracy is not crucial, time of day.
an oral temperature will oOral: 370C (98.60F) is
suffice. considered normal. May
A rectal temperature is vary from 35.80C to
the most accurate. 37.30C (96.40-99.10F)
Unless contraindicated oRectal: Higher than
(as in a patient with a oral by 0.40C to 0.50C
severe cardiac (0.70-0.90F).
arrhythmia), a rectal
temperature is often
preferred.
Nursing Interventions in Clients with Fever
• Monitor V.S
• Assess skin color and temperature
• Monitor WBC, Hct and other pertinent lab
records
• Provide adequate foods and fluids.
• Promote rest
• Monitor I & O
• Provide TSB
• Provide dry clothing and linens
• Give antipyretic as ordered by MD
 Pulse – It’s the wave of blood created by contractions of the
left ventricles of the heart.
Normal Pulse rate
1 year 80-140 beats/min
2 years 80- 130 beats/min
6 years 75- 120 beats/min
10 years 60-90 beats/min
Adult 60-100 beats/min
Tachycardia – pulse rate of above 100 beats/min
Bradycardia- pulse rate below 60 beats/min
Irregular – uneven time interval between beats.
Radial Pulse

• Gently press your index, middle, and ring fingers

on the radial artery, inside the patient’s wrist.
• Excessive pressure may obstruct blood flow
distal to the pulse site
• Counting for a full minute provides a more
accurate picture of irregularities.
Pulse
Palpate the radial Normal adult pulse is
pulse and count for at 60 to 80 beats/min;
least 30 seconds. I f the regular in rhythm.
pulse is irregular, count Elasticity of the arterial
for a full minute and walls, blood volume,
note the number of and mechanical action
irregular beats/min. of the heart muscle are
Note: Whether the beat some of the factors that
of the pulse against your affect strength of the
finger is strong or weak, pulse wave, which
bounding or thread. normally is full and
strong.
Doppler device
• Apply small amount of transmission gel to the
ultrasound probe
• Position the probe on the skin directly over a
selected artery
• Set the volume to the lowest setting
• To obtain best signals, put gel between the skin and
the probe and tilt the probe 45 degrees from the
artery.
• After you have measure the pulse rate, clean the
probe with soft cloth soaked in antiseptic. Do not
immerse the probe
Respiration - is the exchange of oxygen and carbon
dioxide between the atmosphere and the body

Assessing Respiration
• Rate – Normal 14-20/ min in adult
• The best time to assess respiration is
immediately after taking client’s pulse
• Count respiration for 60 second
• As you count the respiration, assess and record
breath sound as stridor, wheezing, or stertor.
Respiration
Count the number of Normally 16 to 20
respirations taken in 15 respirations/min.
seconds and multiply
by 4.
Note: Rhythm and
depth of breathing.
 Blood Pressure
Adult – 90- 132 systolic
60- 85 diastolic
Elderly 140-160 systolic
70-90 diastolic
• Ensure that the client is rested
• Use appropriate size of BP cuff.
• If too tight and narrow- false high BP
• If too lose and wide-false low BP
• Position the patient on sitting or supine
position
• Position the arm at the level of the heart, if
the artery is below the heart level, you may
get a false high reading
• Use the bell of the stethoscope since the blood
pressure is a low frequency sound.
• If the client is crying or anxious, delay
measuring his blood pressure to avoid false-
high BP
 Blood Pressure
Measure the blood pressure
in both arms.
Palpate the systolic
pressure before using the
stethoscope in order to detect
an auscultatory gap.*
Apply cuff firmly; if too
loose, it will give a falsely
high reading.
Use cuff in appropriate size:
a pediatric cuff for children;
a leg cuff for obese people.
The cuff should be
approximately 2.5 cm (1
inch) above the antecubital
fossa.
Normal range:
Systolic—95-140 mm Hg
Diastolic—60-90 mm Hg
A difference of 5 to 10 mm
Hg between arms in
common.
Systolic pressure in lower
extremities is usually 10 mm
Hg higher than reading in
upper extremities.
Going from a recumbent to a
standing position can cause
the systolic pressure to fall 10
to 15 mm Hg and the diastolic
pressure to rise slightly (by 5
mm Hg).
 Electronic Vital Sign Monitor

• An electronic vital signs monitor allows you to

continually tract a patient’s vital sign without having
to reapply a blood pressure cuff each time.
• Example: Dinamap VS monitor 8100
• Lightweight, battery operated and can be attached to
an IV pole
• Before using the device, check the client7s pulse and
BP manually using the same arm you’ll using for the
monitor cuff.
• Compare the result with the initial reading from the
monitor. If the results differ call the supply
department or the manufacturer’s representative.
SPECIFIC SURGICAL POSITIONS
FOR PATIENT
 Bed position for client care
Position Placement Use
Semi- Head of bed 30° Cardiac, respiratory,
Fowler’s angle neurosurgical
condition
Low-Fowler’s Head of bed 15° Necessary degree
angle elevation for ease
breathing, promotes
skin integrity; client’s
comfort
Knee-Gatch Lower section of For client comfort;
bed (under knees) contraindicated for
slightly bent vascular disorder
Position Placement Use

Trendelenburg’s Head of bed Percussion,

lowered and foot vibration, and
raised drainage;
promotes venous
return

Reverse Bed frame is titles Gastric

trendelenburg’s up with foot of the conditions,
bed prevent
esophageal reflux
Amputation: lower extremity
- No pillows under stump after first 24
hours
- Turn patient prone several times a
day
Rationale:
- Prevents flexion deformity of the
limb
 Appendicitis: ruptured

- Keep in fowler’s position - not flat

in bed
Rationale:
- Keeps infection from spreading
upward in the peritoneal cavity
 Burns (extensive)
- Usually flat for first 24 hours
Rationale:
- Potential problem is hypovolemia,
which will be more symptomatic in
a sitting position
 Cast, extremity

- Keep extremity elevated

Rationale:
- Prevent edema
 Craniotomy
- Head elevated with supratentorial incision
- flat with cerebellar or brainstem incision
Rationale:
- Reduces cerebral edema, which
contributes to increase intracranial
pressure
 Flail chest
- Position on affected side
Rationale:
- Reduces the instability of the chest
wall that is causing the paradoxical
respiratory movements
 Gastric resection
- Lie down after meals
Rationale:
- May be useful in preventing
dumping syndrome
Hiatal hernia (before repaired)

- Head of the bed is elevated with

shock blocks
Rationale:
- Prevents esophageal irritation from
gastric regurgitation
 Hip prosthesis
- Keep affected leg in abduction (splint or pillow between
legs)
- Avoid adduction and flexion of the hip
- Use trochanter roll along outside of femur anterior
joints capsule incision to keep affected leg turned
slightly inward
- No trochanter roll with posterior joint capsule incision
as leg is turned slightly outward
Rationale:
- If affected hip is flexed and allowed to adduct and
internally rotate, the head of the femur may be
displaced from the socket
 Laminectomy; fusion
- Avoid twisting motion when getting
out of bed, ambulating
Rationale:
- Prevent shearing force on the spine
 Liver biopsy
Place on right side, and position pillow
for pressure
Rationale:
- Prevents bleeding
 Lobectomy

- Do not put in Trendelenberg position

- position of comfort - sides, back
Rationale:
- Pushes abdominal contents against
diaphragm
- May cause respiratory
embarrassment
 Mastectomy
- Do not abduct arm first few days
Rationale:
- Puts tension on suture line
- Elevate hand and arm higher than
shoulder if lymph glands removed
Rationale:
- Prevents lymphedema
 Pneumonectomy
- Turn only toward operative side for short
periods
- No extreme lateral positioning
Rationale:
- Gives unaffected lung room for full expansion
- Prevents mediastinal shift
- In case of bleeding there will be no drainage into
the unaffected bronchi
 Radium implantation in cervix
- Bed rest - usually may elevate to 30
degrees
Rationale:
- Must keep radium insert positioned
correctly
 Respiratory distress
- Orthopnea position usually desirable
Rationale:
- Allows for maximum expansion of
lungs
 Retinal detachment
- Affected area toward bed - complete bed rest
- No sudden movements of head
- Face down if gas bubble in place
Rationale:
- Gravity may help retina fall in place; prevents
further tearing
- Any sudden increase in intraocular pressure
may further dislodge retina
 Straight traction
- Check specific orders about how
much head may be elevated
Rationale:
- Body is used as the countertraction -
this must not be less than the pull of
the traction
 Balanced suspension traction
- May give patient more freedom to
move a bout than in straight traction
Rationale:
- In balanced suspension additional
weights supply contertraction
 Unconscious patient
- Turn on side with head slightly
lowered - “coma” position
Rationale:
- Important to let secretion drain out
by gravity
- Must prevent aspiration
 Ileofemoral bypass; arterial
insufficiency
- Do not elevate legs
Rationale:
- Arterial flow is helped by gravity

- Flexion of the hip compresses the vessels

of the extremity
Rationale:
- Avoid hip flexion
 Vein strippings; vein ligations
- Keep legs elevated
Rationale:
- Prevents venous stasis

- Do not stand or sit for long periods

Rationale:
- Prevents venous pooling
 Selected Nursing Procedures
Principles and Practices of Surgical Asepsis
All objects used in a sterile field must be sterile.
• All articles are sterilized appropriately by
dry or moist heat, chemicals, or radiation
before use.
• 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.
Sterile objects become unsterile when
touched by unsterile objects.
• Handle sterile objects that will touch
open wounds or enter body cavities only
with sterile forceps or sterile gloved
hands.
• Discard or resterilize objects that are
considered questionable, assume the
article is unsterile.
Sterile items that are out of vision or below the waist
level of the nurse are considered unsterile.
• One left unattended, a sterile field is considered
unsterile.
• Sterile objects are always kept in view. Nurses do not
turn their backs on a sterile field.
• Only the front part of a sterile gown (from the waists to
the shoulder) and 2 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 become unsterile by prolonged
exposure to airbone micro-organisms.
• Keep doors closed and traffic to a minimum in areas
where a sterile procedure is being performed because
moving air can carry dust and microorganisms.
• Keep areas in which sterile procedures are carried out
as clean as possible by frequent damp cleaning with
detergent germicides to minimize contaminants in 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 through a sterile object draws
microorganisms from unsterile surfaces above or
below to the sterile surface by capillary action.
• Sterile moisture-proof barriers are sued beneath
sterile objects. Liquids (sterile saline or antiseptics)
are frequently poured into containers on a sterile
field. If they are spilled onto the sterile field, the
barrier keeps
• The liquid from seeping beneath it.
• Keep the sterile covers on sterile equipment dry.
Damp surfaces can attract microorganisms in the air.
• Replace sterile drapes that do not have a sterile
barrier underneath when they become moist.
 The edges of a sterile field are considered
unsterile
• A 2.5-cm (1-in) margin at each edge of an
opened drape is considered unsterile
because the edges are in contact with
unsterile surfaces.
• Place all sterile objects more than 2.5 cm
(1 in.) inside the edges of a sterile field.
• Any article that falls outside the edges of a
sterile field is considered unsterile.
 The skin cannot be sterilized and is
unsterile.Conscientiousness, alertness, and
honesty are essential qualities in maintaining
surgical asepsis.
• Use sterile gloves or sterile forceps to handle
sterile items. Prior to a surgical aseptic
procedure, wash hands to reduce the number of
microorganisms on them
• When a sterile object becomes unsterile, it does
not necessarily change in appearance. The person
who sees a sterile object become contaminated
must correct or report eh situation. Don’t a set
up a sterile field ahead of time for future use.
 Nosocomial Infections
Most Common Causes
Microorganisms

Urinary Tract Improper catheterization

Escherichia coli (80%) technique
Enterococcus species Contamination of closed
drainage system
Pseudomonas aeruginosa
Inadequate hand washing

Surgical Sites Inadequate hand washing

Staphylococcus aureus Improper dressing change
Enterococcus species technique
Pseudomonas aeruginosa
Bloodstream Inadequate hand washing
Coagulase-negative Improper intravenous fluid,
staphylococci tubing, and site care
Staphylococcus aureus technique
Enterococcus species

Pneumonia Inadequate hand

Staphylococcus aureau washing
Pseudomonas aeruginosa Improper suctioning
Enterobacter species technique
 Steps to follow other Exposure to Blood
borne Pathogens
• Report the incident immediately to appropriate
personnel within the agency.
• Complete an injury report.
• Seek appropriate evaluation and follow-up. This
includes:
– Identification and documentation of the source
individual when feasible and legal
– Testing of the source for hepatitis B, hepatitis C,
and HIV when feasible and consent is given
– Making results of the test available to the source
individual’s health care provider
– Testing of blood of exposed nurse (with consent)
for hepatitis B, hepatitis C, and HIV antibodies
– Postexposure prophylaxis if medically indicated
• For a puncture / laceration:
– Encourage bleeding
– Wash / clean the area with soap and water
– Initiate first-aid and seek treatment if
indicated.
• For a mucous membrane exposure
(eyes, nose, mouth), saline of water flush
for 5 to 10 minutes.
 Postexposure Protocol (PEP)
HIV:
• For “high-risk” exposure (high blood volume and source
with a high HIV titer): three-drug treatment is
recommended. Must be started within 1 hour.
• For “increased risk” exposure (high blood volume or
source with a high HIV titer): three-drug treatment is
recommended. Must be started within 1 hour.
• For “low-risk” exposure (neither high blood volume nor
source with a high HIV titer): two-drug treatment is
considered. Must be started within 1 hour.
• Drug regimens vary. Drugs commonly used are
zidovudine, lamivudine, didanosine, and indinavir.
• HIV antibody test done shortly after expsosure
(baseline), and 6 week, 3 months, and 6 months after
ward.
Hepatitis B
– Anti-HBs testing 1 to 2 months after last vaccine close.
– Anti-BHs testing 1 to 2 months after last vaccine close.
Hepatitis C
– Anti-HVC and ALT at baseline and 34 to 6 months after
exposure
Selected Safety Hazards throughout the Life Span
– Developing fetus: Exposure to maternal smoking, alcohol
consumption, addictive drugs, x-rays (first trimester),
certain pesticides
– Newborns and infants: Falling, suffocation in crib, choking
from aspirated milk or ingested objects, burns from hot
water or other spilled hot liquids, automobile accidents,
crib or playpen injuries, electric shook, poisoning
– Toddlers: Physical trauma from falling, banging
into objects, or getting cut by sharp objects;
automobile accidents; burns; poisoning; drowning;
and electric shock
– 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.
Bathing an Adult or Pediatric Client
Process
• To remove transient microorganisms,
body secretions and excretions, and dead
skin cells
• To stimulate circulation to the skin
• To produce a sense of well-being
• To promote relaxation and comfort
• To prevent or eliminate unpleasant body
odors
Assessment
• Condition of the skin (color, texture and turgor,
presence of pigmented spots, temperature, lesions,
excoriations, and abrasions)
• Fatigue
• Presence of pain and need for adjunctive measure
(e.g., an analgesic) before the bath
• Range of motion of the joints
• Any other aspect of health that affect the client’s
bathing process (e.g., mobility, strength, cognition)
• Need for use of clean gloves during the bath
Equipment
• Basin or skink with warm water (between 43 and 46C
or 3110 and 115F)
• Soap and soap dish
• Linens: bath blanket, two bath towels, washcloth,
clean grown or pajamas or clothes as needed,
additional bed linen and towels, if required
• Gloves, if appropriate (e.g., presence of body fluids or
open lesions)
• Personal hygiene article (e.g., deodorant, powder,
lotions)
• Shaving equipment for male clients
• Table for bathing equipment
 FOR A BED BATH
• Prepare the bed and position the client appropriately.
• Position the bed at a comfortable working height. Lower the
side rail on the side close to you. Keep the other side rail up.
Assist the client to move near you. This avoids undue
reaching and straining and promotes good body mechanics.
• Place bath blanket over top sheet. Remove the top sheet from
under the bath blanket by starting at client’s shoulders and
moving linen down toward client’s feet. Ask the client to
grasp and hold the top of the bath blanket while pulling
linen to the foot of the bed. The bath blanket provides
comfort, warmth, and privacy. Note: If the bed linen is to be
reused, place it over the bedside chair. If it is to be changed,
place it in the linen hamper.
• Remove client’s gown while keeping the client covered with the
bath blanket. Place gown in linen hamper.
Make bath mitt with the washcloth. A bath mitt retains water
and heat better than a cloth loosely held and prevents ends of
washcloth from dragging across the skin.
Wash the face. Circular Motion. Begin the bath at the cleanest
area and work downward to-ward the feet.
• Place towel under client’s head.
• Wash the client’s eyes with water only and dry them well.
Use a separate corner of the washcloth for each eye. Using
separate comers prevents transmitting microorganisms from
one eye to the other. Wipe from the inner to the outer canthus.
This prevents secretions from entering the nasolacrimal
ducts.
• Ask whether the client wants soap used on the face. Soap has a
drying effect, and the face, which is exposed to the air more
than other body parts, tends to be drier.
• Wash, rinse, and dry the client’s face ears, and neck.
• Remove the towel from under the client’s head.
• Wash the client’s eyes with water only and dry them
well. Use a separate corner of the washcloth for each
eye. Using separate comers prevents transmitting
microorganisms from one eye to the other. Wipe from
the inner to the outer canthus. This prevents secretions
from entering the nasolacrimal ducts.
• Ask whether the client wants soap used on the face. Soap
has a drying effect, and the face, which is exposed to the
air more than other body parts, tends to be drier.
• Wash, rinse, and dry the client’s face ears, and neck.
• Remove the towel from under the client’s head.
Wash the arms and hands. (Omit the arms for a partial
bath.)
• Place a towel lengthwise under the arm away from you. It
protects the bed from becoming wet.
• Wash, rinse, and dry the arm by elevating the client’s arm
and supporting the client’s wrist the elbow .Use long, firm
strokes from wrist to shoulder, including the axillary area.
Firm strokes from distal to proximal areas promote
circulation by increasing venous blood return.
• Apply deodorant or powder if desired.
• (Optional) Place a towel on the bed and put a washbasin on
it. Place the client’s hands in the basin. Many clients enjoy
immersing their hands in the basin and washing themselves.
Soaking loosens dirt under the nails. Assist the client as
needed to wash, rinse, and dry the hands, paying particular
attention to the spaces between the fingers.
• Repeat for hand and arm nearest you. Exercise caution if
an intravenous infusion is present, and check its flow after
moving the arm.
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.
 Wash the back and then the perineum.
• Assist the client into a prone or side-lying position
facing away from you. Place the bath towel lengthwise
alongside the back buttocks while keeping the client
covered with the bath blanket as much as possible.
This provides warmth and undue exposure.
• Wash and dry the client’s back, moving from the
shoulders to the buttocks, and upper thighs, paying
attention to the gluteal folds
• Perform back massage now of after completion of
bath.
• Assist the client to the supine position and determine
whether the client can wash the perineal area
independently. If the client cannot do so, drape the
client and wash the area.
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.
Systematic Way for Bed Bath
– Eyes (inner to outer)
– Face (circular)
– Ears & Neck (circular)
– Arms & Hands (distal to proximal)
– Chest & Abdomen (long firm strokes-longitudinal)
– Legs & Feet (distal to proximal)
– Back & Perineum (shoulders to buttocks then
upper thighs - distal to proximal)
 Using a Metered – Dose Inhaler
• Make sure the canister is firmly and fully inserted into
the inhaler.
• Remove the mouthpiece cap and, holding the inhaler
upright; shake the inhaler vigorously for 3 to 5
seconds to mix the medication evenly.
• Exhale comfortably (as in a normal full breath.
• Hold the canister upside down.
• Hold the MDI 2 TO 4 cm (1 to 2 in) from the open
mouth
• Put the mouthpiece far enough into the mouth with its
opening toward the throat. Close the lips tightly
around the mouthpiece. An MDI with a spacer or
extender is always placed in the mouth.
Administering the Medication
• Press down once on the MDI canister (which release
the dose) and inhale slowly and deeply through the
mouth.
• Hold your breath for 10 seconds. This allows the
aerosol to reach deeper airways.
• Remove the inhaler from or away from the mouth.
• Exhale slowly through-pursed lips. Controlled
exhalation keeps the small airways open during
exhalation.
• Repeat the inhalation if ordered. Wait 20 to 30 second
between inhalations of bronchodilator medications so
the first inhalation has a chance to work and the
subsequent dose reaches deeper into the lungs.
• After the inhalation is completed, rinse mouth with tap
water to remove any remaining medication and reduce
irritation and risk of infection.
• Clean the MDI mouthpiece after each use. Use mild
soap and water, rinse it, and let it air dry before
replacing it on the device.
• Store the canister at room temperature. Avoid
extremes of temperature.
• Report adverse reactions such as restlessness,
palpitation, nervousness, or rash to the physician.
• Many MDIs contains steroids for an anti-inflammatory
effect. Prolonged use increases the risk of fungal
infections in the mouth.
 Height and weight
• It is essential in calculating drug dosage, contrast
agents, assessing nutritional status and
determining the height-weight ratio.
• Weight is the best overall indicator of fluid status,
daily monitoring is important for clients receiving
a diuretics or a medication that causes sodium
retention.
• Weight can be measured with a standing scale,
chair scale and bed scale.
• Height can be measured with the measuring bar,
standing scale or tape measure if the client is
confine nin a supine position.
 Pointers:
• Reassure and steady patient who are at risk for
losing their balance on a scale.
• Weight the patient at the same time each day.
(usually before breakfast), in similar clothing
and using the same scale.
• If the patient uses crutches, weigh the client with
the crutches or heavy clothing and subtract their
weight from the total determined patient’
weight.
 Laboratory and Diagnostic
examination
Urine Specimen
1. Clean-Catch mid-stream urine specimen for routine
urinalysis, culture and sensitivity test
• Best time to collect is in the morning,first voided
urine
• Provide sterile container
• Do perineal care before collection of the urine
• Discard the first flow of urine
• Label the specimen properly
• Send the specimen immediately to the laboratory
• Document the time of specimen collection and
transport to the lab.
• Document the appearance, odor, and usual
characteristics of the specimen.
 24-hour urine specimen
• Discard the first voided urine.
• Collect all specimen thereafter,until the following day
• Soak the specimen in a container with ice
• Add preservative as ordered according to hospital
policy
Second-Voided urine – required to assess glucose level
and for the presence of albumen in the urine.
• Discard the first urine
• Give the patient a glass of water to drink
• After few minutes, ask the patient to void
 Catheterized urine specimen
• Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in
the bladder and adequate specimen can be collected.
• Clamping the drainage tube and emptying the urine into a container are
contraindicated after a genitourinary surgery.
• Stool Specimen
1. Fecalysis – to assess gross appearance of stool and presence of ova or
parasite
– Secure a sterile specimen container
– Ask the pt. to defecate into a clean , dry bed pan or a portable
commode.
– Instruct client not to contaminate the specimen with urine or toilet
paper( urine inhibits bacterial growth and paper towel contain
bismuth which interfere with the test result.
 2. Stool culture and sensitivity
test
• To assess specific etiologic agent causing
gastroenteritis and bacterial sensitivity to
various antibiotics.

3. Fecal Occult blood test

– are valuable test for detecting occult blood
(hidden) which may be present in colo-rectal
cancer, detecting melena stool
• Test sample from several portion of the stool.
a Instructions:
• Advise client to avoid ingestion of red meat
for 3 days
• Patient is advise on a high residue diet
• avoid dark food and bismuth compound
• If client is on iron therapy, inform the MD
• Make sure the stool in not contaminated with
urine, soap solution or toilet paper
 Blood specimen
• No fasting for the following tests:
- CBC, Hgb, Hct, clotting studies,
enzyme studies, serum electrolytes
• Fasting is required:
- FBS, BUN, Creatinine, serum
lipid ( cholesterol, triglyceride)
 Sputum Specimen
1. Gross appearance of the sputum
• Collect early in the morning
• Use sterile container
• Rinse the mount with plain water before
collection of the specimen
• Instruct the patient to hack-up sputum
2. Sputum culture and sensitivity test
• Use sterile container
• Collect specimen before the first dose of
antibiotic
 3. Acid-Fast Bacilli
• To assess presence of active pulmonary
tuberculosis
• Collect sputum in three consecutive
morning
4. Cytologic sputum exam-
to assess for presence of abnormal or
cancer cells.
Diagnostic
tests
PPD test – read result 48 – 72 hours after
injection.
 For HIV positive clients, induration of 5 mm is
considered positive
 Bronchography
 Secure consent
 Check for allergies to seafood or iodine or
anesthesia
 NPO 6-8 hours before the test
 NPO until gag reflex return to prevent
aspiration
Thoracentesis – aspiration of fluid in the pleural
space.
 Secure consent, take V/S
 Position upright leaning on overbed table
 Avoid cough during insertion
 Turn to unaffected side after the procedure to
prevent leakage of fluid in the thoracic cavity
 Check for expectoration of blood. This
indicate trauma and should be reported to
MD immediately.
Holter Monitor – it is continuous ECG monitoring,
over 24 hours period
 The portable monitoring is called telemetry unit
Echocardiogram – ultrasound to assess cardiac
structure and mobility
 Client should remain still, in supine position
slightly turned to the left side, with HOB elevated
15-20 degrees
Electrocardiography-
 If the area is excessively hairy, clip it
• Remove client`s jewelry, coins, belt or any metal
• Tell client to remain still during the procedure
Cardiac Catheterization
 Secure consent
 Assess allergy to iodine, V/S for baseline information
• Have client void before the procedure
• Monitor PT, PTT, ECG prior to test
• NPO for 4-6 hours before the test
• Shave the groin or brachial area
• After the procedure: bed rest to prevent bleeding on the site, do
not flex extremity
• Elevate the affected extremities on extended position to
promote blood supply back to the heart and prevent
thrombplebities
• Monitor V/S especially peripheral pulses
• Apply pressure dressing over the puncture site
• Monitor extremity for color, temperature, tingling to assess for
impaired circulation.
MRI-
 secure consent,
 the procedure will last 45-60 minute
 Assess client for claustrophobia
 Remove all metal items
• Client should remain still
• Tell client that he will feel nothing but may hear
noises
• Client with pacemaker, prosthetic valves,
implanted clips, wires are not eligible for MRI.
• Client with cardiac and respiratory complication
may be excluded
 UGIS – Barium Swallow

• NPO after midnight

• force fluid after the test to prevent
constipation/barium impaction
• Tell client that the stool will turn white 24
to 48 hours after the test
 LGIS – Barium Enema
a. instruct client on low-residue diet 1-3 days before the
procedure
b. administer laxative evening before the procedure
c. NPO after midnight
d. administer suppository in AM
e. Enema until clear
f. force fluid after the test to prevent constipation/barium
impaction
g. Tell client that the stool will turn white 24 to 48 hours
after the test
Liver Biopsy
• Secure consent,
• NPO 2-4 hrs before the test
• Monitor PT, Vit K at bedside
• Place the client in supine at the right side of the bed
• Instruct client to inhale and exhale deeply for several
times and then exhale and hold breath while the MD
insert the needle
• Right lateral post procedure for 4 hours to apply
pressure and prevent bleeding
• Bed rest for 24 hours
• Observe for S/S of peritonitis
Paracentesis
 Secure consent, check V/S
 Let the patient void before the
procedure to prevent puncture of the
bladder
 Check for serum protein. excessive loss
of plasma protein may lead to
hypovolemic shock.
 Lumbar Puncture
• obtain consent
• instruct client to empty the bladder
and bowel
• position the client in lateral
recumbent with back at the edge of
the examining table
• instruct client to remain still
• obtain specimen per MDs order
Steam Inhalation
 It is dependent nursing function. Heat
application requires physician’s order.
 Place the spout 12-18 inches away from the
client’s nose or adjust the distance as
necessary.
Suctioning
 Assess the lungs before the procedure for
baseline information.
 Position: conscious – semi-Fowler’s
 Unconscious – lateral position
 Size of suction catheter- adult- fr 12-18
 Hyper oxygenate before and after procedure
 Observe sterile technique
 Apply suction during withdrawal of the catheter
 Maximum time per suctioning –15 sec
Nasogastric Feeding (gastric gavage)
 Insertion:
 Fowler’s position
 Tip of the nose to tip of the earlobe to the xyphoid
• Hyperextend the neck to gently advance the tube to
nasopharynx
• Tilt the head forward once the tube reaches the
throat and ask the client to swallow as the tube is
advance.
Tube Feeding
 Semi-Fowler’s position
 Assess tube placement
 Assess residual feeding
 Height of feeding is 12 inches above the
tube’s point of insertion
 Ask client to remain upright position for
at least 30 min.
 Most common problem of tube feeding is
Diarrhea due to lactose intolerance
 Procedures
Enema
 Check MD’s order
 Provide privacy
 Position left lateral
 Size of tube Fr. 22-32
 Insert 3-4 inches of rectal tube
 If abdominal cramps occur, temporarily
stop the flow until cramps are gone.
 Height of enema can – 18 inches
 COLOSTOMY
IRRIGATION
• Initial colostomy irrigation is done to
stimulate peristalsis; subsequent irrigations
are done to promote evacuation of feces at
a regular and convenient time
• Recommended with sigmoid colostomy
• Initiated 5 to 7 days postop
• Done in semi – Fowler’s position; then
sitting on a toilet bowl once ambulatory.
• Use warm normal saline solution
 Initially, introduce 200 mls. of NSS then 500 to
1,000 mls. Subsequently
 Dilate stoma with lubricated gloved finger before
insertion of catheter
 Lubricate catheter before insertion.
 Insert 3 to 4 inches of the catheter into the stoma
 Height of solution 12 inches above the stoma
 If abdominal cramps occur during introduction
of solution, temporarily stop the flow of solution
until peristalsis relaxes.
• Allow the catheter to remain in place for 5
to 10 minutes for better cleansing effect;
then remove catheter to drain for 15 to 20
minutes.
• Clean the stoma, apply new pouch
 Urinary Catheterization
 Verify MD’s order
 Practice strict asepsis
 Perineal care before the procedure
 Catheter size: male-14-16 , female – 12 – 14
 Length of catheter insertion
male – 6-9 inches ,female – 3-4 inches
For retention catheter:
Male –anchor laterally or upward over the lower
abdomen to prevent penoscrotal pressure
Female- inner aspect of the thigh
Foot Care
 Soaking the feet of diabetic client is no longer
recommended
 Cut nail straight across
Mouth Care
 Eat coarse, fibrous foods (cleansing foods)
such as fresh fruits and raw vegetables
 Dental check every 6 monthhhs
Oral care for unconscious client
 Place in side lying position
 Have the suction apparatus readily available
Hair Shampoo
 Place client diagonally in bed
 Cover the eyes with wash cloth
 Plug the ears with cotton balls
 Massage the scalp with the fatpads of the
fingers to promote circulation in the scalp.
 Fundamentals of nursing
Normal Values
Bleeding time 1-9 min
Prothrombin time 10-13 sec
Hematocrit Male 42-52%
Female 36-48%
Hemoglobin male 13.5-16 g/dl
female 12-16 g/dl
Platelet 150,00- 400,000
RBC male 4.5-6.2 million/L
female 4.2-5.4 million/L
 Normal Values
Amylase 80-180 IU/L
Bilirubin(serum)direct 0-0.4 mg/dl
indirect 0.2-0.8 mg/dl
total 0.3-1.0 mg/dl
PaCo2 35-45
pH 7.35-7.45
HCO3 22-26 mEq/L
Pa O2 80-100 mmHg
SaO2 94-100%
 • Normal values
Sodium 135- 145 mEq/L
Potassium 3.5- 5.0 mEq/L
Calcium 4.2- 5.5 mg/dL
Chloride 98-108 mEq/L
Magnesium 1.5-2.5 mg/dl
BUN 10-20 mg/dl
Creatinine 0.4- 1.2
CPK-MB male 50 –325 mu/ml
female 50-250 mu/ml
Fibrinogen 200-400 mg/dl
FBS 80-120 mg/dl
Glycosylated Hgb 4.0-7.0%
(HbA1c)
Uric Acid 2.5 –8 mg/dl
ESR male 15-20 mm/hr
female 20-30 mm/hr
Cholesterol 150- 200 mg/dl
Triglyceride 140-200 mg/dl
Lactic Dehydrogenase 100-225 mu/ml
Alkaline phospokinase 32-92 U/L
Albumin 3.2- 5.5 mg/dl
 THERAPEUTIC DIET
CONGESTIVE HEART FAILURE
• Low sodium
– Do not add salt or seasoning containing sodium
when preparing foods.
– Do not use salt in the table
– Avoid high sodium foods
– Limit milk products to 2 cups daily
– Substituting lemon juice and various spices to
enhance food flavor and to be more palatable
NEED TO AVOID:
• Processed foods smoked and cured products,
canned meat and sardines.
• Commercial soups, bouillon cubes, powdered
dehydrated soups
• MSG, Worcestershire, soy sauce, mustard,
horseradish, , bbq sauce, steak sauce, catsup
• Saltines, baking powder, muffins, bisquick,
pretzels, corn bread
• Olives, pickles, salted popcorn, TV dinners
LOW FAT DIET
Need to avoid:
• Fats, avocados, meat, olives, nuts

LOWCHOLESTEROL DIET
• The fat content of the diet is modified to
increase the ratio of polysaturated fatty acids
to saturated fatty acids.
• Organ meats are restricted because they are
high in cholesterol although low in total fat.
• Only 2 whole eggs per week are used because
egg yolk is high in cholesterol. Egg white may
use as desire.
Coronary artery disease
Low fat diet:
• Visible fat (e.g. butter, cream, salad
dressing, cooking oil) is restricted to 1 tsp
per meal
• Only lean milk, skim milk, and no more
than 7 eggs per week are used.
• Foods are not prepared with added fat for
cooking
• Vegetables oil is used in cooking and food
preparation. Coconuts and palm oils are not
allowed because of their high content of
saturated fats.
RESPIRATORY PROBLEMS
Pneumonia
– High calorie, high CHON, high CHO
– Small frequent feeding
– Provide mouth care prior to feeding
Pulmonary Tuberculosis
• High calorie, high CHON, high CHO
• Small frequent feeding
• Oral care before feeding
Bronchial asthma
• High calorie food
• Avoid over eating
• Increase fluid to 2 – 3 liters per day
• Liver cirrhosis
• High in calorie
• 3000 calories per day
• High CHO content
• Moderate to high CHON
• Moderate to low fat
If with hepatic encephalopathy low to no CHON
• Food allowed:
• Toast, cereals, rice, tea, fruit juice, and
hard candies
• Limit CHON to 20g per day at the onset
of severe hepatic failure
• Na is also restricted as well as fluid
when edema and ascites are present.
• Crisp foods should be avoided because
of the possibility of esophageal varices
Acute pancreatitis
• Initially NPO to reduce pancreatic secretions
• When food is allowed: small frequent feeding
• High CHO because it least stimulate the
pancreas
• High CHON, low fat
• Usually bland diet
• No stimulants (e.g. caffeine)
• No alcohol
• Supplemental fat soluble vitamins may be
given
Renal Calculi
Oxalate stones
Foods not allowed:
• Spinach, rhubarb, asparagus, cabbage, tomatoes,
beets, nuts, celery, parsley, runner beans ,
chocolate, cocoa, instant coffee, ovaltine, tea
• Calcium stone
• Foods not allowed
• Milk, cheese, ice cream, yogurt, food containing
flour, all beans except green beans, lentils, fish
with fine bones, dried fruits, chocolate, cocoa
Uric Acid Stone
Foods need to avoid
• Sardines, herring, mussels, sweet breads, liver,
kidney, goose, venison, meat soup, chicken, salmon,
crab, veal, mutton, bacon, pork, beef, ham, legumes,
salted anchovies.

Chronic Renal Failure

• Protein, sodium, potassium, phosphorus and fluids
are controlled to meet each client’s need
• Protein source should be of high biologic value.
• High Na and high K foods should be avoided
• Sufficient calories and nutrients are provided to meet
daily requirements
• Foods to avoid:
– Foods high in Na – cured meats, pickled
foods, canned soup and stew, cold cuts,
soy sauce, salad dressing
– Avoid salt substitute because they contain
KCl
– Foods high in K – dried foods, legumes,
orange, banana, melons, deep green and
deep yellow vegetables, beans and peas.
– Foods high in CHON – 0.5 g/kg ideal body
weight
Diabetes Mellitus
• Distribution of daily calories averages:
• 50%-60% from CHO – (of 90% - 95%
should be complex carbohydrates)
• 20 % from CHON
• 30 % from fats (of which 20 % should
be polysaturated)
• Diet should also include 10 to 15 g of
fiber
Hyperthyroidism
• High calorie diet – 4000 to 5000 kcal/day
• This is accomplished with six full meals a day
and snacks high in CHON, CHO, minerals
and vitamins and ascorbic acids
• Offering fluids frequently prevent volume
deficit to diaphoresis and insensible water loss
• Highly seasoned and high fiber food should be
avoided. (Hypermotile GI tract)
• Avoid coffee, cola and tea
• Milk is an excellent food source that provide
both Ca and CHON
1. How should the a. Draw up the NPH
nurse prepare for an insulin, then the
injection for a regular insulin in
patient who takes the same syringe
both regular and b. Draw the regular
NPH insulin? insulin, then the
NPH insulin in the
same syringe
c. Use two separate
syringe
d. Check with the
physician
2. Which of the a. Maintain the drainage
following is the tubing and collection
primary nursing bag level with the
intervention patient’s bladder
necessary for all b. Irrigate the patient with
patients with a 1% Neosporin solution
foley catheter in three times daily
place? c. Clamp the catheter for
1 hour to maintain the
bladder elasticity
d. Maintain the drainage
tubing and collection
bag below bladder level
to facilitate drainage by
gravity.
3. How does a 24-hour a. The first voided
urine collection differ specimen is
from a simple discarded
urinalysis? b. The last voided
specimen id
discarded
c. Urine does not need
to refrigerate
d. The specimen must
be labeled
4. While coughing, a a. Notify the physician
post-op abdominal immediately
surgery patient b. apply a sterile strip
complains of a to the wound edges
sudden sharp c. Encourage the
abdominal pain. The client to cough
nurse observes that harder
the patient’s wound d. Apply a sterile wet
edges have separated saline compress
and the viscera are
exposed. The nurse
should?
5. A hemovac is use to a. Promote wound
do all of the following healing
except? b. Remove the
drainage from the
surgical wound
c. Lessen
postoperative
discomfort
d. Prevent wound
infection
6. All of the following a. Prepare the
nursing interventions injection site with
are correct when alcohol
using Z tract method b. Use a needle that is
of drug injection at least 1 inch long
except? c. Aspirate for blood
before injection
d. Rub the site
vigorously after the
injection to promote
absorption
7. The best way to a. Instruct the patient to look
instill eye drops upward, and drop the
is to: medication into the center
of the lower lid.
b. Instruct the patient to look
ahead, and drop the
medication into the center
of the lower lid
c. Drop the medication into
the lower cantus
regardless of position
d. Drop the medication into
the center of the cantus
regardless of the position
8. If transfusion a. Call the MD and wait the
reaction occurs, order based on the
the nurse should: specific type f reaction
b. Stop the transfusion
immediately and keep the
vein open with saline
c. Slow the transfusion rate
and observe for an
increase in severity of the
reaction
d. Slow the transfusion and
request a venipuncture
for retyping to start the
second transfusion
9. Gilda, a 19- a. Have the patient shower and
yr-old wash the perineal area before
student, has the examination
been sexually
assaulted. b. Assess and document any
When bruises and laceration
assisting the c. Record a history of the event,
physical
examination, using the patient’s own
the nurse words
should do all d. Label all blood clothes and
of the
following place each item in a separate
except: brown bag so that any
evidence can be given to the
police
10. What stages of a. Medical care
illness is considered contract
when a person comes b. Assumption of sick
to believe something roll
is wrong? c. Symptoms
experience
d. Dependent patient
roll
11. A client will receive a. Sim’s
an IM injection. The b. Prone
nurse decided to give c. Prone with toes
it in the dorsogluteal pointing inward
area. The position is:
d. standing
12. In giving enema, it a. 12 inches above the
is recommended that patient’s buttocks
the enema cannot be b. 12 inches above the
held higher than: floor
c. 18 inches above the
patient’s buttocks
d. 18 inches above the
floor
13. The most common a. Lying down with
position for taking arms at heart with
the blood pressure is: palm down
b. Sitting with arms at
heart level with
palm down
c. Sitting with arm at
the level of heart
with palm up
d. Lying down with
arms at heart level
with palm up
14. An unconscious a. Conjunctivitis
client tend to keep b. Corneal scarring
her eyes open. The c. Development of
nurse should give retinitis
special eye care and
be kept closed to d. All of these
prevent:
15. A 19-yr-old female a. Allow her as much
is admitted with a as she need for each
diagnosis of anorexia meal
nervosa. Which of b. Explain the
the following should importance of an
the nurse include in adequate diet
the care plan? c. Observe her during
and one hour after
each meal
d. Use a random
pattern for surprise
weight
16. The nurse is giving a. Ask the mother what
medication to an the child’s name is
infant. What is the b. Look at sign above the
best way to assess the bed that states the
identity of the child’s name
infant? c. Compare the bed
number with the bed
number of the care
plan
d. Compare the ankle
band with the name of
the care plan
17. The nurse is
a. Wrap each wrist with
caring for a
gauze dressing beneath
client who has
the restraints
been placed in
cloth restraints. b. Remove the restraints
To ensure the every two hours and
client’s safety, inspect the wrists
the nurse should: c. Keep the head of the
bed flat at all times
d. tie the restraints using
a square knot
18. An elderly woman 1. Increase heart rate
receives Digoxin 0.25 2. Decrease cardiac
mg for treatment of output
her CHF. Which of
the following 3. Increase urine
physiologic responses output
indicates that the 4. Decrease
Digoxin is having the myocardial
desired effect? contraction force
19. The nurse is a. Implement strict
planning care for a isolation protocol
client with cervical b. Provide a lead
radiation implants. apron fro the client
Which nursing c. Use only disposable
intervention will be supplies and
included in the plan equipment in the
of care? client’s room
d. Limit visitors to 30
minutes per day
20.The nurse is a. Maintain
planning care for a nasogastric tube
client who is having a b. Assess gag reflex
gastroscopy prior to
performed. Included administration of
in the plan of care for fluid
the immediate post c. Assess frequently
gastroscopy period for pain and
will be* medicate as per
MDs order
d. Measure abdominal
girth every four
hours
21. The nurse is caring a. Prone with the head
for a client who is to turned to the left
have a lumbar b. Side-lying in a fetal
puncture (LP). How position
should the client be c. Sitting at the edge
position during the of the bed
procedure?
d. Trendelenburg
position
22. A adult client a. Notify the MD and
has central line administer oxygen via
placed for IV nasal cannula immediately
fluids. When the
nurse enters the b. Hang another IV bag as
room, the IV soon as possible, and
bottle is empty, remove the air from the
the IV line is full IV catheter
of air, and the c. Clamp the tubing and
client is place the client on the left
dyspneic. What side with the head down
is the best
nursing action? d. Begin CPR and call the
code team
23. The nurse is a. Place the stump flat on
caring for the bed to prevent
client who has contractures
just returned to b. Place the stump on a
the nursing unit pillow to prevent edema
following a left- c. Place the client on
above-the-knee prone position to
amputation. How prevent contractures
should the client d. Place the client in
be positioned? reverse Trendelenburg
position to promote
arterial flow
24. The nurse is caring a. Present of an aura
for a person during b. Length of seizure
seizure. What is the c. What precipitated
priority assessment
the seizure
at this time?
d. Type and
progression of
seizure activity
25. The physician has a. Teach the client to
ordered a sputum deep breathing and
specimen for culture coughing techniques
and sensitivity. In b. Use nasotracheal
order to obtain a suctioning
good specimen, the c. Obtain the specimen
nurse should: after starting
antibiotics
d. Withhold food and
fluid 30 minutes prior
to specimen collection
26. A nurse is called to a. Evacuate the unit
a client’s room by
b. Extinguished the
another nurse. When
fire
the nurse arrives at
the room, the nurse c. Confine the fire
discovers that a fire d. Activate the alarm
had occurred in the
client’s waste basket.
The first nurse has
removed the client
from the room. What
is the second nurse’s
next action?
27. A nurse is planning a. Provide detailed
care for a client who explanation of all
is experiencing procedures
anxiety following a b. Administer
myocardial cyclobenzaprine
infarction. Which (Flexeril) to promote
nursing intervention relaxation
should be included in c. Limit family
the plan of care? involvement during
the acute phase
d. Answer questions
with factual
information
 a. Blood glucose of 112
28. A nurse is caring
mg/dL
for a client with type
I diabetes mellitus. b. Ketonuria
Which of the c. Blood urea nitrogen
following laboratory (BUN) 18 mg/dL
results would d. Potassium 4.2 mEq
indicate a potential
complication
associated with this
disorder?
29. A client has had a. Respiratory acidosis
arterial blood gases b. Respiratory
drawn. The results alkalosis
are as follows: pH
of 7.34, PaCo2 of 37 c. Metabolic acidosis
mm Hg, PaO2 of 79, d. Metabolic alkalosis
HCO3 of 19 mEq/L.
A nurse interprets
that the client is
experiencing:
30. A woman comes a. Remain with the
into an emergency client
room in a severe b. Put the client in a
state of anxiety quiet room
following a car
accident. The most c. Teach the client
important nursing deep breathing
intervention at this d. Encourage the
time would be to: client to talk about
her feelings and
concerns
31. A nurse has an a. Instruct the client
order to institute not to strain with
aneurism bowel movements
precautions for a b. Allow the client to
client with a cerebral read and watch
aneurysm. Which of television
the following items c. Limit out-of-bed
would the nurse activities to twice a
document in the plan day
of care for this
client? d. Encourage the
client to take his or
her own bath
32. A home health care a. Self-care such as
nurse is assessing a toileting, feeding
client’s functional and ambulating
abilities and ability
b. The normal
to perform activities
everyday routine in
of daily living
the home
(ADL’s) The nurse
focuses the c. Ability to do light
assessment on: housework, heavy
house work and pay
the bills
d. Ability to drive a
car
33. A nurse is given
a. Avoid carrying heavy
instructions on site
care to a objects on the right
hemodialysis client arm
who has had a b. Sleep on the right side
arteriovenous (AV) c. Report increased
fistula implanted to
the right arm. The temperature, redness,
nurse determines or drainage at the site
that the client d. Perform range of
needs further motion exercises
instructions if the routinely on the right
client states an side
intention to:
34. The nurse is caring
A. Implementing a
for a newly admitted
ventilation flow
adult client with a
diagnosis of Hepatitis B. Wearing a mask
A. The MOST during care
significant routine C. Using a gown to
infection control change linens
strategy, in addition D. Gloving while
to handwashing, is handling bedpans
35. Which of the A. Sensory perceptual
following nursing alterations related to
diagnosis would decrease vision
place an 86 year-old B. Alteration in
client at GREATEST mobility related to
risk for falls? fatigue
C. Impaired gas
exchange related to
retained secretions
D. Altered patterns of
urinary elimination
related to Nocturia
36. When a. The nurse initiates
suctioning a suction as the catheter
client with a is withdrawn.
tracheostomy, b. The nurse inserts 3-5
which of the inches of the catheter
following is into the tracheostomy.
inappropriate c. The nurse applies
action by the suction for 5-10
nurse? seconds
d. The nurse uses a new
sterile catheter with
each insertion
37. After a subtotal a. Helping an oral
gastrectomy, a client airway in place
was returned to the b. Maintaining a
surgical unit. The constant oxygen
nurse can best flow rate
prevent pulmonary c. Promoting frequent
complications by: turning and deep
breathing to
mobilize secretions
d. Suctioning
secretions are
necessary
38. The client with a. Intellectual
Parkinson's impairment
disease would b. Toni-clonic seizures
most likely c. Flattened affect
manifest which of d. Changes in
the following? sensation
39. A client with a. Bladder distension
cervical injury
b. Drop in blood
complains of
pressure
throbbing headache,
blurring vision, and c. Increased pulse rate
nasal congestion. The d. Adventitious breath
nurse should assess sound
for:
40. The client had an a. Place a pillow
amputation of the between the thigh
right lower limb. To b. Lie on the abdomen
prevent hip flexion 30 minutes qid
contracture, the c. Turn from side to
nurse teach the client side every two
to: hours
d. Perform hamstring
muscle setting
exercises tid
41. To assess the a. Palpate the femoral
neurovascular artery of the affected
status of an leg
extremity casted b. Assess the affected leg
from the ankle to for positive Homan’s
the thigh, the sign
nurse should: c. Compress and release
the toenails of the
affected foot
d. Instruct the client to
flex and extend the knee
of the affected leg
42. On the first a. Encouraging the client
postoperative to wear a breast
day after the left prosthesis
modified radical b. Keeping the left arm
mastectomy, the and shoulder
NCP of the client immobilize
should include
c. Placing the client in
which of the
semi-Fowler’s position
following? with left arm and head
elevated
d. Changing the pressure
dressing as necessary
43. The type I diabetic
a. Exercise regularly
client is on insulin
therapy. To avoid b. Massage the
lipodystrophy, the injection site
nurse should teach c. Inject insulin at
the client to do which room temperature
of the following: d. Rotate injection site
1. A, b only
2. a, c, d
3. C, d only
4. b, c, d
44. The nurse is caring a. Copius, moist
for an 82-year-old cerumen
male client. The b. Difficulty hearing
client experienced woman’s voice
hearing loss caused
by aging. The nurse c. Red/ swollen
expect which of the tympanic
following in the membrane
client? d. Hearing better in
noisy environment
45. The client had been a. Stinging sensation is
diagnosed to have experience under the
angina pectoris. His tongue
physician prescribed b. The tablets are
nitroglycerine SL stored in clear plastic
tablets for chest pain. c. Pain is unrelieved
The nurse should but facial flushing is
teach a client to increased
suspect that the d. Onset of relief of
tablets have lost their chest pain is delayed
potency when:
46. When taking the a. Calcium
blood pressure of a b. Magnesium
client who has had c. Bicarbonate
thyroidectomy, the
d. Potassium chloride
nurse notices the
client has spasm of
the hand and notifies
the MD. While
awaiting the MD;s
order, the nurse
should prepare for
replacement of:
47. A client with a a. Elevate the arm no
fracture of the radius higher than heart
had a plaster cast level
applied 2 days ago. b. Remove the cast
The client complains c. Assess capillary
of constant pain and refill of the exposed
swelling of the hand and fingers
fingers. The first
action of the nurse d. Apply a warm soak
should be to the hand
48. A client has a serum A) repeat
glucose of 385 mg/dl. glycohemoglobin in
Which of these 24 hours
orders would the B) B) document
nurse question first? accuchecks, intake
and output every 4
hours
C) C) humulin N 20
units IV push
D) D) IV fluids of
0.9% normal saline
at 125 ml per hour
49. During a fluid exchange A) Slight pink -
for the client who is 48 tinged drainage
hours post insertion of
B) Abdominal
the abdominal Tenckhoff
discomfort
catheter for peritoneal
dialysis, the nurse knows C) Muscle weakness
that the appearance of D) Cloudy drainage
which of the following
needs to be reported to
the health care provider
immediately?
50. The nurse is caring a. Reconnect the tube
for a client with a b. Raise the collection
chest tube. On the chamber above the
second postoperative client's chest
day, the chest tube c. Call the health care
accidentally provider
disconnects from the
drainage tube. The d. Clamp the chest
first action the nurse tube
should take is
51. To prevent a a. Limit the client’s
pulmonary embolus fluid intake
in a client on bed b. Encourage deep
rest, the nurse breathing and
should: coughing
c. Use the knee gatch
when the client is in
bed rest
d. Teach the client to
move the legs when
in bed
52. In the post a. Client pushes the
anesthesia unit, while airway out
caring for the client b. client has snoring
who has received a respiration
general anesthetic, c. Respirations are
the nurse should regular but shallow
notify the physician d. Systolic BP drops
if the: from 130 to 90
mmHg
53. When teaching a a. Wearing support
client about stocking
orthostatic continuously
hypotension, the b. Lying down for 30
nurse should explain minutes after taking
that it can be medications
modified by: c. Avoiding tasks that
require high energy
expenditure
d. Sitting on the edge
of the bed a short
time before rising
54. A client has edema a. Lung disease
in the lower
b. Pulmonary edema
extremities during
the day and c. Myocardial
disappears at night. infarction
The nurse should d. Right ventricular
suspect: infarction
55. A client is a. Restrict fluids
admitted to the b. Elevate the legs
hospital and has c. Apply elastic
edematous ankles. bandage
To best limit d. Do range of motion
edema of the feet, exercise
the nurse should
prepare to:
56. Two hours after a a. Call the physician
cardiac
b. Check the client’s
catheterization that
pedal pulses
was assess via the
right femoral route. c. Take the client’s
An adult client is blood pressure
complaining of d. Recognize that this
numbness and pain is an expected
in the right foot. The response
nurse should:
57. A client has an IV a. Elevate the IV site
infusion. If the IV
b. Discontinue the
infusion infiltrates,
infusion
the nurse should;
c. Attempt to flash the
tube
d. Apply warm moist
soaks
58. A client receiving a. Ferrous sulfate
an anticoagulant for b. Acetylsalycylic acid
a pulmonary c. Isoxsuprine
embolism. The drug (vasodiland]
that is
contraindicated for d. Thorazine
client receiving
anticoagulant is:
59. After a client has an A) Abdominal x-ray
enteral feeding tube B) Auscultation
inserted, the most
accurate method for C) Flushing tube with
verification of saline
placement is D) Aspiration for
gastric contents
60. A patient has just A. Check the surgical
returned from the dressing to ensure
operating room with that it is intact.
a retention (Foley) B. Confirm the
catheter, an IV, and placement of the oral
an oral airway, and airway.
is still unresponsive. C. Examine the IV site
Which assessment for infiltration.
should be made first?
D. Observe the Foley
for drainage.
61. A nurse is providing A) Increase oral fluid
care to a 63 year-old intake
client with B) Encourage visits
pneumonia. Which from family and
intervention friends
promotes the client’s
comfort? C) Keep conversations
short
pneumonia.
D) Monitor vital signs
frequently
62. The physician A. increase the rate of
orders an arterial oxygen flow the
blood gas (ABG) for patient is receiving.
a 50-year-old man B. elevate the head of
receiving oxygen at 6 the bed.
L/min. Results show C. document the results
pH 7.37, HCO3 26 in the chart.
mmHg, pCO2 42 D. instruct the patient
mmHg, pO2 90 to cough and deep
mmHg. The nurse breathe.
should:
63. When caring a. Cover the entire cannula
for a client with an elastic bandage
who has just b. Use strict aseptic
had a technique when giving
arteriovenous shunt care
shunt inserted
for c. Notify the physician if
hemodialysis, bruits is heard in the
the nurse cannula
should: d. Take the blood pressure
every 4 hours from the
arm that contain the
shunt
64. Preoperative a. Remaining flat for 3
teaching for a client hours
is to have a cataract b. Eating a soft diet
surgery should for 2 days
include the c. Breathing and
importance of: coughing deeply
d. Avoiding bending
from the waist
65. When caring for a a. Help client to
client after a cardiac ambulate
catheterization, it is
b. Administer oxygen
most important that
the nurse: c. Check the ECG
every 30 minutes
d. Check the pulse
distal to the insertion
site
66.The physician a. Withholding all fluid
performs a for 72 hours
colostomy. During b. Limiting fluid intake
the immediate for several days
postoperative period,
nursing care should c. Having the client
include: change the stoma bag
d. Keeping the skin
around the stoma
clean and dry
67. Formation of a. High fluid intake
urinary calculi is a
b. Inadequate kidney
complication that
function
may be encountered
by the client with c. Increase intake of
paraplegia. A factor calcium
that contributes to d. Accelerated bone
this condition is: demineralization
68. Which client is at A) A 79 year-old
highest risk for malnourished client
development of on bed rest
decubitus ulcers?
B) An obese client who
uses a wheelchair
C) A client who had
3 incontinent diarrhea
stools
D) An 80 year-old
ambulatory diabetic
client
69. As the nurse is
A) Mouth sores
speaking with a
group of teens which B) Fatigue
of these side effects of C) Diarrhea
chemotherapy for D) Hair loss
cancer would the
nurse expect this
group to be more
interested in during
the discussion?
70. It may be redundant that health care
provider, including professional nurse, agree to
“do no harm” to their client. The principle that
describes this agreement is called:

a. Beneficence
b. Accountability
c. Nonmaleficence
d. Respect for autonomy