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Medical asepsis
1. Includes all practices intended to confine a specific microorganism to a
specific area
2. Limits the number, growth, and transmission of microorganisms
3. Objects referred to as clean or dirty (soiled, contaminated)
Surgical asepsis
1. Sterile technique
2. Practices that keep an area or object free of all microorganisms
3. Practices that destroy all microorganisms and spores
4. Used for all procedures involving sterile areas of the body

Principles of Aseptic Technique
1. Only sterile items are used within sterile field.
2. Sterile objects become unsterile when touched by unsterile objects.
3. Sterile items that are out of vision or below the waist level of the nurse are
considered unsterile.
4. Sterile objects can become unsterile by prolong exposure to airborne
5. Fluids flow in the direction of gravity.
6. Moisture that passes through a sterile object draws microorganism from
unsterile surfaces above or below to the surface by capillary reaction.
7. The edges of a sterile field are considered unsterile.
8. The skin cannot be sterilized and is unsterile.
9. Conscientiousness, alertness and honesty are essential qualities in
maintaining surgical asepsis

Signs of Localized Infection
Localized swelling
Localized redness
Pain or tenderness with palpation or movement
Palpable heat in the infected area
Loss of function of the body part affected, depending on the site and
extent of involvement
Signs of Systemic Infection
Increased pulse and respiratory rate if the fever high
Malaise and loss of energy
Anorexia and, in some situations, nausea and vomiting
Enlargement and tenderness of lymph nodes that drain the area of
Factors Influencing Microorganisms Capability to Produce Infection
Number of microorganisms present
Virulence and potency of the microorganisms (pathogenicity)
Ability to enter the body
Susceptibility of the host
Ability to live in the hosts body
Anatomic and Physiologic Barriers Defend Against Infection
Intact skin and mucous membranes
Moist mucous membranes and cilia of the nasal passages
Alveolar macrophages
High acidity of the stomach
Resident flora of the large intestine
Low pH of the vagina
Urine flow through the urethra
NANDA Diagnosis
Risk for Infection
o State in which an individual is at increased risk for being invaded
by pathogenic microorganisms
Risks factors
o Inadequate primary defenses
o Inadequate secondary defenses

Related Diagnoses
Potential Complication of Infection: Fever
Imbalanced Nutrition: Less than Body Requirement
Acute Pain
Impaired Social Interaction or Social Isolation
Interventions to Reduce Risk for Infection
Proper hand hygiene techniques
Environmental controls
Sterile technique when warranted
Identification and management of clients at risk

Chain of Infection
1. The chain of infection refers to those elements that must be present to
cause an infection from a microorganism
2. Basic to the principle of infection is to interrupt this chain so that an
infection from a microorganism does not occur in client
3. Infectious agent; microorganisms capable of causing infections are
referred to as an infectious agent or pathogen
4. Modes of transmission: the microorganism must have a means of
transmission to get from one location to another, called direct and indirect
5. Susceptible host describes a host (human or animal) not possessing
enough resistance against a particular pathogen to prevent disease or
infection from occurring when exposed to the pathogen; in humans this
may occur if the persons resistance is low because of poor nutrition, lack
of exercise of a coexisting illness that weakens the host.
6. Portal of entry: the means of a pathogen entering a host: the means of
entry can be the same as one that is the portal of exit (gastrointestinal,
respiratory, genitourinary tract).
7. Reservoir: the environment in which the microorganism lives to ensure
survival; it can be a person, animal, arthropod, plant, oil or a combination
of these things; reservoirs that support organism that are pathogenic to
humans are inanimate objects food and water, and other humans.
8. Portal of exit: the means in which the pathogen escapes from the reservoir
and can cause disease; there is usually a common escape route for each
type of microorganism; on humans, common escape routes are the
gastrointestinal, respiratory and the genitourinary tract.
Breaking the Chain of Infection

Etiologic agent
Correctly cleaning, disinfecting or sterilizing articles before use
Educating clients and support persons about appropriate methods to
clean, disinfect, and sterilize article
Reservoir (source)
Changing dressings and bandages when soiled or wet
Appropriate skin and oral hygiene
Disposing of damp, soiled linens appropriately
Disposing of feces and urine in appropriate receptacles
Ensuring that all fluid containers are covered or capped
Emptying suction and drainage bottles at end of each shift or before full or
according to agency policy
Portal of exit
Avoiding talking, coughing, or sneezing over open wounds or sterile fields
Covering the mouth and nose when coughing or sneezing
Method of transmission
Proper hand hygiene
Instructing clients and support persons to perform hand hygiene before
handling food, eating, after eliminating and after touching infectious
Wearing gloves when handling secretions and excretions
Wearing gowns if there is danger of soiling clothing with body substances
Placing discarded soiled materials in moisture-proof refuse bags
Holding used bedpans steadily to prevent spillage
Disposing of urine and feces in appropriate receptacles
Initiating and implementing aseptic precautions for all clients
Wearing masks and eye protection when in close contact with clients who
have infections transmitted by droplets from the respiratory tract
Wearing masks and eye protection when sprays of body fluid are possible
Portal of entry
Using sterile technique for invasive procedures, when exposing open
wounds or handling dressings
Placing used disposable needles and syringes in puncture-resistant
containers for disposal
Providing all clients with own personal care items
Susceptible host
Maintaining the integrity of the clients skin and mucous membranes
Ensuring that the client receives a balanced diet
Educating the public about the importance of immunizations
Modes of Transmission
1. Direct contact: describes the way in which microorganisms are transferred
from person to person through biting, touching, kissing, or sexual
intercourse; droplet spread is also a form of direct contact but can occur
only if the source and the host are within 3 feet from each other;
transmission by droplet can occur when a person coughs, sneezes, spits, or
2. Indirect contact: can occur through fomites (inanimate objects or
materials) or through vectors (animal or insect, flying or crawling); the
fomites or vectors act as vehicle for transmission
3. Air: airborne transmission involves droplets or dust; droplet nuclei can
remain in the air for long periods and dust particles containing infectious
agents can become airborne infecting a susceptible host generally through
the respiratory tract
Course of Infection
1. Incubation: the time between initial contact with an infectious agent until
the first signs of symptoms the incubation period varies from different
pathogens; microorganisms are growing and multiplying during this stage
2. Prodromal Stage: the time period from the onset of nonspecific symptoms
to the appearance of specific symptoms related to the causative pathogen
symptoms range from being fatigued to having a low-grade fever with
malaise; during this phase it is still possible to transmit the pathogen to
another host
3. Full Stage: manifestations of specific signs & symptoms of infectious agent;
referred to as the acute stage; during this stage, it may be possible to
transmit the infectious agent to another, depending on the virulence of the
infectious agent
4. Convalescence: time period that the host takes to return to the pre-illness
stage; also called the recovery period; the host defense mechanisms have
responded to the infectious agent and the signs and symptoms of the
disease disappear; the host, however, is more vulnerable to other
pathogens at this time; an appropriate nursing diagnostic label related to
this process would be Risk for Infection

The protective response of the tissues of the body to injury or infection;
the physiological reaction to injury or infection is the inflammatory
response; it may be acute or chronic

Bodys response
1. The inflammatory response begins with vasoconstriction that is followed
by a brief increase in vascular permeability; the blood vessels dilate
allowing plasma to escape into the injured tissue
2. WBCs (neutrophils, monocytes, and macrophages) migrate to the area of
injury and attack and ingest the invaders (phagocytosis); this process is
responsible for the signs of inflammation
3. Redness occurs when blood accumulates in the dilated capillaries; warmth
occurs as a result of the heat from the increased blood in the area, swelling
occurs from fluid accumulation; the pain occurs from pressure or injury to
the local nerves.

Immune Response
1. The immune response involves specific reactions in the body to antigens or
foreign material
2. This specific response is the bodys attempt to protect itself, the body
protects itself by activating 2 types of lymphocytes, the T-lymphocytes and
3. Cell mediated immunity: T-lymphocytes are responsible for cellular
o When fungi , protozoa, bacteria and some viruses activate T-
lymphocytes, they enter the circulation from lymph tissue and
seek out the antigen
o Once the antigen is found they produce proteins (lymphokines)
that increase the migration of phagocytes to the area and keep
them there to kill the antigen
o After the antigen is gone, the lymphokines disappear
o Some T-lymphocytes remain and keep a memory of the antigen
and are reactivated if the antigen appears again.
4. Humoral response: the ability of the body to develop a specific antibody to
a specific antigen (antigen-antibody response)
o B-lymphocytes provide humoral immunity by producing
antibodies that convey specific resistance to many bacterial and
viral infections
o Active immunity is produced when the immune system is
activated either naturally or artificially.
Natural immunity involves acquisition of immunity
through developing the disease
Active immunity can also be produced through
vaccination by introducing into the body a weakened or
killed antigen (artificially acquired immunity)
Passive immunity does not require a host to develop
antibodies, rather it is transferred to the individual,
passive immunity occurs when a mother passes
antibodies to a newborn or when a person is given
antibodies from an animal or person who has had the
disease in the form of immune globulins; this type of
immunity only offers temporary protection from the
Types of Immunity

Active Immunity
Host produces antibodies in response to natural antigens or artificial
Natural active immunity
o Antibodies are formed in presence of active infection in the body
o Duration lifelong
Artificial active immunity
o Antigens administered to stimulate antibody formation
o Lasts for many years
o Reinforced by booster
Passive Immunity
Host receives natural or artificial antibodies produced from another
Natural passive immunity
o Antibodies transferred naturally from an immune mother to baby
through the placenta or in colostrums
o Lasts 6 months to 1 year
Artificial passive immunity
o Occurs when immune serum (antibody) from an animal or
another human is injected
o Lasts 2 to 3 weeks

Nosocomial Infection
1. Nosocomial Infections: are those that are acquired as a result of a
healthcare delivery system
2. Iatrogenic infection: these nosocomial infections are directly related to the
clients treatment or diagnostic procedures; an example of an iatrogenic
infection would be a bacterial infection that results from an intravascular
line or Pseudomonas aeruginosa pneumonia as a result of respiratory
3. Exogenous Infection: are a result of the healthcare facility environment or
personnel; an example would be an upper respiratory infection resulting
from contact with a caregiver who has an upper respiratory infection
4. Endogenous Infection: can occur from clients themselves or as a
reactivation of a previous dormant organism such as tuberculosis; an
example of endogenous infection would be a yeast infection arising in a
woman receiving antibiotic therapy; the yeast organisms are always
present in the vagina, but with the elimination of the normal bacterial
flora, the yeast flourish.
Risks for Nosocomial Infections
Diagnostic or therapeutic procedures
o Iatrogenic infections
Compromised host
Insufficient hand hygiene
Factors Increasing Susceptibility to Infection
1. Age: young infants & older adults are at greater risk of infection because of
reduced defense mechanisms
o Young infants have reduced defenses related to immature
immune systems
o In elderly people, physiological changes occur in the body that
make them more susceptible to infectious disease; some of these
changes are:
Altered immune function (specifically, decreased
phagocytosis by the neutrophils and by the
Decreased bladder muscle tone resulting in urinary
Diminished cough reflex, loss of elastic recoil by the lungs
leading to inability to evacuate normal secretions
Gastrointestinal changes resulting in decreased
swallowing ability and delayed gastric emptying.
2. Heredity: some people have a genetic predisposition or susceptibility to
some infectious diseases
3. Cultural practices: healthcare beliefs and practices, as well as nutritional
and hygiene practices, can influence a persons susceptibility to infectious
4. Nutrition: inadequate nutrition can make a person more susceptible to
infectious diseases; nutritional practices that do not supply the body with
the basic components necessary to synthesized proteins affect the way the
bodys immune system can respond to pathogens
5. Stress: stressors, both physical and emotional, affect the bodys ability to
protect against invading pathogens; stressors affect the body by elevating
blood cortisone levels; if elevation of serum cortisone is prolonged, it
decreases the anti-inflammatory response and depletes energy stores,
thus increasing the risk of infection
6. Rest, exercise and personal health habits: altered rest and exercise
patterns decrease the bodys protective, mechanisms and may cause
physical stress to the body resulting in an increased risk of infection;
personal health habits such as poor nutrition and unhealthy lifestyle habits
increase the risk of infectious over time by altering the bodys response to
7. Inadequate defenses: any physiological abnormality or lifestyle habit can
influence normal defense mechanisms in the body, making the client more
susceptible to infection; the immune system functions throughout the
body and depends on the following:
o Intact skin and mucous membranes
o Adequate blood cell production and differentiation
o A functional lymphatic system and spleen
o An ability to differentiate foreign tissue and pathogens from
normal body tissue and flora; in autoimmune disease, the body
has a problem with recognizing its own tissue and cells; people
with autoimmune disease are at increased risk of infection related
to their immune system deficiencies.
8. Environmental: an environment that exposes individuals to an increased
number of toxins or pathogens also increases the risk of infection;
pathogens grow well in warm moist areas with oxygen (aerobic) or without
oxygen (anaerobic) depending on the microorganism, an environment that
increases exposure to toxic substances also increases risk
9. Immunization history: inadequately immunized people have an increased
risk of infection specifically for those diseases for which vaccines have
been developed.
10. Medications and medical therapies: examples of therapies and
medications that increase clients risk for infection includes radiation
treatment, anti-neo-plastic drugs, anti inflammatory drugs and surgery
Diagnostic Tests Used to Screen for Infection
1. Signs and symptoms related to infections are associated with the area
infected; for instance, symptoms of a local infection on the skin or mucous
membranes are localized swelling, redness, pain and warmth
2. Symptoms related to systemic infections include fever, increased pulse &
respirations, lethargy, anorexia, and enlarged lymph nodes
3. Certain diagnostic tests are ordered to confirm the presence of an
Category-specific Isolation Precautions
Strict isolation
Contact isolation
Respiratory isolation
Tuberculosis isolation
Enteric precautions
Drainage/secretions precautions
Blood/body fluid precautions
Disease-specific Isolation Precautions
Delineate practices for control of specific diseases
o Use of private rooms with special ventilation
o Cohorting clients infected with the same organism
o Gowning to prevent gross soilage of clothes
Universal Precautions (UP)
Used with all clients
Decrease the risk of transmitting unidentified pathogens
Obstruct the spread of bloodborne pathogens (hepatitis B and C viruses
and HIV)
Used in conjunction with disease-specific or category-specific precautions

Body Substance Isolation (BSI)
Employs generic infection control precautions for all clients
Body substances include:
o Blood
o Urine
o Feces
o Wound drainage
o Oral secretions
o Any other body product or tissue

Standard Precautions
Used in the care of all hospitalized persons regardless of their diagnosis or
possible infection status
Apply to:
o Blood
o All body fluids, secretions, and excretions except sweat (whether
or not blood is present or visible)
o Nonintact skin and mucous membranes
Combine the major features of UP and BSI

Transmission-based Precautions
Used in addition to standard precautions
For known or suspected infections that are spread in one of three ways:
o Airborne
o Droplet
o Contact
May be used alone or in combination but always in addition to standard
Managing Equipment Used for Isolation Clients
Many supplied for single use only
Disposed of after use
Agencies have specific policies and procedures for handling soiled reusable
Nurses need to become familiar with these practices

Bloodborne Pathogen Exposure
Report the incident immediately
Complete injury report
Seek appropriate evaluation and follow-up
Identification and documentation of the source individual when feasible
and legal
Testing of the source for hepatitis B, C and HIV when feasible and consent
is given
Making results of the test available to the source individuals health care
Testing of blood exposed nurse (with consent) for hepatitis B, C, and HIV
please check these to match style used in book fairly certain it should be
caped antibodies
Postexposure prophylaxis if medically indicated
Medical and psychologic counseling
Encourage bleeding
Wash/clean the area with soap and water
Initiate first aid and seek treatment if indicated
Mucous membrane exposure (eyes, nose, mouth)
Flush with saline or water flush for 5 to 10 minutes
Postexposure Protocol (PEP) for HIV
Start treatment as soon as possible preferably within hours after exposure
For high-risk exposure (high blood volume and source with a high HIV
titer), three drug treatment is recommended
For increased risk exposure (high blood volume or source with high HIV
titer), three-drug treatment is recommended
For low risk exposure (neither high blood volume nor source with a high
HIV titer), two-drug treatment is considered
Drug prophylaxis continues for 4 weeks
Drug regimens vary and new drugs and regimens continuously being
HIV antibody tests should be done shortly after exposure (baseline), and 6
weeks, 3 months, and 6 months afterward

Postexposure Protocol (PEP) for Hepatitis B
Anti-HBs testing 1 to 2 months after last vaccine dose
HBIG and/or hepatitis B vaccine within 1 to 7 days following exposure for
nonimmune workers

Postexposure Protocol (PEP) for Hepatitis C
Anti-HCV and ALT at baseline and 4 to 6 months after exposur
Assessment : first step in nursing process
It is systematic and continuous collection, validation and communication of
client data as compared to what is standard/norm.
It includes the clients perceived needs, health problems, related
experiences, health practices, values and lifestyles.


To establish a data base (all the information about the client):
nursing health history
physical assessment
the physicians history & physical examination
results of laboratory & diagnostic tests material from other health

FOUR Types of Assessment
1. Initial assessment assessment performed within a specified time on
o Ex: nursing admission assessment
2. Problem-focused assessment use to determine status of a specific
problem identified in an earlier assessment
o Ex: problem on urination-assess on fluid intake & urine output
3. Emergency assessment rapid assessment done during any
physiologic/physiologic crisis of the client to identify life threatening
o Ex: assessment of a clients airway, breathing status & circulation
after a cardiac arrest.
4. Time-lapsed assessment reassessment of clients functional health
pattern done several months after initial assessment to compare the
clients current status to baseline data previously obtained.

1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data

Observation of the patient + Interview of patient, family & SO +
examination of the patient + Review of medical record

Collection of data
gathering of information about the client
includes physical, psychological, emotion, socio-cultural, spiritual factors
that may affect clients health status
includes past health history of client (allergies, past surgeries, chronic
diseases, use of folk healing methods)
includes current/present problems of client (pain, nausea, sleep pattern,
religious practices, meds or treatment the client is taking now)
Types of Data
1. Subjective data
o also referred to as Symptom/Covert data
o Information from the clients point of view or are described by the
person experiencing it.
o Information supplied by family members, significant others; other
health professionals are considered subjective data.
o Example: pain, dizziness, ringing of ears/Tinnitus
2. Objective data
o also referred to as Sign/Overt data
o Those that can be detected observed or measured/tested using
accepted standard or norm.
o Example: pallor, diaphoresis, BP=150/100, yellow discoloration of
Methods of Data Collection
1. Interview
o A planned, purposeful conversation/communication with the
client to get information, identify problems, evaluate change, to
teach, or to provide support or counseling.
o it is used while taking the nursing history of a client
2. Observation
o Use to gather data by using the 5 senses and instruments.
3. Examination
o Systematic data collection to detect health problems using unit of
measurements, physical examination techniques (IPPA),
interpretation of laboratory results.
o should be conducted systematically:
1. Cephalocaudal approach head-to-toe assessment
2. Body System approach examine all the body system
3. Review of System approach examine only particular
area affected
Source of data
1. Primary source data directly gathered from the client using interview and
physical examination.
2. Secondary source data gathered from clients family members,
significant others, clients medical records/chart, other members of health
team, and related care literature/journals.
o In the Assessment Phase, obtain a Nursing Health History - a
structured interview designed to collect specific data and to
obtain a detailed health record of a client.
Components of a Nursing Health History:
o Biographic data name, address, age, sex, martial status,
occupation, religion.
o Reason for visit/Chief complaint primary reason why client seek
consultation or hospitalization.
o History of present Illness includes: usual health status,
chronological story, family history, disability assessment.
o Past Health History includes all previous immunizations,
experiences with illness.
o Family History reveals risk factors for certain disease diseases
(Diabetes, hypertension, cancer, mental illness).
o Review of systems review of all health problems by body
o Lifestyle include personal habits, diets, sleep or rest patterns,
activities of daily living, recreation or hobbies.
o Social data include family relationships, ethnic and educational
background, economic status, home and neighborhood
o Psychological data information about the clients emotional
o Pattern of health care includes all health care resources:
hospitals, clinics, health centers, family doctors.

Validation of Data
The act of double-checking or verifying data to confirm that it is accurate
and complete.
Purposes of data validation
1. ensure that data collection is complete
2. ensure that objective and subjective data agree
3. obtain additional data that may have been overlooked
4. avoid jumping to conclusion
5. differentiate cues and inferences
Subjective or objective data observed by the nurse; it is what the client
says, or what the nurse can see, hear, feel, smell or measure.
The nurse interpretation or conclusion based on the cues.
o Red swollen wound = infected wound
o Dry skin = dehydrated

Organization of Data

Uses a written or computerized format that organizes assessment data
1. Maslows basic needs
2. Body System Model
3. Gordons Functional Health Patterns:
Gordons Functional Health Patterns
1. Health perception-health management pattern.
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern

Analyze data
Compare data against standard and identify significant cues.
Standard/norm are generally accepted measurements, model, pattern:
o Ex: Normal vital signs, standard Weight and Height, normal
laboratory/diagnostic values, normal growth and development
Communicate/Record/Document Data
nurse records all data collected about the clients health status
data are recorded in a factual manner not as interpreted by the nurse
Record subjective data in clients word; restating in other words what
client says might change its original meaning.

Assessment- Objective & Subjective Data
Review of clinical record
1. Client records contain information collected by many members of the
healthcare team, such as demographics, past medical history, diagnostic
test results and consultations
2. Reviewing the clients record before beginning an assessment prevents the
nurse from repeating questions that the client has already been asked and
identifies information that needs clarification.

1. The purpose of an interview is to gather and provide information, identify
problems of concerns, and provide teaching and support.
2. The goals of an interview are to develop a rapport with the client and to
collect data
3. An interview has 3 major stages:
1. Opening: purpose is to establish rapport by creating
goodwill and trust; this is often achieved through a self
introduction, nonverbal gestures (a handshake), and
small talk about the weather, local sports team, or recent
current event; the purpose of the interview is also
explained to the client at this time.
2. Body: during this phase, the client responds to open and
closed-ended questions asked by the nurse.
3. Closing: either the client or the nurse may terminate the
interview, it is important fro the nurse to try to maintain
the rapport and trust that was developed thus far during
the interview process.
4. Types of questions
1. Closed questions used in directive interview
Re____ short factual answers; e.g. Do you have pain?
Answers usually reveal limited amounts of information
Useful with clients who are highly stressed and/or have
difficulty communicating
2. Open-ended questions used in nondirective interview
Encourage clients to express and clarify their thoughts
and feelings; e.g. How have you been sleeping lately?
Specify the broad area to be discussed and invite longer
Useful at the start of an interview or to change the
3. Leading questions
Direct the clients answer; e.g. You dont have any
questions about your medications, do you?
Suggests what answer is expected
Can result in client giving inaccurate data to please the
Can limit client choice of topic for discussion
Nursing History
1. Collection of information about the effect of the clients illness on daily
functioning and ability to cope with the stressor (the human response)
2. Subjective data
o May be called covert data
o Not measurable or observable
o Obtained from client (primary source), significant others, or
health professionals (secondary sources).
o For example, the client states, I have a headache
o Objective data
o May be called overt data
o Can be detected by someone other than the client
o Includes measurable and observable client behavior
o For example, a blood pressure reading of 190/110 mmHg.

Physical assessment
1. Systematic collection of information about the body systems through the
use of observation, inspection, auscultation, palpation and percussion
2. A body system format for physical assessment is found below:
o General assessement
o Integumentary system
o Head, ears, eyes, nose, throat
o Breast and axillae
o Thorax and lungs
o Cardiovascular system
o Nervous system
o Abdomen and gastrointestinal system
o Anus and rectum
o Genitourinary system
o Reproductive system
o Musculoskeletal system

Psychosocial assessment
1. Helpful framework for organizing data
2. A suggested format for psychosocial assessment is found below:
o Vocation/education/financial
o Home and Family
o Social, leisure, spiritual and cultural
o Sexual
o Activities of daily living
o Health Habits
o Psychological
3. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget
may also be helpful for guiding data collection

1. The nurse collects data from multiple sources: primary (client) and
secondary (family members, support persons, healthcare professionals and
2. Consultation with individuals who can contribute to the clients database is
helpful in achieving the most complete and accurate information about a
3. Supplemental information from secondary sources (any source other then
the client) can help verify information, provide information for a client who
cannot do so, and convey information about the clients status prior to

Review of literature
1. A professional nurse engages in continued education to maintain
knowledge of current information related to health care
2. Reviewing professional journals and textbooks can help provide additional
data to support or help analyze the client database

Diagnosis - Second Step in the Nursing Process
Is the 2nd step of the nursing process.
the process of reasoning or the clinical act of identifying problems

To identify health care needs and prepare a Nursing Diagnosis.
To diagnose in nursing
It means to analyze assessment information and derive meaning from this

Nursing Diagnosis
Is a statement of a clients potential or actual health problem resulting
from analysis of data.
Is a statement of clients potential or actual alterations/changes in his
health status.
A statement that describes a clients actual or potential health problems
that a nurse can identify and for which she can order nursing interventions
to maintain the health status, to reduce, eliminate or prevent
Is the problem statement that the nurse makes regarding a clients
condition which she uses to communicate professionally.
It uses the critical-thinking skills analysis and synthesis in order to identify
client strengths & health problems that can be resolves/prevented by
collaborative and independent nursing interventions.
o Analysis separation into components or the breaking down of
the whole into its parts.
o Synthesis the putting together of parts into whole

Three Activities in Diagnosing:
1. Data Analysis
2. Problem Identification
3. Formulation of Nursing Diagnosis

Characteristics of Nursing Diagnosis
1. It states a clear and concise health problem.
2. It is derived from existing evidences about the client.
3. It is potentially amenable to nursing therapy.
4. It is the basis for planning and carrying out nursing care.

Components of A nursing diagnosis (PES or PE)
1. Problem statement/diagnostic label/definition = P
2. Etiology/related factors/causes = E
3. Defining characteristics/signs and symptoms = S
*Therefore may be written as 2-Part or a 3-Part statement.

Types of Nursing Diagnosis

1. Actual Nursing Diagnosis a client problem that is present at the time of the
nursing assessment. It is based on the presence of signs and symptoms.

Imbalanced Nutrition: Less than body requirements r/t decreased appetite
Disturbed Sleep Pattern r/t cough, fever and pain.
Constipation r/t long term use of laxative.
Ineffective airway clearance r/t to viscous secretions
Noncompliance (Medication) r/t unknown etiology
Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis
Acute Pain (Chest) r/t cough 2nrdary to pneumonia
Activity Intolerance r/t general weakness.
Anxiety r/t difficulty of breathing & concerns over work
2. Potential Nursing diagnosis one in which evidence about a health problem is
incomplete or unclear therefore requires more data to support or reject it; or the
causative factors are unknown but a problem is only considered possible to occur.

Possible nutritional deficit
Possible low self-esteem r/t loss job
Possible altered thought processes r/t unfamiliar surroundings
3. Risk Nursing diagnosis is a clinical judgment that a problem does not exist,
therefore no S/S are present, but the presence of RISK FACTORS is indicates that a
problem is only is likely to develop unless nurse intervene or do something about it.
No subjective or objective cues are present therefore the factors that cause the
client to be more vulnerable to the problem are the etiology of a risk nursing

Risk for Impaired skin integrity (left ankle) r/t decrease peripheral
circulation in diabetes.
Risk for interrupted family processes r/t mothers illness & unavailability to
provide child care.
Risk for Constipation r/t inactivity and insufficient fluid intake
Risk for infection r/t compromised immune system.
Risk for injury r/t decreased vision after cataract surgery.

Formula in writing nursing diagnosis (PES or PE)
1. Actual nursing diagnosis = Patient problem + Etiology replace the (+)
symbol with the words RELATED TO abbreviated as r/t. = Problem +
Etiology + S/S
2. Risk Nursing diagnosis = Problem + Risk Factors
3. Possible nursing diagnosis = Problem + Etiology
Qualifiers words added to the diagnostic label/problem statement to gain
additional meaning.
deficient - inadequate in amount, quality, degree, insufficient,
impaired made worse, weakened, damaged, reduced, deteriorated
decreased lesser in size, amount, degree
ineffective not producing the desired effect
Activities during diagnosis:
1. Compare data against standards
2. Cluster or group data
3. Data analysis after comparing with standards
4. Identify gaps and inconsistencies in data
5. Determine the clients health problems, health risks, strengths
6. Formulate Nursing Diagnosis prioritize nursing diagnosis based on what
problem endangers the clients life

Situation: Functional Health Pattern Activity/Exercise
Anna, 35 years of laundry woman seeks consultation at the Philippine
General Hospital due to fever 2 days prior to admission PTA. She
verbalizes: Bigla na lang ako giniginaw, masakit ang ulo at mainit ang
pakiramdam pagkatapos kong maglaba sa kabilang kanto. (I suddenly felt
cold, headache and warm after I done laundry). She has 3 children she
walks off to school everyday before she goes to work
Vital Signs
Temperature (T) =39.2C Respiratory Rate (RR) = 35 P = 96; with flush skin
and warm to touch, teary eyed and with dry lips and mucous membrane.
Nursing Diagnosis
Hyperthermia [related to (r/t)] environmental condition AMB T = 39C,
flush skin, warm to touch, teary eyed and dry lip and mucous membrane.

Situation: Functional Health Pattern = Nutritional/Metabolic
1. States, No appetite since having cough
2. Has not eaten today; last fluids at noon today
3. Has lost 8 lbs in past 2 weeks
4. Nauseated x 2 days
Nursing Diagnosis
Imbalanced Nutrition: Less than body Requirements r/t decreased appetite
and nausea 2ndary to disease process/cough

Situation: Functional Health Pattern = Activity/Exercise
1. Difficulty sleeping because of cough
2. States, Cant breath lying down
3. Report pain on chest when coughing
Nursing Diagnosis
Disturbed Sleep Pattern r/t a disease process, orthopnea and pain. Acute
Pain (chest) r/t pathologic condition 2ndary to pneumonia

Situation: Functional Health Pattern = Coping/Stress
1. Anxious
2. State, I cant breath
3. Facial muscles tense, trembling
4. Expresses concern and worry over leaving daughter with neighbors
5. Husband out of town, will be back next week.
Nursing Diagnosis
Anxiety r/t difficulty of breathing and concerns over parenting roles.
Assist Patient from the Bed to Chair or Wheelchair
I. Purpose
1. To strengthen the patient gradually.
2. To provide a change in position. (In wheelchair to take her around for a

II. Equipment
Chair or wheelchair
Patients robe and slippers
Blanket, sheet or draw sheet

III. Procedure
1. See that the chair or wheelchair is in good condition.
2. Place the chair conveniently at night angles to the bedback of chair
parallel to the foot of the bed and facing the head of bed.
3. Place pillow on the seat of the chair. If using wheelchair, line it with a
blanket or sheet and arrange pillows on the seat and against the back. Put
the foot rest up and lock the wheels.
4. Take the patients pulse
5. Assist the patient to a sitting position on bed, i.e., put one arm under the
head and shoulders and the other arm under her knees and pivot her to a
sitting position with the legs hanging over the side of the bed.
6. Watch the patient for a minute to defect any change in his color, pulse and
respiratory rate.
7. Put on patients robe and slippers. Place the foot stool under the patients
8. Stand directly in front of the patient and with a hand under each axilla,
assist him to stand, step down and turn around, with his back to the chair.
Let patient flex his knees and lower body to seat him to the chair. Anchor
chair with foot or have someone hold it on. (Or let patient place his arm
over your shoulders while you put your arm around his waist. Turn patient
around with his back to the chair and seat him gently). Help him get
comfortable in the chair.
9. Adjust the pillows and wrap blanket over patients lap. If in a wheelchair
adjust the foot rests.
10. Observe frequently for changes in color and pulse rate, dizziness or sign of
11. To put him back to bed, assist to stand, help to turn and stand on stool and
back to bed. Support patient while he sits on the side of bed. Remove robe
and slippers. Pivot to a sitting position in bed, supporting her head and
shoulders with one arm and her knees with the other arm, and lower
slowly to bed in lying position.
12. Draw up bedding. Take pulse after.
Back Care
After bathing and drying the back, it should be massaged or rubbed thoroughly.

I. Purpose
1. To stimulate the circulation and give general relief.
2. To prevent bedsore
3. To give comfort to the patient.

II. Equipment
Alcohol 25%
Talcum powder
Bath towel
III. Procedure
1. Help the patient to turn on his abdomen or on his side with his back
toward the nurse and his body near the edge of the bed so that he is as
near the operator as possible. If the supine position is used and the patient
is a woman, pillow under the abdomen removes pressure from the breasts
and favor relaxation.
2. Raise the camisa and gown.
3. Apply to back rubbing lotion or talcum powder to reduce friction. In
rubbing the back use firm long strokes and kneading motions. The amount
of pressure to exert depends upon the patients condition. Begun from
neck and shoulders then proceed over the entire back.
4. Massage with both hands working with a strong stroke. In upward than in
downward motions. Give particular attention to pressure areas in rubbing
(Alcohol 25%) to 50% is generally used for its refreshing effect, but rubbing
lotion may be used.)
5. Powder again the area at the completion of the rubbing process which
should consume from 3-5 minutes.
6. Turn patient on his back and put on camisa or gown.
7. Fix and make patient comfortable.

Movements Used
1. Effleurage (strokingis a long sweeping movement with palm of hand
conforming to the contour of the surface treated, over small surface (on
the neck) the thumb and fingers are used. Strokes should be slow,
rhythmical and gentle with pressure constant and in the direction of
venous stream.
2. Kneadingperformed with the ulnar side palm resting on the surface and
the fingers, and thumble grasping the skin and subcutaneous tissues which
move with the hand of the operator.
3. Frictionis performed with the whole palmar surface of the hand or
fingers and thumbs over limited areas. This movement is a circular from of
kneading with pressure against the underlying part of tissue which cannot
be grasped.
Blood Transfusion Therapy
Blood transfusion therapy involves transfusing whole blood or blood components
(specific portion or fraction of blood lacking in patient). One unit of whole blood
consists of 450 mL of blood collected into 60 to 70 mL of preservative or
anticoagulant. Whole blood stored for more than 6 hours does not provide
therapeutic platelet transfusion, nor does it contain therapeutic amounts of labile
coagulation factors (factors V and VIII).

Blood components include:
1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma
originally present in one unit of whole blood), indicated to increase the
oxygen-carrying capacity of blood with minimal expansion of blood.
2. Leukocyte-poor packed RBCs, indicated for patients who have experience
previous febrile no hemolytic reactions.
3. Platelets, either HLA (human leukocyte antigen) matched or unmatched.
4. Granulocytes ( basophils, eosinophils, and neutrophils )
5. Fresh frozen plasma, containing all coagulation factors, including factors V
and VIII (the labile factors).
6. Single donor plasma, containing all stable coagulation factors but reduced
levels of factors V and VIII; the preferred product for reversal of Coumadin-
induced anticoagulation.
7. Albumin, a plasma protein.
8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor
XIII, and fibronectin.
9. Factor IX concentrate, a concentrated form of factor IX prepared by
pooling, fractionating, and freeze-drying large volumes of plasma.
10. Factor VIII concentrate, a concentrated form of factor IX prepared by
pooling, fractionating, and freeze-drying large volumes of plasma.
11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and
some factor XI.
Advantages of blood component therapy
1. Avoids the risk of sensitizing the patients to other blood components.
2. Provides optimal therapeutic benefit while reducing risk of volume
3. Increases availability of needed blood products to larger population.

Principles of blood transfusion therapy
1. Whole blood transfusion
o Generally indicated only for patients who need both increased
oxygen-carrying capacity and restoration of blood volume when
there is no time to prepare or obtain the specific blood
components needed.
2. Packed RBCs
o Should be transfused over 2 to 3 hours; if patient cannot tolerate
volume over a maximum of 4 hours, it may be necessary for the
blood bank to divide a unit into smaller volumes, providing proper
refrigeration of remaining blood until needed. One unit of packed
red cells should raise hemoglobin approximately 1%, hemactocrit
3. Platelets
o Administer as rapidly as tolerated (usually 4 units every 30 to 60
minutes). Each unit of platelets should raise the recipients
platelet count by 6000 to 10,000/mm3: however, poor
incremental increases occur with alloimmunization from previous
transfusions, bleeding, fever, infection, autoimmune destruction,
and hypertension.
4. Granulocytes
o May be beneficial in selected population of infected, severely
granulocytopenic patients (less than 500/mm3) not responding to
antibiotic therapy and who are expected to experienced
prolonged suppressed granulocyte production.
5. Plasma
o Because plasma carries a risk of hepatitis equal to that of whole
blood, if only volume expansion is required, other colloids (e.g.,
albumin) or electrolyte solutions (e.g., Ringers lactate) are
preferred. Fresh frozen plasma should be administered as rapidly
as tolerated because coagulation factors become unstable after
6. Albumin
o Indicated to expand to blood volume of patients in hypovolemic
shock and to elevate level of circulating albumin in patients with
hypoalbuminemia. The large protein molecule is a major
contributor to plasma oncotic pressure.
7. Cryoprecipitate
o Indicated for treatment of hemophilia A, Von Willebrands
disease, disseminated intravascular coagulation (DIC), and uremic
8. Factor IX concentrate
o Indicated for treatment of hemophilia B; carries a high risk of
hepatitis because it requires pooling from many donors.
9. Factor VIII concentrate
o Indicated for treatment of hemophilia A; heat-treated product
decreases the risk of hepatitis and HIV transmission.
10. Prothrombin complex-Indicated in congenital or acquired deficiencies of
these factors.
1. To increase circulating blood volume after surgery, trauma, or hemorrhage
2. To increase the number of RBCs and to maintain hemoglobin levels in
clients with severe anemia
3. To provide selected cellular components as replacements therapy (e.g.
clotting factors, platelets, albumin)

Nursing Interventions
1. Verify doctors order. Inform the client and explain the purpose of the
2. Check for cross matching and typing. To ensure compatibility
3. Obtain and record baseline vital signs
4. Practice strict Asepsis
5. At least 2 licensed nurse check the label of the blood transfusion
o Check the following:
Serial number
Blood component
Blood type
Rh factor
Expiration date
Screening test (VDRL, HBsAg, malarial smear) - *this is to
ensure that the blood is free from blood-carried diseases
and therefore, safe from transfusion.
6. Warm blood at room temperature before transfusion to prevent chills.
7. Identify client properly. Two Nurses check the clients identification.
8. Use needle gauge 18 to 19. This allows easy flow of blood.
9. Use BT set with special micron mesh filter. To prevent administration of
blood clots and particles.
10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30
minutes. Adverse reaction usually occurs during the first 15 to 20 minutes.
11. Monitor vital signs. Altered vital signs indicate adverse reaction.
12. Do not mix medications with blood transfusion. To prevent adverse effects
o Do not incorporate medication into the blood transfusion
o Do not use blood transfusion lines for IV push of medication.
13. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids
with dextrose. Dextrose causes hemolysis.
14. Administer BT for 4 hours (whole blood, packed RBC). For plasma,
platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can
easily be destroyed.
15. Observe for potential complications. Notify physician.

Complications of Blood Transfusion
1. Allergic Reaction it is caused by sensitivity to plasma protein of donor
antibody, which reacts with recipient antigen.
o Assessments:
Rush, hives
Laryngeal edema, difficulty of breathing
2. Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white
cells, platelets or plasma proteins. This is the most symptomatic
complication of blood transfusion
o Assessments:
Sudden chills and fever
3. Septic Reaction it is caused by the transfusion of blood or components
contaminated with bacteria.
o Assessment:
Rapid onset of chills
Marked Hypotension
High fever
4. Circulatory Overload it is caused by administration of blood volume at a
rate greater than the circulatory system can accommodate.
o Assessment:
Rise in venous pressure
Crackles or rales
Distended neck vein
Elevated BP
5. Hemolytic reaction. It is caused by infusion of incompatible blood
o Assessment:
Low back pain (first sign). This is due to inflammatory
response of the kidneys to incompatible blood.
Feeling of fullness
Vascular collapse
Acute renal failure
Assessment findings
1. Clinical manifestations of transfusions complications vary depending on
the precipitating factor.
2. Signs and symptoms of hemolytic transfusion reaction include:
o Fever
o Chills
o low back pain
o flank pain
o headache
o nausea
o flushing
o tachycardia
o tachypnea
o hypotension
o hemoglobinuria (cola-colored urine)
3. Clinical signs and laboratory findings in delayed hemolytic reaction include:
o fever
o mild jaundice
o gradual fall of hemoglobin
o positive Coombs test
4. Febrile non-hemolytic reaction is marked by:
o Temperature rise during or shortly after transfusion
o Chills
o headache
o flushing
o anxiety
5. Signs and symptoms of septic reaction include;
o Rapid onset of high fever and chills
o vomiting
o diarrhea
o marked hypotension
6. Allergic reactions may produce:
o hives
o generalized pruritus
o wheezing or anaphylaxis (rarely)
7. Signs and symptoms of circulatory overload include:
o Dyspnea
o cough
o rales
o jugular vein distention
8. Manifestations of infectious disease transmitted through transfusion may
develop rapidly or insidiously, depending on the disease.
9. Characteristics of GVH disease include:
o skin changes (e.g. erythema, ulcerations, scaling)
o edema
o hair loss
o hemolytic anemia
10. Reactions associated with massive transfusion produce varying
Possible Nursing Diagnosis
1. Ineffective breathing pattern
2. Decreased Cardiac Output
3. Fluid Volume Deficit
4. Fluid Volume Excess
5. Impaired Gas Exchange
6. Hyperthermia
7. Hypothermia
8. High Risk for Infection
9. High Risk for Injury
10. Pain
11. Impaired Skin Integrity
12. Altered Tissue Perfusion

Planning and Implementation
1. Help prevent transfusion reaction by:
o Meticulously verifying patient identification beginning with type
and cross match sample collection and labeling to double check
blood product and patient identification prior to transfusion.
o Inspecting the blood product for any gas bubbles, clothing, or
abnormal color before administration.
o Beginning transfusion slowly ( 1 to 2 mL/min) and observing the
patient closely, particularly during the first 15 minutes (severe
reactions usually manifest within 15 minutes after the start of
o Transfusing blood within 4 hours, and changing blood tubing
every 4 hours to minimize the risk of bacterial growth at warm
room temperatures.
o Preventing infectious disease transmission through careful donor
screening or performing pretest available to identify selected
infectious agents.
o Preventing GVH disease by ensuring irradiation of blood products
containing viable WBCs (i.e., whole blood, platelets, packed RBCs
and granulocytes) before transfusion; irradiation alters ability of
donor lymphocytes to engraft and divide.
o Preventing hypothermia by warming blood unit to 37 C before
o Removing leukocytes and platelets aggregates from donor blood
by installing a microaggregate filter (20-40-um size) in the blood
line to remove these aggregates during transfusion.
2. On detecting any signs or symptoms of reaction:
o Stop the transfusion immediately, and notify the physician.
o Disconnect the transfusion set-but keep the IV line open with
0.9% saline to provide access for possible IV drug infusion.
o Send the blood bag and tubing to the blood bank for repeat typing
and culture.
o Draw another blood sample for plasma hemoglobin, culture, and
o Collect a urine sample as soon as possible for hemoglobin
3. Intervene as appropriate to address symptoms of the specific reaction:
o Treatment for hemolytic reaction is directed at correcting
hypotension, DIC, and renal failure associated with RBC hemolysis
and hemoglobinuria.
o Febrile, nonhemolytic transfusion reactions are treated
symptomatically with antipyretics; leukocyte-poor blood products
may be recommended for subsequent transfusions.
o In septic reaction, treat septicemia with antibiotics, increased
hydration, steroids and vasopressors as prescribed.
o Intervene for allergic reaction by administering antihistamines,
steroids and epinephrine as indicated by the severity of the
reaction. (If hives are the only manifestation, transfusion can
sometimes continue but at a slower rate.)
o For circulatory overload, immediate treatment includes
positioning the patient upright with feet dependent; diuretics,
oxygen and aminophylline may be prescribed.

Nursing Interventions when complications occurs in Blood transfusion
1. If blood transfusion reaction occurs. STOP THE TRANSFUSION.
2. Start IV line (0.9% Na Cl)
3. Place the client in fowlers position if with SOB and administer O2 therapy.
4. The nurse remains with the client, observing signs and symptoms and
monitoring vital signs as often as every 5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer emergency drugs such as antihistamines,
vasopressor, fluids, and steroids as per physicians order or protocol.
7. Obtain a urine specimen and send to the laboratory to determine presence
of hemoglobin as a result of RBC hemolysis.
8. Blood container, tubing, attached label, and transfusion record are saved
and returned to the laboratory for analysis.
1. The patient maintains normal breathing pattern.
2. The patient demonstrates adequate cardiac output.
3. The patient reports minimal or no discomfort.
4. The patient maintains good fluid balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin integrity, with no lesions or pruritus.
8. The patient maintains or returns to normal electrolyte and blood chemistry
Bowel Elimination
The Large Intestine
Primary organ of bowel elimination
Extends from the ileocecal valve to the anus
Completion of absorption of H2O, Nutrients (chyme from sm. intest. - 1-1.5
Manufacture of some vitamins
Formation of feces
Expulsion of feces from the body

The Small and Large Intestines

Process of Peristalsis
Peristalsis is under control of nervous system
Contractions occur every 3 to 12 minutes
Mass peristalsis sweeps occur 1 to 4 times each 24-hour period
One-third to one-half of food waste is excreted in stool within 24 hours
Peristalic Movements in the Intestine Colonic peristalsis is slow. Mass peristalsis
is strong, few waves per day, stimulated by food in small intestine.

Factors that influence Bowel Elimination
1. Age
2. Diet
3. Position
4. Pregnancy
5. Fluid Intake
6. Activity
7. Psychological
8. Personal Habits
9. Pain
10. Medications
11. Surgery/Anesthesia

Developmental Considerations
Infantscharacteristics of stool and frequency depend on formula or
breast feedings
Toddler physiologic maturity is first priority for bowel training (1 2 yrs)
Child, adolescent, adultdefecation patterns vary in quantity, frequency,
and rhythmicity
Older adultconstipation is often a chronic problem

Foods Affecting Bowel Elimination
Constipating foods cheese, lean meat, eggs, & pasta
Foods with laxative effectfruits and vegetables, bran, chocolate, alcohol,
Gas-producing foodsonions, cabbage, beans, cauliflower

Effect of Medications on Stool
Aspirin, anticoagulants pink, red, or black stool
Iron saltsblack stool
Antacids white discoloration or speckling in stool
Antibioticsgreen-gray color

Physical Assessment of the Abdomen
Inspectionobserve contour, any masses, scars, or distension
Auscultationlisten for bowel sounds in all quadrants
Note frequency and character, audible clicks, and flatus
Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible
Percussionexpect resonant sound or tympany
Areas of increased dullness may be caused by fluid, a mass, or tumor
Palpationnote any muscular resistance, tenderness, enlargement of
organs, masses

Physical Assessment of the Anus and Rectum
Inspection and palpation
Examine anal area for cracks, nodules, distended veins, masses or polyps,
fecal mass
Insert gloved finger into anus to assess sphincter tone & smoothness of
mucosal lining
Inspect perineal area for skin irritation secondary to diarrhea

Stool Collection
Medical aseptic technique is imperative
Wear disposable gloves
Wash hands before and after glove use
Do not contaminate outside of container with stool
Obtain stool and package, label, and transport according to agency policy

Patient Guidelines for Stool Collection
Void first so urine is not in stool sample
Defecate into the container rather than toilet bowl
Do not place toilet tissue in bedpan or specimen container
Notify nurse when specimen is available
get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff.

Types of Direct Visualization Studies
Esophagogastroduodenoscopy (EGD)
Wireless capsule endoscopy

Indirect Visualization Studies
Upper gastrointestinal (UGI)
Small bowel series
Barium enema

Scheduling Diagnostic Tests
1 fecal occult blood test
2 barium studies (should precede UGI) make sure ALL barium is
3 endoscopic examinations
Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination
Patient has a soft-formed bowel movement every 1-3 days without
The relationship between bowel elimination and diet, fluid, and exercise is
Patient should seek medical evaluation if changes in stool color or
consistency persist

Promoting Regular Bowel Habits
Timing -attend to urges promptly
Positioning have pt. sit up, gravity aids in BM
Privacy close door & pull curtain
Exercise abdominal muscles & thighs
Abdominal settings
Thigh strengthening

Individuals at High Risk for Constipation
Patients on bed rest taking constipating medications
Patients with reduced fluids or bulk in their diet
Patients who are depressed
Patients with central nervous system disease or local lesions that cause
*Valsalva maneuver (straining & holding breath) intrathoracic / intracranial
pressure possible brain injury

Nursing Measures for the Patient With Diarrhea
Answer call lights immediately
Remove the cause of diarrhea whenever possible (e.g., medication)
If there is impaction, obtain physician order for rectal examination
Give special care to the region around the anus
After diarrhea stops, suggest the intake of fermented dairy products
Fecal seepage may indicate impaction

Preventing Food Poisoning
Never buy food with damaged packaging
Never use raw eggs in any form
Do not eat ground meat uncooked
Never cut meat on a wooden surface
Do not eat seafood that is raw or has unpleasant odor
Clean all vegetables and fruits before eating
Refrigerate leftovers within 2 hours of eating them
Give only pasteurized fruit juices to small children

Methods of Emptying the Colon of Feces
Rectal suppositories
Rectal catheters
Digital removal of stool

Types of Enemas
Cleansing high volume
Retention - oil
Return-flow bag of solution taken in (100-300 ml fluid) for pt with gas
Retention Enemas
Oil-retentionlubricate the stool and intestinal mucosa easing
Carminativehelp expel flatus from rectum
Medicatedprovide medications absorbed through rectal mucosa
Anthelminticdestroy intestinal parasites
Nutritiveadminister fluids and nutrition rectally

Bowel Training Programs
Manipulate factors within the patient's control
Food and fluid intake, exercise, time for defecation
Eliminate a soft, formed stool at regular intervals without laxatives
When achieved, discontinue use of suppository if one was used

Types of Colostomies each has different stool consistency
Sigmoid colostomy
Descending colostomy
Transverse colostomy
Ascending colostomy
Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy
Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy
Location of an Ileostomy

Colostomy Care
Keep patient as free of odors as possible; empty appliance frequently
Inspect the patient's stoma regularly
Note the size, which should stabilize within 6 to 8 weeks
Keep the skin around the stoma site clean and dry
Measure the patient's fluid intake & output
Explain each aspect of care to the patient and self-care role
Encourage patient to care for and look at ostomy

Normal-Appearing Stoma

Patient Teaching for Colostomies
Community resources are available for assistance
Initially encourage patients to avoid foods high in fiber
Avoid foods that cause diarrhea or flatus
Drink two quarts of water daily
Teach about medications
Teach about odor control (intake of dark green vegetables helps control
Resume normal activity including work and sexual relations
Comfort Measures
Encourage recommended diet and exercise
Use medications only as needed
Apply ointments or astringent (witch hazel)
Use suppositories that contain anesthetics

Characteristics of Normal Stool
1. Color varies from light to dark brown foods & medications may affect
2. Odor aromatic, affected by ingested food and persons bacterial flora
3. Consistency formed, soft, semi-solid; moist
4. Frequency varies with diet (about 100 to 400 g/day)
5. Constituents small amount of undigested roughage, sloughed dead
bacteria and epithelial cells, fat, protein, dried constituents of digestive
juices (bile pigments); inorganic matter (calcium, phosphates)

Common Bowel Elimination Problems
1. Constipation abnormal frequency of defecation and abnormal hardening
of stools
2. Impaction accumulated mass of dry feces that cannot be expelled
3. Diarrhea increased frequency of bowel movements (more than 3 times a
day) as well as liquid consistency and increased amount; accompanied by
urgency, discomfort and possibly incontinence
4. Incontinence involuntary elimination of feces
5. Flatulence expulsion of gas from the rectum
6. Hemorrhoids dilated portions of veins in the anal canal causing itching
and pain and bright red bleeding upon defecation

Documenting and Reporting
Guidelines for Good Documentation and Reporting

1. Fact information about clients and their care must be factual. A record should
contain descriptive, objective information about what a nurse sees, hears, feels and
2. Accuracy information must be accurate so that health team members have
confidence in it
3. Completeness the information within a record or a report should be complete,
containing concise and thorough information about a clients care. Concise data are
easy to understand
4. Currentness ongoing decisions about care must be based on currently reported
At the time of occurrence include the following:
a. Vital signs
b. Administration of medications and treatments
c. Preparation of diagnostic tests or surgery
d. Change in status
e. Admission, transfer, discharge or death of a client
f. Treatment fro a sudden change in status
5. Organization the nurse communicate in a logical format or order
6. Confidentiality a confidential communication is information given by one
person to another with trust and confidence that such information will not be

Anything written or printed that is relied on as a record of proof fro
authorized persons.
Purposes of Records
1. Communication
2. Planning Client Care
3. Auditing Health Agencies
4. Research
5. Education
6. Reimbursement
7. Legal Documentation
8. Health Care Analysis

Documentation Systems

1. Source Oriented Record

a. The traditional client record
b. Each person or department makes notations in a separate section or sections of
the clients chart
c. It is convenient because care providers from each discipline can easily locate the
forms on which to record data and it is easy to trace the information
d. Example: the admissions department has an admission sheet; the physician has a
physicians order sheet, a physicians history sheet & progress notes
e. NARRATIVE CHARTING is a traditional part of the source-oriented record

2. Problem Oriented Medical Record (POMR)
a. Established by Lawrence Weed
b. The data are arranged according to the problems the client has rather than the
source of the information.

The four (4) basic components:
i. Database consists of all information known about the client when the client first
enters the health care agency. It includes the nursing assessment, the physicians
history, social & family data

ii. Problem List derived from the database. Usually kept at the front of the chart &
serves as an index to the numbered entries in the progress notes. Problems are
listed in the order in which they are identified & the list is continually updated as
new problems are identified & others resolved

iii. Plan of Care care plans are generated by the person who lists the problems.
Physicians write physicians orders or medical care plans; nurses write nursing
orders or nursing care plans

iv. Progress Notes chart entry made by all health professionals involved in a
clients care; they all use the same type of sheet fro notes. Numbered to
correspond to the problems on the problem list and may be lettered for the type of

Example: SOAP Format or SOAPIE and SOAPIER
S Subjective data
O Objective data
A Assessment
P Plan
I Intervention
E Evaluation
R- Revision

Advantages of POMR:
It encourages collaboration
Problem list in the front of the chart alerts caregivers to the clients
needs & makes it easier to track the status of each problem.
Disadvantages of POMR:
Caregivers differ in their ability to use the required charting format
Takes constant vigilance to maintain an up-to-date problem list
Somewhat inefficient because assessments & interventions that
apply to more than one problem must be repeated.
3. PIE (Problems, Interventions, and Evaluation)
a. Groups information in to three (3) categories
b. This system consists of a client care assessment floe sheet & progress notes
c. FLOW SHEET uses specific assessment criteria in a particular format, such as
human needs or functional health patterns
d. Eliminate the traditional care plan & incorporate an ongoing care plan into the
progress notes

4. Focus Charting
a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns fro recording are usually used: date & time, focus & progress

5. Charting by Exception
a. Documentation system in which only abnormal or significant findings or
exceptions to norms are recorded
b. Incorporates three (3) key elements:
i. Flow sheets
ii. Standards of nursing care
iii. Bedside access to chart forms

6. Computerized Documentation
a. Developed as a way to manage the huge volume of information required in
contemporary health care
b. Nurses use computers to store the clients database, add new data, create &
revise care plans & document client progress.
7. Case Management
a. Emphasizes quality, cost-effective care delivered within an established length of
b. Uses a multidisciplinary approach to planning & documenting client care, using
critical pathways.

Nursing Care Plan (NCP)

Two Types:
1. Traditional Care Plan written fro each client; it has 3 columns: nursing
diagnoses, expected outcomes & nursing interventions.
2. Standardized Care Plan based on an institutions standards of practice; thereby
helping to provide a high quality of nursing care

Widely used, concise method of organizing & recording data about a client,
making information quickly accessible to all health professionals. Consists
of a series of cards kept in a portable index file or on computer generated
Information may be organized into sections:
1. Pertinent information about the client
2. List of medications
3. List of IVF
4. List of daily treatments & procedures
5. List of Diagnostic procedures
6. Allergies
7. Specific data on how the clients physical need is to be met
8. A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge / Referral Summaries
Completed when the client is being discharged & transferred to another
institution or to a home setting where a visit by a community health nurse
is required. Regardless of format, it includes some or all of the following:
1. Description of clients physical, mental & emotional state
2. Resolved health problems
3. Unresolved continuing health problems
4. Treatments that can be continued (e.g. wound care, oxygen therapy)
5. Current medications
6. Restrictions that relate to activity, diet & bathing
7. Functional/self-care abilities
8. Comfort level
9. Support networks
10. Client education provided in relation to disease process
11. Discharge destination
12. Referral Services (e.g. social worker, home health nurse)

Head-To-Toe Assessment
Head (Skull, Scalp, Hair)
Eyebrows, Eyes and Eyelashes
Eye lids and Lacrimal Apparatus
Anterior Chamber and Iris
Cranial Nerve II (optic nerve)
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
Nose and Paranasal Sinuses
Cranial Nerve I (olfactory Nerve)
Thorax ( Cardiovascular System)
Skull, Scalp & Hair
Observe the size, shape and contour of the skull.
Observe scalp in several areas by separating the hair at various locations;
inquire about any injuries. Note presence of lice, nits, dandruff or lesions.
Palpate the head by running the pads of the fingers over the entire surface
of skull; inquire about tenderness upon doing so. (wear gloves if necessary)
Observe and feel the hair condition.
Normal Findings:

Generally round, with prominences in the frontal and occipital area.
No tenderness noted upon palpation.
Lighter in color than the complexion.
Can be moist or oily.
No scars noted.
Free from lice, nits and dandruff.
No lesions should be noted.
No tenderness or masses on palpation.
Can be black, brown or burgundy depending on the race.
Evenly distributed covers the whole scalp (No evidences of Alopecia)
Maybe thick or thin, coarse or smooth.
Neither brittle nor dry.
1. Observe the face for shape.
2. Inspect for Symmetry.
o Inspect for the palpebral fissure (distance between the eye lids);
should be equal in both eyes.
o Ask the patient to smile, There should be bilateral Nasolabial fold
(creases extending from the angle of the corner of the mouth).
Slight asymmetry in the fold is normal.
o If both are met, then the Face is symmetrical
3. Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)

1. Sensory Function
Ask the client to close the eyes.
Run cotton wisp over the fore head, check and jaw on both sides of the
Ask the client if he/she feel it, and where she feels it.
Check for corneal reflex using cotton wisp.
The normal response in blinking.
2. Motor function
Ask the client to chew or clench the jaw.
The client should be able to clench or chew with strength and force.
CN VII (Facial)

1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
Normally, the client can identify the taste.
2. Motor function
Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or
puff the cheeks.
Normal Findings
Shape maybe oval or rounded.
Face is symmetrical.
No involuntary muscle movements.
Can move facial muscles at will.
Intact cranial nerve V and VII.

Eyebrows, Eyes and Eyelashes
All three structures are assessed using the modality of inspection.
Normal findings

Symmetrical and in line with each other.
Maybe black, brown or blond depending on race.
Evenly distributed.
Evenly placed and inline with each other.
None protruding.
Equal palpebral fissure.
Color dependent on race.
Evenly distributed.
Turned outward.
Eyelids and Lacrimal Apparatus

1. Inspect the eyelids for position and symmetry.

2. Palpate the eyelids for the lacrimal glands.
a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index
finger against the clients upper orbital rim.
b.Inquire for any pain or tenderness.

3. Palpate for the nasolacrimal duct to check for obstruction.
a.To assess the nasolacrimal duct, the examiner presses with the index finger
against the clients lower inner orbital rim, at the lacrimal sac, NOT AGAINST
b. In the presence of blockage, this will cause regurgitation of fluid in the puncta

Normal Findings

Upper eyelids cover the small portion of the iris, cornea, and sclera when
eyes are open.
No PTOSIS noted. (Drooping of upper eyelids).
Meets completely when eyes are closed.
Lacrimal Apparatus
Lacrimal gland is normally non palpable.
No tenderness on palpation.
No regurgitation from the nasolacrimal duct.
The bulbar and palpebral conjunctivae are examined by separating the
eyelids widely and having the client look up, down and to each side. When
separating the lids, the examiner should exert NO PRESSURE against the
eyeball; rather, the examiner should hold the lids against the ridges of the
bony orbit surrounding the eye.
In examining the palpebral conjunctiva, everting the upper eyelid in necessary
and is done as follow:
1. Ask the client to look down but keep his eyes slightly open. This relaxes the
levator muscles, whereas closing the eyes contracts the orbicularis muscle,
preventing lid eversion.
2. Gently grasp the upper eyelashes and pull gently downward. Do not pull
the lashes outward or upward; this, too, causes muscles contraction.
3. Place a cotton tip application about I can above the lid margin and push
gently downward with the applicator while still holding the lashes. This
everts the lid.
4. Hold the lashes of the everted lid against the upper ridge of the bony orbit,
just beneath the eyebrow, never pushing against the eyebrow.
5. Examine the lid for swelling, infection, and presence of foreign objects.
6. To return the lid to its normal position, move the lid slightly forward and
ask the client to look up and to blink. The lid returns easily to its normal
Normal Findings:
Both conjunctivae are pinkish or red in color.
With presence of many minutes capillaries.
No ulcers
No foreign objects
The sclerae is easily inspected during the assessment of the conjunctivae.
Normal Findings
Sclerae is white in color (anicteric sclera)
No yellowish discoloration (icteric sclera).
Some capillaries maybe visible.
Some people may have pigmented positions.

The cornea is best inspected by directing penlight obliquely from several
Normal findings
There should be no irregularities on the surface.
Looks smooth.
The cornea is clear or transparent. The features of the iris should be fully
visible through the cornea.
There is a positive corneal reflex.
Anterior Chamber and Iris
The anterior chamber and the iris are easily inspected in conjunction with
the cornea. The technique of oblique illumination is also useful in assessing
the anterior chamber.
Normal Findings:
The anterior chamber is transparent.
No noted any visible materials.
Color of the iris depends on the persons race (black, blue, brown or
From the side view, the iris should appear flat and should not be bulging
forward. There should be NO crescent shadow casted on the other side
when illuminated from one side.
Examination of the pupils involves several inspections, including
assessment of the size, shape reaction to light is directed is observed for
direct response of constriction. Simultaneously, the other eye is observed
for consensual response of constriction.
The test for papillary accommodation is the examination for the change in papillary
size as it is switched from a distant to a near object.
Ask the client to stare at the objects across room.
Then ask the client to fix his gaze on the examiners index fingers, which is
placed 5 5 inches from the clients nose.
Visualization of distant objects normally causes papillary dilation and
visualization of nearer objects causes papillary constriction and
convergence of the eye.
Normal Findings
Pupillary size ranges from 3 7 mm, and are equal in size.
Equally round.
Constrict briskly/sluggishly when light is directed to the eye, both directly
and consensual.
Pupils dilate when looking at distant objects, and constrict when looking at
nearer objects.
If all of which are met, we document the findings using the notation PERRLA, pupils
equally round, reactive to light, and accommodate
Cranial Nerve II (optic nerve)
The optic nerve is assessed by testing for visual acuity and peripheral
Visual acuity is tested using a snellen chart, for those who are illiterate and
unfamiliar with the western alphabet, the illiterate E chart, in which the
letter E faces in different directions, maybe used.
The chart has a standardized number at the end of each line of letters;
these numbers indicates the degree of visual acuity when measured at a
distance of 20 feet.
The numerator 20 is the distance in feet between the chart and the client,
or the standard testing distance. The denominator 20 is the distance from
which the normal eye can read the lettering, which correspond to the
number at the end of each letter line; therefore the larger the
denominator the poorer the version.
Measurement of 20/20 vision is an indication of either refractive error or
some other optic disorder.
In testing for visual acuity you may refer to the following:
The room used for this test should be well lighted.
A person who wears corrective lenses should be tested with and without
them to check fro the adequacy of correction.
Only one eye should be tested at a time; the other eye should be covered
by an opaque card or eye cover, not with clients finger.
Make the client read the chart by pointing at a letter randomly at each
line; maybe started from largest to smallest or vice versa.
A person who can read the largest letter on the chart (20/200) should be
checked if they can perceive hand movement about 12 inches from their
eyes, or if they can perceive the light of the penlight directed to their yes.
Peripheral Vision or visual fields
The assessment of visual acuity is indicative of the functioning of the
macular area, the area of central vision. However, it does not test the
sensitivity of the other areas of the retina which perceive the more
peripheral stimuli. The Visual field confrontation test, provide a rather
gross measurement of peripheral vision.
The performance of this test assumes that the examiner has normal visual
fields, since that clients visual fields are to be compared with the
Follow the steps on conducting the test:
1. The examiner and the client sit or stand opposite each other, with the eyes
at the same, horizontal level with the distance of 1.5 2 feet apart.
2. The client covers the eye with opaque card, and the examiner covers the
eye that is opposite to the client covered eye.
3. Instruct the client to stare directly at the examiners eye, while the
examiner stares at the clients open eye. Neither looks out at the object
approaching from the periphery.
4. The examiner hold an object such as pencil or penlight, in his hand and
gradually moves it in from the periphery of both directions horizontally
and from above and below.
5. Normally the client should see the same time the examiners sees it. The
normal visual field is 180 degrees.
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
All the 3 Cranial nerves are tested at the same time by assessing the Extra
Ocular Movement (EOM) or the six cardinal position of gaze.
Follow the given steps:
1. Stand directly in front of the client and hold a finger or a penlight about 1
ft from the clients eyes.
2. Instruct the client to follow the direction the object hold by the examiner
by eye movements only; that is with out moving the neck.
3. The nurse moves the object in a clockwise direction hexagonally.
4. Instruct the client to fix his gaze momentarily on the extreme position in
each of the six cardinal gazes.
5. The examiner should watch for any jerky movements of the eye
6. Normally the client can hold the position and there should be no

1. Inspect the auricles of the ears for parallelism, size position, appearance
and skin color.
2. Palpate the auricles and the mastoid process for firmness of the cartilage
of the auricles, tenderness when manipulating the auricles and the
mastoid process.
3. Inspect the auditory meatus or the ear canal for color, presence of
cerumen, discharges, and foreign bodies.
o For adult pull the pinna upward and backward to straiten the
o For children pull the pinna downward and backward to straiten
the canal
4. Perform otoscopic examination of the tympanic membrane, noting the
color and landmarks.
Normal Findings
The ear lobes are bean shaped, parallel, and symmetrical.
The upper connection of the ear lobe is parallel with the outer canthus of
the eye.
Skin is same in color as in the complexion.
No lesions noted on inspection.
The auricles are has a firm cartilage on palpation.
The pinna recoils when folded.
There is no pain or tenderness on the palpation of the auricles and mastoid
The ear canal has normally some cerumen of inspection.
No discharges or lesions noted at the ear canal.
On otoscopic examination the tympanic membrane appears flat,
translucent and pearly gray in color.

Nose and Paranasal Sinuses

The external portion of the nose is inspected for the following:
1. Placement and symmetry.
2. Patency of nares (done by occluding nosetril one at a time, and noting for
difficulty in breathing)
3. Flaring of alae nasi
4. Discharge
The external nares are palpated for:
1. Displacement of bone and cartilage.
2. For tenderness and masses
The internal nares are inspected by hyper extending the neck of the client, the ulnar
aspect of the examiners hard over the fore head of the client, and using the thumb
to push the tip of the nose upward while shining a light into the nares.

Inspect for the following:
1. Position of the septum.
2. Check septum for perforation. (Can also be checked by directing the
lighted penlight on the side of the nose, illumination at the other side
suggests perforation).
3. The nasal mucosa (turbinates) for swelling, exudates and change in color.
Paranasal Sinuses
Examination of the paranasal sinuses is indirectly. Information about their
condition is gained by inspection and palpation of the overlying tissues.
Only frontal and maxillary sinuses are accessible for examination.
By palpating both cheeks simultaneously, one can determine tenderness of
the maxillary sinusitis, and pressing the thumb just below the eyebrows,
we can determine tenderness of the frontal sinuses.
Normal Findings
Nose in the midline
No Discharges.
No flaring alae nasi.
Both nares are patent.
No bone and cartilage deviation noted on palpation.
No tenderness noted on palpation.
Nasal septum in the mid line and not perforated.
The nasal mucosa is pinkish to red in color. (Increased redness turbinates
are typical of allergy).
No tenderness noted on palpation of the paranasal sinuses.
Cranial Nerve I (Olfactory Nerve)
To test the adequacy of function of the olfactory nerve:
1. The client is asked to close his eyes and occlude.
2. The examiner places aromatic and easily distinguish nose. (E.g. coffee).
3. Ask the client to identify the odor.
4. Each side is tested separately, ideally with two different substances.
Mouth and Oropharynx Lips
Inspected for:
1. Symmetry and surface abnormalities.
2. Color
3. Edema
Normal Findings:
1. With visible margin
2. Symmetrical in appearance and movement
3. Pinkish in color
4. No edema

Palpate while the mouth is opened wide and then closed for:
1. Crepitous
2. Deviations
3. Tenderness
Normal Findings:
1. Moves smoothly no crepitous.
2. No deviations noted
3. No pain or tenderness on palpation and jaw movement.

Inspected for:
1. Color
2. Bleeding
3. Retraction of gums.
Normal Findings:
1. Pinkish in color
2. No gum bleeding
3. No receding gums

Inspected for:
1. Number
2. Color
3. Dental carries
4. Dental fillings
5. Alignment and malocclusions (2 teeth in the space for 1, or overlapping
6. Tooth loss
7. Breath should also be assessed during the process.
Normal Findings:
1. 28 for children and 32 for adults.
2. White to yellowish in color
3. With or without dental carries and/or dental fillings.
4. With or without malocclusions.
5. No halitosis.
Palpated for:
1. Texture
Normal Findings:
1. Pinkish with white taste buds on the surface.
2. No lesions noted.
3. No varicosities on ventral surface.
4. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the
5. Gag reflex is present.
6. Able to move the tongue freely and with strength.
7. Surface of the tongue is rough.

Inspected for:
1. Position
2. Color
3. Cranial Nerve X (Vagus nerve) Tested by asking the client to say Ah
note that the uvula will move upward and forward.
Normal Findings:
1. Positioned in the mid line.
2. Pinkish to red in color.
3. No swelling or lesion noted.
4. Moves upward and backwards when asked to say ah
Inspected for:
1. Inflammation
2. Size
A Grading system used to describe the size of the tonsils can be used.
Grade 1 Tonsils behind the pillar.
Grade 2 Between pillar and uvula.
Grade 3 Touching the uvula
Grade 4 In the midline.
The neck is inspected for position symmetry and obvious lumps visibility of
the thyroid gland and Jugular Venous Distension
Normal Findings:
1. The neck is straight.
2. No visible mass or lumps.
3. Symmetrical
4. No jugular venous distension (suggestive of cardiac congestion).
The neck is palpated just above the suprasternal note using the thumb and
the index finger.

Normal Findings:
1. The trachea is palpable.
2. It is positioned in the line and straight.
Lymph nodes are palpated using palmar tips of the fingers via systemic
circular movements. Describe lymph nodes in terms of size, regularity,
consistency, tenderness and fixation to surrounding tissues.
Normal Findings:
May not be palpable. Maybe normally palpable in thin clients.
Non tender if palpable.
Firm with smooth rounded surface.
Slightly movable.
About less than 1 cm in size.
The thyroid is initially observed by standing in front of the client and asking
the client to swallow. Palpation of the thyroid can be done either by
posterior or anterior approach.
Posterior Approach:
1. Let the client sit on a chair while the examiner stands behind him.
2. In examining the isthmus of the thyroid, locate the cricoid cartilage and
directly below that is the isthmus.
3. Ask the client to swallow while feeling for any enlargement of the thyroid
4. To facilitate examination of each lobe, the client is asked to turn his head
slightly toward the side to be examined to displace the
sternocleidomastoid, while the other hand of the examiner pushes the
thyroid cartilage towards the side of the thyroid lobe to be examined.
5. Ask the patient to swallow as the procedure is being done.
6. The examiner may also palate for thyroid enlargement by placing the
thumb deep to and behind the sternocleidomastoid muscle, while the
index and middle fingers are placed deep to and in front of the muscle.
7. Then the procedure is repeated on the other side.
Anterior approach:
1. The examiner stands in front of the client and with the palmar surface of
the middle and index fingers palpates below the cricoid cartilage.
2. Ask the client to swallow while palpation is being done.
3. In palpating the lobes of the thyroid, similar procedure is done as in
posterior approach. The client is asked to turn his head slightly to one side
and then the other of the lobe to be examined.
4. Again the examiner displaces the thyroid cartilage towards the side of the
lobe to be examined.
5. Again, the examiner palpates the area and hooks thumb and fingers
around the sternocleidomastoid muscle.
Normal Findings:
1. Normally the thyroid is non palpable.
2. Isthmus maybe visible in a thin neck.
3. No nodules are palpable.
Auscultation of the Thyroid is necessary when there is thyroid enlargement. The
examiner may hear bruits, as a result of increased and turbulence in blood flow in
an enlarged thyroid.
Check the Range of Movement of the neck.
Thorax (Cardiovascular System)
Inspection of the Heart
The chest wall and epigastrum is inspected while the client is in supine
position. Observe for pulsation and heaves or lifts

Normal Findings:
1. Pulsation of the apical impulse maybe visible. (this can give us some
indication of the cardiac size).
2. There should be no lift or heaves.
Palpation of the Heart
The entire precordium is palpated methodically using the palms and the
fingers, beginning at the apex, moving to the left sternal border, and then
to the base of the heart.
Normal Findings:
1. No, palpable pulsation over the aortic, pulmonic, and mitral valves.
2. Apical pulsation can be felt on palpation.
3. There should be no noted abnormal heaves, and thrills felt over the apex.
Percussion of the Heart
The technique of percussion is of limited value in cardiac assessment. It
can be used to determine borders of cardiac dullness.
Auscultation of the Heart

Anatomic areas for auscultation of the heart:
Aortic valve Right 2nd ICS sternal border.
Pulmonic Valve Left 2nd ICS sternal border.
Tricuspid Valve - Left 5th ICS sternal border.
Mitral Valve - Left 5th ICS midclavicular line
Positioning the client for auscultation:
If the heart sounds are faint or undetectable, try listening to them with the
patient seated and learning forward, or lying on his left side, which brings
the heart closer to the surface of the chest.
Having the client seated and learning forward s best suited for hearing
high-pitched sounds related to semilunar valves problem.
The left lateral recumbent position is best suited low-pitched sounds, such
as mitral valve problems and extra heart sounds.
Auscultating the heart:
1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and
2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of
semilunar valve). S1 sound is best heard over the mitral valve; S2 is best
heard over the aortric valve.
3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
4. Count heart rate at the apical pulse for one full minute.
Normal Findings:
1. S1 & S2 can be heard at all anatomic site.
2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
3. Cardiac rate ranges from 60 100 bpm.
Inspection of the Breast

There are 4 major sitting position of the client used for clinical breast examination.
Every client should be examined in each position.
1. The client is seated with her arms on her side.
2. The client is seated with her arms abducted over the head.
3. The client is seated and is pushing her hands into her hips, simultaneously
eliciting contraction of the pectoral muscles.
4. The client is seated and is learning over while the examiner assists in
supporting and balancing her.
While the client is performing these maneuvers, the breasts are carefully
observed for symmetry, bulging, retraction, and fixation.
An abnormality may not be apparent in the breasts at rest a mass may
cause the breasts, through invasion of the suspensory ligaments, to fix,
preventing them from upward movement in position 2 and 4.
Position 3 specifically assists in eliciting dimpling if a mass has infiltrated
and shortened suspensory ligaments.
Normal Findings:
1. The overlying the breast should be even.
2. May or may not be completely symmetrical at rest.
3. The areola is rounded or oval, with same color, (Color va,ies form light pink
to dark brown depending on race).
4. Nipples are rounded, everted, same size and equal in color.
5. No orange peel skin is noted which is present in edema.
6. The veins maybe visible but not engorge and prominent.
7. No obvious mass noted.
8. Not fixated and moves bilaterally when hands are abducted over the head,
or is learning forward.
9. No retractions or dimpling.
Palpation of the Breast
Palpate the breast along imaginary concentric circles, following a clockwise
rotary motion, from the periphery to the center going to the nipples. Be
sure that the breast is adequately surveyed. Breast examination is best
done 1 week post menses.
Each areolar areas are carefully palpated to determine the presence of
underlying masses.
Each nipple is gently compressed to assess for the presence of masses or
Normal Findings:
No lumps or masses are palpable.
No tenderness upon palpation.
No discharges from the nipples.
NOTE: The male breasts are observed by adapting the techniques used for female
clients. However, the various sitting position used for woman is unnecessary.
In abdominal assessment, be sure that the client has emptied the bladder
for comfort. Place the client in a supine position with the knees slightly
flexed to relax abdominal muscles.
Inspection of the abdomen
Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and
Contour (flat, rounded, scapold)
Respiratory movement.
Visible peristalsis.
Normal Findings:
Skin color is uniform, no lesions.
Some clients may have striae or scar.
No venous engorgement.
Contour may be flat, rounded or scapoid
Thin clients may have visible peristalsis.
Aortic pulsation maybe visible on thin clients.
Auscultation of the Abdomen
This method precedes percussion because bowel motility, and thus bowel
sounds, may be increased by palpation or percussion.
The stethoscope and the hands should be warmed; if they are cold, they
may initiate contraction of the abdominal muscles.
Light pressure on the stethoscope is sufficient to detect bowel sounds and
bruits. Intestinal sounds are relatively high-pitched, the bell may be used in
exploring arterial murmurs and venous hum.
Peristaltic sounds
These sounds are produced by the movements of air and fluids through
the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant
to the motility of bowel.
Listening to the bowel sounds (borborygmi) can be facilitated by following these
1. Divide the abdomen in four quadrants.
2. Listen over all auscultation sites, starting at the right lower quadrants,
following the cross pattern of the imaginary lines in creating the abdominal
quadrants. This direction ensures that we follow the direction of bowel
3. Peristaltic sounds are quite irregular. Thus it is recommended that the
examiner listen for at least 5 minutes, especially at the periumbilical area,
before concluding that no bowel sounds are present.
4. The normal bowel sounds are high-pitched, gurgling noises that occur
approximately every 5 15 seconds. It is suggested that the number of
bowel sound may be as low as 3 to as high as 20 per minute, or roughly,
one bowel sound for each breath sound.
Some factors that affect bowel sound:
1. Presence of food in the GI tract.
2. State of digestion.
3. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic
ileus, peritonitis).
4. Bowel surgery
5. Constipation or Diarrhea.
6. Electrolyte imbalances.
7. Bowel obstruction.
Percussion of the abdomen
Abdominal percussion is aimed at detecting fluid in the peritoneum
(ascites), gaseous distension, and masses, and in assessing solid structures
within the abdomen.
The direction of abdominal percussion follows the auscultation site at each
abdominal guardant.
The entire abdomen should be percussed lightly or a general picture of the
areas of tympany and dullness.
Tympany will predominate because of the presence of gas in the small and
large bowel. Solid masses will percuss as dull, such as liver in the RUQ,
spleen at the 6th or 9th rib just posterior to or at the mid axillary line on
the left side.
Percussion in the abdomen can also be used in assessing the liver span and
size of the spleen.
Percussion of the liver
The palms of the left hand are placed over the region of liver dullness.
1. The area is strucked lightly with a fisted right hand.
2. Normally tenderness should not be elicited by this method.
3. Tenderness elicited by this method is usually a result of hepatitis or
Renal Percussion
1. Can be done by either indirect or direct method.
2. Percussion is done over the costovertebral junction.
3. Tenderness elicited by such method suggests renal inflammation.
Palpation of the Abdomen

Light palpation
It is a gentle exploration performed while the client is in supine position.
With the examiners hands parallel to the floor.
The fingers depress the abdominal wall, at each quadrant, by
approximately 1 cm without digging, but gently palpating with slow circular
This method is used for eliciting slight tenderness, large masses, and
muscles, and muscle guarding.
Tensing of abdominal musculature may occur because of:
1. The examiners hands are too cold or are pressed to vigorously or deep
into the abdomen.
2. The client is ticklish or guards involuntarily.
3. Presence of subjacent pathologic condition.
Normal Findings:
1. No tenderness noted.
2. With smooth and consistent tension.
3. No muscles guarding.
Deep Palpation
It is the indentation of the abdomen performed by pressing the distal half
of the palmar surfaces of the fingers into the abdominal wall.
The abdominal wall may slide back and forth while the fingers move back
and forth over the organ being examined.
Deeper structures, like the liver, and retro peritoneal organs, like the
kidneys, or masses may be felt with this method.
In the absence of disease, pressure produced by deep palpation may
produce tenderness over the cecum, the sigmoid colon, and the aorta.
Liver palpation
There are two types of bi manual palpation recommended for palpation of the liver.
The first one is the superimposition of the right hand over the left hand.
1. Ask the patient to take 3 normal breaths.
2. Then ask the client to breath deeply and hold. This would push the liver
down to facilitate palpation.
3. Press hand deeply over the RUQ
The second methods:
1. The examiners left hand is placed beneath the client at the level of the
right 11th and 12th ribs.
2. Place the examiners right hands parallel to the costal margin or the RUQ.
3. An upward pressure is placed beneath the client to push the liver towards
the examining right hand, while the right hand is pressing into the
abdominal wall.
4. Ask the client to breath deeply.
5. As the client inspires, the liver maybe felt to slip beneath the examining
Normal Findings:
The liver usually can not be palpated in a normal adult. However, in
extremely thin but otherwise well individuals, it may be felt the costal
When the normal liver margin is palpated, it must be smooth, regular in
contour, firm and non-tender.


1. Observe for size, contour, bilateral symmetry, and involuntary movement.
2. Look for gross deformities, edema, presence of trauma such as ecchymosis
or other discoloration.
3. Always compare both extremities.
1. Feel for evenness of temperature. Normally it should be even for all the
2. Tonicity of muscle. (Can be measured by asking client to squeeze
examiners fingers and noting for equality of contraction).
3. Perform range of motion.
4. Test for muscle strength. (performed against gravity and against
Table showing the Lovett scale for grading for muscle strength and functional level
Functional level Lovett
Grade Percentage of
No evidence of contractility Zero (Z) 0 0
Evidence of slight contractility Trace (T) 1 10
Complete ROM without gravity Poor (P) 2 25
Complete ROM with gravity Fair (F) 3 50
Complete range of motion against gravity with some
Good (G) 4 75
Complete range of motion against gravity with full
Normal (N) 5 100
Normal Findings
Both extremities are equal in size.
Have the same contour with prominences of joints.
No involuntary movements.
No edema
Color is even.
Temperature is warm and even.
Has equal contraction and even.
Can perform complete range of motion.
No crepitus must be noted on joints.
Can counter act gravity and resistance on ROM.

1. Is the fundamental right of every human being. It is the state of integration
of the body and mind
2. Health and illness are highly individualized perception. Meanings and
descriptions of health and illness vary among people in relation to
geography and to culture.
3. Health - is the state of complete physical, mental, and social well-being,
and not merely the absence of disease or infirmity. (WHO)
4. Health is the ability to maintain the internal milieu. Illness is the result of
failure to maintain the internal environment.(Claude Bernard)
5. Health is the ability to maintain homeostasis or dynamic equilibrium.
Homeostasis is regulated by the negative feedback mechanism.(Walter
6. Health is being well and using ones power to the fullest extent. Health is
maintained through prevention of diseases via environmental health
factors.(Florence Nightingale)
7. Health is viewed in terms of the individuals ability to perform 14
components of nursing care unaided. (Henderson)
8. Positive Health symbolizes wellness. It is value term defined by the
culture or individual. (Rogers)
9. Health is a state of a process of being becoming an integrated and whole
as a person.(Roy)
10. Health is a state the characterized by soundness or wholeness of
developed human structures and of bodily and mental functioning.(Orem)
11. Health- is a dynamic state in the life cycle; illness is interference in the life
cycle. (King)
12. Wellness is the condition in which all parts and subparts of an individual
are in harmony with the whole system. (Neuman)
13. Health is an elusive, dynamic state influenced by biologic, psychologic,
and social factors. Health is reflected by the organization, interaction,
interdependence and integration of the subsystems of the behavioral
As defined by the World Health Organization (WHO): state of complete
physical, mental and social well-being, not merely the absence of disease
or infirmity.

1. A concern for the individual as a total system
2. A view of health that identifies internal and external environment
3. An acknowledgment of the importance of an individuals role in life
*A dynamic state in which the individual adapts to changes in internal and external
environment to maintain a state of well being

Models of Health and Illness

1. Health-Illness Continuum (Neuman) Degree of client wellness that exists at any
point in time, ranging from an optimal wellness condition, with available energy at
its maximum, to death which represents total energy depletion.

2. High Level Wellness Model (Halbert Dunn) It is oriented toward maximizing
the health potential of an individual.This model requires the individual to maintain
a continuum of balance and purposeful direction within the environment.

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
Agent any internal or external factor that disease or illness.
Host the person or persons who may be susceptible to a particular illness
or disease
Environment consists of all factors outside of the host
4. Health Belief Model Addresses the relationship between a persons 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

Four Components
The individual is perception of susceptibility to an illness
The individuals perception of the seriousness of the illness
The perceived threat of a disease
The perceived benefits of taking the necessary preventive measures
5. Evolutionary Based Model Illness and death serves as a evolutionary
function. Evolutionary viability reflects the extent to which individuals function to
promote survival and well-being. The model interrelates the following elements:
Life events
Life style determinants
Evolutionary viability within the social context
Control perceptions
Viability emotions
Health outcomes
6. Health Promotion Model A complimentary counterpart models of health
protection. Directed at increasing a clients level of well being. Explain the reason
for clients participation health-promotion behaviors. The model focuses on three
It identifies factors (demographic and socially) enhance or decrease the
participation in health promotion
It organizes cues into pattern to explain likelihood of a clients participation
health-promotion behaviors
It explains the reasons that individuals engage in health activities

State in which a persons physical, emotional, intellectual, social
developmental or spiritual functioning is diminished or impaired. It is a
condition characterized by a deviation from a normal, healthy state.
3 Stages of Illness
1. Stage of Denial Refusal to acknowledge illness; anxiety, fear, irritability
and aggressiveness.
2. Stage of Acceptance Turns to professional help for assistance
3. Stage of Recovery (Rehabilitation or Convalescence) The patient goes
through of resolving loss or impairment of function

1. A dynamic, health oriented process that assists individual who is ill or
disabled to achieve his greatest possible level of physical, mental, spiritual,
social and economical functioning.
2. Abilities not disabilities are emphasized.
3. Begins during initial contact with the patient
4. Emphasis is on restoring the patient to independence or regain his pre-
illness/predisability level of function as short a time as possible
5. Patient must be an active participant in the rehabilitation goal setting an
din rehabilitation process.
Focuses of Rehabilitation
1. Coping pattern
2. Functional ability focuses on self-care: activities of daily living (ADL);
feeding, bathing/hygiene, dressing/grooming, toileting and mobility
3. Mobility
4. Integrity of skin
5. Control of bowel and bladder function
Health and Wellness

Presence or absence of disease
Complete physical, mental, social well-being
Ability to maintain normal roles
Process of adaptation to physical and social environment
Striving toward optimal wellness
Individual definitions
State of well-being
Basic aspects include:
An ultimate goal
A dynamic, growing process
Daily decision-making in areas related to health
Whole being of the individual
Subjective perception of vitality and feeling well
Described objectively, experienced, measured
Can be plotted on a continuum

Dimensions of Wellness

Physical Dimension
Ability to carry out daily tasks
Achieve fitness
Maintain nutrition
Avoid abuses
Social Dimension
Interact successfully
Develop and maintain intimacy
Develop respect and tolerance for others
Emotional Dimension
Ability to manage stress
Ability to express emotion
Intellectual Dimension
Ability to learn
Ability to use information effectively
Spiritual Dimension
Belief in some force that serves to unite
Occupational Dimension
Ability to achieve balance between work and leisure
Environmental Dimension
Ability to promote health measure that improves
o Standard of living
o Quality of life

Models of Health
Medical Model
Agent-Host-Environment Model
Health-Illness Continuum
Medical Model
Provides the narrowest interpretation of health
People viewed as physiologic systems
Health identified by the absence of signs and symptoms of disease or
State of not being sick
Opposite of health is disease or injury
Agent-Host-Environment Model
Each factor constantly interacts with the others
When in balance, health is maintained
When not in balance, disease occurs
Travis Health-Illness Continuum
Measure persons perceived level of wellness
Health and illness/disease opposite ends of a health continuum
Move back and forth within this continuum day by day
Wide ranges of health or illness

Ardells Wellness Model

5 Dimensions of Wellness

Nutritional Awareness
Making healthy food choices on a regular basis.
Physical Fitness
Regular exercise program.
Stress Management

Determining the stress factors in one's life is one thing, but doing something about
it is another thing you could do to manage their stress levels
positive visualization
taking time out
listening to music
journal writing
regular physical activity are all
Environmental Sensitivity
Living lightly on the earth, helping in anyway you can to keep the planet
healthy is important as personal wellness depends on planetary wellness.
Self- Responsibility
Ardell says, all dimensions of wellness are important, but self-responsibility
seems more equal than all the rest. Personal accountability for our own
lifestyle is of utmost importance

Bellins Model for Competency Improvement
Bellins Health System, focus is health care delivery system
is based upon the belief that outcomes are the results of processes that
can be improved through:
o Identification of success metrics,
o Setting of goals and the Plan Do Study Act (PDSA) change process.
Statistical process control charts are used to track identified processes for
stability and response to improvement efforts. Measurement is focused
o Growth
o Effectiveness
o Efficiency
o Engagement
o Innovation

Iceberg Model
The Iceberg Model shows us that our state of physical health or illness is
only the visible "tip" of the iceberg.
In order to completely understand our physical condition, we need to look
beneath the surface to our
o Choices of lifestyle (our eating habits, exercise level, addictions to
alcohol, food, adrenaline, shopping, drugs, etc),
o Psychological beliefs (the thoughts, feelings, attitudes and beliefs
we hold)
o Spirituality (our inner life, our belief in a higher power and our
degree of acceptance and love of self and others).

Factors Affecting Health Status, Beliefs, and Practices

Internal Variables
Biologic dimension (genetic makeup, gender, age, and developmental
Psychologic dimension (mind-body interactions and self-concept)
Cognitive dimension (intellectual factors include lifestyle choices and
spiritual and religious beliefs)
External Variables
Physical environment
Standards of living
Family and cultural beliefs
Social support networks

Factors Affecting Health Care Adherence
Client motivation
Degree of lifestyle change necessary
Perceived severity of problem
Value placed on reducing the threat of illness
Difficulty in understanding and performing specific behaviors
Degree of inconvenience of the illness itself or of the regimens
Complexity, side effects, and duration of the proposed therapy
Specific cultural heritage that may make adherence difficult
Degree of satisfaction and quality and type of relationship with the health
care providers
Overall cost of prescribed therapy

A highly personal state
Persons physical, emotional, intellectual, social, developmental, or
spiritual functioning is diminished
Not synonymous with disease
May or may not be related to disease
Only person can say he or she is ill
Alteration in body function
A reduction of capacities or a shortening of the normal life span
Acute Illness
Characterized by severe symptoms of relatively short duration
Symptoms often appear abruptly, subside quickly
May or may not require intervention by health care professionals
Most people return to normal level of wellness
Chronic Illness
Lasts for an extended period
Usually has a slow onset
Often have periods of remissions and exacerbations
Care includes promoting independence, sense of control, and wellness
Learn how to live with physical limitations and discomfort
Parsons Four Aspects of the Sick Role
Clients are not held responsible for their condition
Clients are not excused from certain social roles and tasks
Clients are obligated to try to get well as quickly as possible
Clients or their families are obligated to seek competent help

Schumans Stages of Illness

Stage 1: Symptom experience
Believe something is wrong
Stage 2: Assumption of the sick role
Accepts the sick role and seeks confirmation
Stage 3: Medical care contact
Seeks advice of a health professional
Stage 4: Dependent client role
Becomes dependent on the professional for help
Stage 5: Recovery or rehabilitation
Relinquish the dependent role Resume former roles and responsibilities
Impact of Illness on the Client
Behavioral and emotional changes
Loss of autonomy
Self-concept and body image changes
Lifestyle changes On the Family
Depends on:
o Member of the family who is ill
o Seriousness and length of the illness
o Cultural and social customs the family follows
Impact of Illness: Family Changes
Role changes
Task reassignments
Increased demands on time
Anxiety about outcomes
Conflict about unaccustomed responsibilities
Financial problems
Loneliness as a result of separation and pending loss
Change in social customs
Illness and Disease
Is a personal state in which the person feels unhealthy.
Illness is a state in which a persons physical, emotional, intellectual, social,
developmental, or spiritual functioning is diminished or impaired
compared with previous experience.
Illness is not synonymous with disease.

An alteration in body function resulting in reduction of capacities or a
shortening of the normal life span.

Common Causes of Disease
1. Biologic agent e.g. microorganism
2. Inherited genetic defects e.g. cleft palate
3. Developmental defects e.g. imperforate anus
4. Physical agents e.g. radiation, hot and cold substances, ultraviolet rays
5. Chemical agents e.g. lead, asbestos, carbon monoxide
6. Tissue response to irritations/injury e.g. inflammation, fever
7. Faulty chemical/metabolic process e.g. inadequate insulin in diabetes
8. Emotional/physical reaction to stress e.g. fear, anxiety

Stages of Illness
1. Symptoms Experience- experience some symptoms, person believes
something is wrong 3 aspects physical, cognitive, emotional
2. Assumption of Sick Role acceptance of illness, seeks advice
3. Medical Care Contact- Seeks advice to professionals for validation of real
illness, explanation of symptoms, reassurance or predict of outcome
4. Dependent Patient Role
o The person becomes a client dependent on the health
professional for help.
o Accepts/rejects health professionals suggestions.
o Becomes more passive and accepting.
5. Recovery/Rehabilitation - Gives up the sick role and returns to former
roles and functions.

Risk Factors of a Disease
1. Genetic and Physiological Factors
o For example, a person with a family history of diabetes mellitus, is
at risk in developing the disease later in life.
2. Age
o Age increases and decreases susceptibility ( risk of heart diseases
increases with age for both sexes
3. Environment
o The physical environment in which a person works or lives can
increase the likelihood that certain illnesses will occur.
4. Lifestyle
o Lifestyle practices and behaviors can also have positive or
negative effects on health.

Classification of Diseases

1. According to Etiologic Factors

a. Hereditary due to defect in the genes of one or other parent which is
transmitted to the
i. offspring
b. Congenital due to a defect in the development, hereditary factors, or
prenatal infection
c. Metabolic due to disturbances or abnormality in the intricate processes of
d. Deficiency results from inadequate intake or absorption of essential dietary
e. Traumatic- due to injury
f. Allergic due to abnormal response of the body to chemical and protein
substances or to physical stimuli.
g. Neoplastic due to abnormal or uncontrolled growth of cell.
h. Idiopathic Cause is unknown; self-originated; of spontaneous origin
i. Degenerative Results from the degenerative changes that occur in the tissue
and organs.
j. Latrogenic result from the treatment of the disease

2. According to Duration or Onset
Acute Illness An acute illness usually has a short duration and is severe.
Signs and symptoms appear abruptly, intense and often subside after a
relatively short period.
Chronic Illness chronic illness usually longer than 6 months, and can also
affects functioning in any dimension. The client may fluctuate between
maximal functioning and serious relapses and may be life threatening. Is
characterized by remission and exacerbation.
o Remission- periods during which the disease is controlled and
symptoms are not obvious.
o Exacerbations The disease becomes more active given again at a
future time, with recurrence of pronounced symptoms.
Sub-Acute Symptoms are pronounced but more prolonged than the
acute disease.
3. Disease may also be Described as:

a. Organic results from changes in the normal structure, from
recognizable anatomical changes in an organ or tissue of the body.
b. Functional no anatomical changes are observed to account from the
symptoms present, may result from abnormal response to stimuli.
c. Occupational Results from factors associated with the occupation
engage in by the patient.
d. Venereal usually acquired through sexual relation
e. Familial occurs in several individuals of the same family
f. Epidemic attacks a large number of individuals in the community at
the same time. (E.g. SARS)
g. Endemic Presents more or less continuously or recurs in a
community. (E.g. malaria, goiter)
h. Pandemic An epidemic which is extremely widespread involving an
entire country or continent.
i. Sporadic a disease in which only occasional cases occur. (E.g. dengue,
Leavell and Clarks Three Levels of Prevention
Primary Prevention
Seeks to prevent a disease or condition at a prepathologic state; to stop
something from ever happening.
Health Promotion
health education
marriage counseling
genetic screening
good standard of nutrition adjusted to developmental phase of life
Specific Protection
use of specific immunization
attention to personal hygiene
use of environmental sanitation
protection against occupational hazards
protection from accidents
use of specific nutrients
protections from carcinogens
avoidance to allergens

Secondary Prevention
Also known as Health Maintenance. Seeks to identify specific illnesses or
conditions at an early stage with prompt intervention to prevent or limit
disability; to prevent catastrophic effects that could occur if proper
attention and treatment are not provided
Early Diagnosis and Prompt Treatment
case finding measures
individual and mass screening survey
prevent spread of communicable disease
prevent complication and sequelae
shorten period of disability
Disability Limitations
Adequate treatment to arrest disease process and prevent further
complication and sequelae.
Provision of facilities to limit disability and prevent death.

Tertiary Prevention
Occurs after a disease or disability has occurred and the recovery process
has begun; Intent is to halt the disease or injury process and assist the
person in obtaining an optimal health status. To establish a high-level
wellness. To maximize use of remaining capacities
Restoration and Rehabilitation
Work therapy in hospital
Use of shelter colony
Maslows Hierarchy of Basic Human Needs
Each individual has unique characteristics, but certain needs are common
to all people.
A need is something that is desirable, useful or necessary. Human needs
are physiologic and psychological conditions that an individual must meet
to achieve a state of health or well-being.

1. Oxygen
2. Fluids
3. Nutrition
4. Body temperature
5. Elimination
6. Rest and sleep
7. Sex

Safety and Security
1. Physical safety
2. Psychological safety
3. The need for shelter and freedom from harm and danger

Love and belonging
1. The need to love and be loved
2. The need to care and to be cared for.
3. The need for affection: to associate or to belong
4. The need to establish fruitful and meaningful relationships with people,
institution, or organization

Self-Esteem Needs
1. Self-worth
2. Self-identity
3. Self-respect
4. Body image

Self-Actualization Needs
1. The need to learn, create and understand or comprehend
2. The need for harmonious relationships
3. The need for beauty or aesthetics
4. The need for spiritual fulfillment

Characteristics of Basic Human Needs
1. Needs are universal.
2. Needs may be met in different ways
3. Needs may be stimulated by external and internal factor
4. Priorities may be deferred
5. Needs are interrelated

Maslows Characteristics of a Self-Actualized Person
1. Is realistic, sees life clearly and is objective about his or her observations
2. Judges people correctly
3. Has superior perception, is more decisive
4. Has a clear notion of right or wrong
5. Is usually accurate in predicting future events
6. Understands art, music, politics and philosophy
7. Possesses humility, listens to others carefully
8. Is dedicated to some work, task, duty or vocation
9. Is highly creative, flexible, spontaneous, courageous, and willing to make
10. Is open to new ideas
11. Is self-confident and has self-respect
12. Has low degree of self-conflict; personality is integrated
13. Respect self, does not need fame, and possesses a feeling of self-control
14. Is highly independent, desires privacy
15. Can appear remote or detached
16. Is friendly, loving and governed more by inner directives than by society
17. Can make decisions contrary to popular opinion
18. Is problem centered rather than self-centered
19. Accepts the world for what it is
20. Nursing Process
The term Nursing Process was first used/ mentioned by Lydia Hall, a
nursing theorist, in 1955 wherein she introduced 3 STEPs: observation,
administration of care and validation.
Since then, nursing process continue to evolve: it used to be a 3-step
process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step
process (ADOPIE) Assessment, Diagnosis, Outcome, Identification,
Planning, Implementaton and Evaluation.

Is a systematic, organized method of planning, and providing quality and
individualized nursing care.
It is synonymous with the PROBLEM SOLVING APPROACH that directs the
nurse and the client to determine the need for nursing care, to plan and
implement the care and evaluate the result.
It is a G O S H approach (goal-oriented, organized, systematic and
humanistic care) for efficient and effective provision of nursing care.

Goal-oriented nurse make her objective based on clients health needs.
Remember: Goals and plan of care should be base according to clients
problems/needs NOT according to your own problem as the nurse.
Organized/Systematic the nursing process is composed of 6 sequential
and interrelated steps and these 6 phases follow a logical sequence.

Humanistic care
Plan to care is developed and implemented taking into consideration the
unique needs of the individual client.
plan of care therefore is individualized (no 2 person has the same health
needs even with same health condition/illness)
in providing care, it involves respect of human dignity
Efficient plan of case is relevant/ related to the needs of the client
thereby promoting client satisfaction and progress.
Effective in planning care, utilized resources wisely (staff, time,
Aside from GOSH, other characteristic of Nursing Process:
Cyclic and Dynamic in nature data from each phase provides the input
into the next phase so that is becomes a sequence of events (cycle) that
are constantly changing (dynamic) base on clients health status.
Involves skill in Decision-making nurse makes important decisions
related to client care, she choose the best action/steps to meet a desired
goal or to solve a problem. She must make decisions whenever several
choices or options are available.
Uses Critical Thinking skills the nurse may encounter new ideas or less-
than-routine or non-ordinary situations where decisions must be made
using critical thinking.

Purpose of Nursing Process:
1. To identify a clients health status; his Actual/Present and
potential/possible health problems or needs.
2. To establish a plan of care to meet identified needs.
3. To provide nursing interventions to meet those needs.
4. To provide an individualized, holistic, effective and efficient nursing care.

Steps/Phases of the Nursing Process:
1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Involves determining before and the strategies or course of actions to be
taken before implementation of nursing care. To be effective, the client
and his family should be involve in planning.

To determine the goals of care and the course of actions to be undertaken
during the implementation phase.
To promote continuity of care.
To focus charting requirements.
To allow for delegation of specific activities.
1. Establish/Set priorities
Priority is something that takes precedence in position, and considered
the most important among several items. It is a decision making process
that ranks the order of nursing diagnosis in terms of importance to the
Guideline for setting priorities:
1. Life-threatening situations should be given highest priority.
2. Use the principle of ABCs (airway, breathing, circulation)
3. Use Maslows hierarchy of needs.
4. Consider something that is very important to the client.
5. Actual problems take precedence over potential concerns.
6. Clients with unstable condition should be given priority over those with
stable conditions. Ex: attend to client with fever before attending to client
who is scheduled for physical therapy in the afternoon.
7. Consider the amount of time, materials, equipment required to care for
clients. Ex: attend to client who requires dressing change for postop
wound before attending to client who requires health teachings & is ready
to be discharged late in the afternoon.
8. Attend to client before equipment. Ex: assess the client before checking IV
fluids, urinary catheter, and drainage tube.
2. Plan nursing interventions/nursing orders to direct activities to be carried out in
the implementation phase.

Nursing interventions
Any treatment, based upon clinical judgment and knowledge, that a nurse
performs to enhance client outcomes.
They are used to monitor health status; prevent, resolve or control a
problem; assist with activities of daily living; or promote optimum health
and independence.
They maybe independent, dependent and independent/collaborative
activities that nurses carry out to provide client care.
o Independent Nursing Intervention those activities that the
nurse is licensed to initiate as a result of the nurses own
knowledge and skills.
o Dependent Nursing Intervention those activities carried out on
the order of a physician, under a physicians supervision, or
according to specific routines.
o Interdependent/Collaborative those activities the nurse carries
out in collaboration or in relation with other members of the
health care team.
3. Write a Nursing Care Plan

Nursing Care Plan (NCP)
A written summary of the care that a client is to receive.
It is the blueprint of the nursing process.
It is nursing centered in that the nurse remains in the scope of nursing
practice domain in treating human responses to actual or potential health
It is s step-by-step process as evidence by:
1. Sufficient data are collected to substantiate nursing diagnosis.
2. At least one goal must be stated for each nursing diagnosis.
3. Outcome criteria must be identified for each goal.
4. Nursing interventions must be specifically designed to meet the
identified goal.
5. Each intervention should be supported by a scientific rationale,
which is the justification or reason for carrying out the
6. Evaluation must address whether each goal was completely met,
partially met or completely unmet.
Is putting the nursing care plan into action.

To carry out planned nursing interventions to help the client attain goals
and achieve optimal level of health.

1. Reassessing to ensure prompt attention to emerging problems.
2. Set priorities to determine the order in which nursing interventions are
carried out.
3. Perform nursing interventions these may be independent. Dependent or
collaborative measures.
4. Record actions to complete nursing interventions, relevant
documentation should be done. Remember: Something that is NOT written
is considered as NOT done at all.

Requirements of Implementation
1. Knowledge include intellectual skills like problem-solving, decision-
making and teaching.
2. Technical skills to carry out treatment and procedures.
3. Communication skills use of verbal and non-verbal communication to
carry out planned nursing interventions.
4. Therapeutic use of self is being willing and being able to care
5. Outcome Identification
Refers to formulating and documenting measurable, realistic and client-
focused goals that will provide the basis for evaluating nursing diagnosis.

1. To provide individualized care
2. To promote client participation
3. To plan care that is realistic and measurable
4. To allow involvement of support people

Activities during Outcome Identification
1. Establish clients goals and outcome criteria
Client Goal
Is an educated guess made as a broad statement about what the clients
state or condition will be AFTER the nursing intervention is carried out.
Are written to indicate a desired state. They contain action word/verb and
a qualifier that indicate the level of performance that needs to be
Example of verbs used in client goals:
o Calculate
o Classify
o Communicate
o Compare
o Define
o Demonstrate
o Describe
o Construct
o Contrast
o Distinguish
o Draw
o Explain
o Express
o Identify
o List
o Name
o Maintain
o Perform
o Particular
o Practice
o Recall
o Recite
o Record
o State
o Use
o Verbalize
o Ambulates
*a Qualifier is a description of the parameter or criteria for achieving the
o Ambulates safely with one-person assistance.
o Identifies actual & risk environmental hazards.
o Demonstrates signs of sufficient rest before Surgery.

Goals may be short term or long term
Short Term Goal (STG) can be met in a short period (within days or less
than a week)
Long Term Goal (LTG) requires more time (several weeks or months)
Outcome Criteria are specific, measurable, realistic statements goal
attainment. They are written in a manner that they answer the questions:
who, what actions, under what circumstance, how well and when.
Therefore the characteristic of well-stared outcome criteria are:
S = smart
M = measurement
A = attainable
R = realistic
T = time-framed

Example of Goals and Outcome Criteria

1. Goal The client will report a decreased anxiety level regarding Surgery.

Possible Outcome Criteria:
The client discusses fears & concern regarding surgical procedure after
client teaching.
After client teaching, the client verbalizes decreased anxiety.
The client identifies a support system and strategies to use to reduce stress
and anxiety related to the surgical experience.
2. Goal The client will demonstrate safety habits when performing activities of
daily living.

Possible Outcome Criteria:
Immediately after instruction by the nurse, the client uses call light system
for assistance when needs to use the bathroom.
The client demonstrates safety practices when dressing and doing personal
The client uses over-the-bed lights, non-skid slippers when transferring to
chair or getting out of bed.
The client identifies modification for home safety (removal of throw
pillows, installation of hand rails in hallway, better lighting of hallway and
stairway), 12 hours after nurses instruction about home safety.
3. Goal The client will mobilize lung secretions.

Possible Outcome Criteria:
After teaching session, the client demonstrates proper coughing
The client drinks at least 6 glasses of water per day while in the hospital.
The caregiver or significant other demonstrates proper technique of chest
physiotherapy including percussion, vibration and postural drainage before
Is assessment the clients response to nursing interventions and then
comparing that response to predetermined standards or outcome criteria.

To appraise the extent to which goals and outcome criteria of nursing care
have been achieved.

1. Collect data about the clients response.
2. Compare the clients response to goals and outcome criteria.
3. The four possible judgments that may be made are as follows:
o The goal was completely met.
o The goal was partially met.
o The goal was completely unmet.
o New problems & nursing diagnosis have developed.
4. Analyze the reasons for the outcomes.
5. Modify plan of care as needed.
Vital Signs
These are indices of health, or signposts in determining clients condition.
This is also known as cardinal signs and it includes body temperature,
pulse, respirations, and blood pressure. These signs have to be looked at in
total, to monitor the functions of the body.

Different considerations in taking Vital signs
1. The frequency of taking TPR and BP depends upon the condition of the
client and the policy of the institution.
2. The procedure should be explained to the client before taking his TPR and
3. Obtain baseline data.

Vital Signs or Cardinal Signs are:
Body temperature
Blood pressure

Body Temperature
The balance between the heat produced by the body and the heat loss
from the body.
Types of Body Temperature
Core temperature temperature of the deep tissues of the body.
Surface body temperature
Alteration in body Temperature
Pyrexia Body temperature above normal range( hyperthermia)
Hyperpyrexia Very high fever, 41C(105.8 F) and above
Hypothermia Subnormal temperature.
Normal Adult Temperature Ranges
Oral 36.5 37.5 C
Axillary 35.8 37.0 C
Rectal 37.0 38.1 C
Tympanic 36.8 37.9C
Methods of Temperature-Taking

I. Oral most accessible and convenient method.
1. Put on gloves, and position the tip of the thermometer under the patients
tongue on either of the frenulun as far back as possible. It promotes
contact to the superficial blood vessels and ensures a more accurate
2. Wash thermometer before use.
3. Take oral temp 2-3 minutes.
4. Allow 15 min to elapse between clients food intakes of hot or cold food,
5. Instruct the patient to close his lips but not to bite down with his teeth to
avoid breaking the thermometer in his mouth.
Young children an infant
Patients who are unconscious or disoriented
Who must breathe through the mouth
Seizure prone
Patient with N/V
Patients with oral lesions/surgeries
II. Rectal- most accurate measurement of temperature
1. Position- lateral position with his top legs flexed and drapes him to provide
2. Squeeze the lubricant onto a facial tissue to avoid contaminating the
lubricant supply.
3. Insert thermometer by 0.5 1.5 inches
4. Hold in place in 2minutes
5. Do not force to insert the thermometer
Patient with diarrhea
Recent rectal or prostatic surgery or injury because it may injure inflamed
Recent myocardial infarction
Patient post head injury
III. Axillary safest and non-invasive
1. Pat the axilla dry
2. Ask the patient to reach across his chest and grasp his opposite shoulder.
This promote skin contact with the thermometer
3. Hold it in place for 9 minutes because the thermometer isnt close in a
body cavity
Use the same thermometer for repeat temperature taking to ensure more
consistent result
Store chemical-dot thermometer in a cool area because exposure to heat
activates the dye dots.
IV. Tympanic thermometer
1. Make sure the lens under the probe is clean and shiny
2. Stabilized the patients head; gently pull the ear straight back (for children
up to age 1) or up and back (for children 1 and older to adults)
3. Insert the thermometer until the entire ear canal is sealed
4. Place the activation button, and hold it in place for 1 second
V. Chemical-dot thermometer
1. Leave the chemical-dot thermometer in place for 45 seconds
2. Read the temperature as the last dye dot that has change color, or fired.
Factors that Affect Body Temperature
1. Age
o The infant is greatly influenced by the temperature of the
environment and must be protected from extreme changes.
Childrens temperature continues to be more labile than those of
adults until puberty. Elderly people are at risk of hypothermia for
variety of reasons. Such as lack of central heating, inadequate
diet, loss of subcutaneous fat, lack of activity, and reduced
thermoregulatory efficiency.
2. Diurnal variations (circadian rhythms)
o This refers to the sleep wake rhythm of the body, a pattern that
varies slightly from person to person. Body temperature normally
changes throughout the day, varying as much as 1.0C between
the early morning and the late afternoon.
3. Exercise
o Hard work or strenuous exercise can increase body temperature
4. Hormones
o Women usually experience more hormones fluctuations than men
do. Progesterone secretion at the time of ovulation raises body
temperature above basal temperature
5. Stress
o Stimulation of SNS can increase the production of epinephrine
and norepinephrine, thereby increasing metabolic activity and
heat production
6. Environment
o Extremes in environmental temperatures can affect a persons
temperature regulatory systems.
Nursing Interventions in Clients with Fever
1. Monitor V.S
2. Assess skin color and temperature
3. Monitor WBC, Hct and other pertinent lab records
4. Provide adequate foods and fluids.
5. Promote rest
6. Monitor I & O
7. Provide TSB
8. Provide dry clothing and linens
9. Give antipyretic as ordered by MD
Heat producing & Heat losing Mechanisms
Heat production: most body heat is produced by the oxidation of foods;
the rate at which it is produced is called METABOLIC RATE.
Heat Loss:
Pre optic area of the Hypothalamus
Temperature regulator; thermostat
Receives input from temp receptors in the skin & mucous membranes
(peripheral thermoreceptors) & internal structures (central
* If blood temp increases, neurons of the pre optic area fire nerve if it
Heat Promoting Centers
1. Vasoconstriction
o =Less blood flow from the internal organs to the skin= less heat
transfer from the internal organs to the skin= increases internal
body temperature
2. Sympathetic Stimulation
o = stimulation of sympathetic nerves leading to the adrenal
medulla = secretes epinephrine & norepinephrine = Increases
cellular metabolism = increases heat production
3. Skeletal Muscles
o = stimulation of part of the brain that increases muscle tone
(stretch reflex + contraction of muscles = SHIVERING) = heat
4. Thyroxine
o = increases metabolism = increase in body temperature
Body Temperature Abnormalities
1. Fever/hyperthermia/hyperpyrexia
o An abnormally high temp mainly results from infection from
bacteria (& their toxins) & viruses. (Stimulates prostaglandin
o Other causes: heart attacks, tumors, tissue destruction by x ray,
surgery or trauma & rxns to vaccines.
2. Heat cramps and Heat exhaustion
o Due to fluid & electrolyte loss
3. Heat Stroke
4. Hypothermia
The Thermometer
A glass clinical thermometer is most commonly used to measure body
It has 2 parts:
Bulb contains mercury which expands when exposed to heat & rise in the
Stem is calibrated in degrees of Celcius or Fahrenheit

This is a wave of blood created by contraction of the left ventricle of the
heart. The heart is a pulsating pump, and the blood enters the arteries
with each heartbeat, causing pressure pulses or pulse waves. Generally,
the pulse wave represents the stroke volume and the compliance of the
Stroke volume is the amount of blood that enters the arteries with each
contraction in a healthy adult.
Compliance of the arteries is their ability to contract and expand. When a
persons arteries lose their distensibility, greater pressure is required to
pump the blood into the arteries.
Peripheral pulse is the pulse located in the periphery of the body, for
example in the foot, hand and neck. Apical pulse is a central pulse. It is
located at the apex 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.
What you need:
1. Watch with second hand
2. Stethoscope (for apical pulse)
3. Doppler ultrasound blood flow detector if necessary
Obtaining Radial Pulse
1. Wash your hand and tell your client that you are going to take his pulse
2. Place the client in sitting or supine position with his arm on his side or
across his chest
3. Gently press your index, middle, and ring fingers on the radial artery, inside
the patients wrist.
4. Excessive pressure may obstruct blood flow distal to the pulse site
5. Counting for a full minute provides a more accurate picture of irregularities
Obtaining Pulse Using Doppler device
1. Apply small amount of transmission gel to the ultrasound probe
2. Position the probe on the skin directly over a selected artery
3. Set the volume to the lowest setting
4. To obtain best signals, put gel between the skin and the probe and tilt the
probe 45 degrees from the artery.
5. After you have measure the pulse rate, clean the probe with soft cloth
soaked in antiseptic. Do not immerse the probe
Factors Affecting Pulse Rate
1. Age
o As age increases, the pulse rate gradually decreases
2. Sex
o After puberty, the average males pulse rate is slightly lower than
the females.
3. Exercise
o Pulse rate usually increases with activity
4. Fever
o The pulse rate increases in response to the lowered blood
pressure that results from peripheral vasodilation associated with
elevated body temperature, and because of the increased
metabolic rate.
5. Medications
o Some medications decrease the pulse rate, and others increase it.
6. Hemorrhage
o Loss of blood from the vascular system normally increases pulse
7. Stress
o In response to stress, sympathetic nervous stimulation increases
the overall activity of the heart. Stress increases the rate as well
as the force of the heartbeat.
8. Position changes
o When a person assumes a sitting or standing position, blood
usually pools in dependent vessels of the venous system. Pooling
results in a transient decrease in the venous blood return to the
heart and a subsequent reduction in blood pressure reduction in
blood pressure and increase in the heart rate.
Characteristics of Normal Pulse
1. Rate
o This is the number of pulse beats per minute (70 80 beats/min
in the adult). An excessively fast heart rate (100 beats/min) is
referred to as tachycardia. A heart rate in the adult of 60
beats/minute or less is called bradycardia.
2. Pulse rhythm
o This is the pattern of the beats and the intervals between the
beats. Equal time elapses between beats of a normal pulse. A
pulse with an irregular rhythm is referred to as a dysrhythmia or
arrhythmia. It may consist of random, irregular beats or a
predictable pattern of irregular beats.
3. Pulse volume
o This is also called the pulse strength or amplitude. It refers to the
force of blood with each beat. It can range from absent to
bounding. A normal pulse can be felt with moderate pressure of
the fingers and can be obliterated with greater pressure. A
forceful or full blood volume that is obliterated only with difficulty
is called a full or bounding pulse. A pulse that is readily obliterated
with pressure from the fingers is referred to as weak, feeble, or
thready. A pulse volume is usually measured on a scale 0 to 3.

Pulse Sites
1. Temporal, where the temporal artery passes over the temporal bone of
the head. The site is superior and lateral to the eye.
2. Carotid, at the side of the neck below the lobe of the ear, where the
carotid artery runs between the trachea and the sternocleidomastoid
3. Apical, at the apex of the heart.
4. Brachial, at the inner aspect of the biceps muscle of the arm (especially in
infants) or medially in the antecubital space (elbow crease).
5. Radial, where the radial artery runs along the radial bone, on the thumb
site of the inner aspect of the wrist.
6. Femoral, where the femoral artery passes alongside the inguinal ligament.
7. Popliteal, where the popliteal artery passes behind the knee. This point is
difficult to find, but it can be palpated if the client flexes the knee slightly.
8. Poserior tibial, on the medial surface of the ankle where the posterior
tibial artery passes behind the medial malleolus.
9. Pedal (dorsalis pedis), where the dorsalis pedis artery passes over the
bones of the foot. This artery can be palpated by feeling the dorsum of the
foot on the imaginary line drawn from the middle of the ankle to the space
between the big and second toes.

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 clients
Count respiration for 60 second
As you count the respiration, assess and record breath sound as stridor,
wheezing, or stertor.
Respiratory rates of less than 10 or more than 40 are usually considered
abnormal and should be reported immediately to the physician.
Resting respirations should be assessed when the client is at rest because
exercise affects respirations, and increase their rate and depth as well.
Respiration may also need to be assessed after exercise to identify the
clients tolerance to activity. Before assessing a clients respirations, a
nurse should be aware of:
o The clients normal breathing pattern.
o The influence of the clients health problems on respirations.
o Any medications or therapies that might affect respirations.
o The relationship of the clients respirations to cardiovascular
Characteristics of Normal Respiration
1. Respiratory rate
o This is described in breaths per minute. A healthy adult normally
takes between 15 and 20 breaths per minute. Breathing that is
normal in rate is eupnea. Abnormally slow respirations are
referred to as bradypnea, and abnormally fast respirations are
called tachypnea or polypnea.
2. Depth
o This can be established by watching the movement of the chest. It
is generally described as normal, deep, or shallow.
3. Respiratory rhythm or pattern
o This refers to the regularity of the expirations and the
inspirations. Normally, respirations are evenly spaced. Respiratory
rhythm can be described as regular or irregular.
4. Respiratory quality or character
o This refers to those aspects of breathing that are different from
normal, effortless breathing. It includes:
Amount of effort a client must exert to breathe. Usually,
breathing does not require noticeable effort.
The sound of breathing. Normal breathing is silent, but a
number of abnormal sounds such as a wheeze are
obvious to the nurses ear.
Blood Pressure
This is the force exerted by the blood against a vessel wall. Arterial blood
pressure is a measure of the pressure exerted by the blood as it flows
through the arties. There are two blood pressure measures:
1. Systolic pressure. This is the pressure of the blood because of contraction of
the ventricles, which is the height of the blood wave.
2. Diastolic pressure. This is the pressure when the ventricles are at rest. It is
the lower pressure present at all times within the arteries.
Pulse pressure is the difference between the diastolic and systolic
Blood pressure is measured in millimeters of mercury (mm Hg) and
recorded as a fraction. The systolic pressure is written over the diastolic
pressure. The average blood pressure of a healthy adult is 120/80 mm Hg.
A number of conditions are reflected by changes in blood pressure. The
most common is hypertension, an abnormally high blood pressure.
Hypotension is an abnormally low blood pressure below 100min Hg

Adult 90- 132 systolic
60- 85 diastolic
Elderly- 140-160 systolic
70-90 diastolic
1. Ensure that the client is rested
2. Use appropriate size of BP cuff.
3. If too tight and narrow- false high BP
4. If too lose and wide-false low BP
5. Position the patient on sitting or supine position
6. Position the arm at the level of the heart, if the artery is below the heart
level, you may get a false high reading
7. Use the bell of the stethoscope since the blood pressure is a low frequency
8. If the client is crying or anxious, delay measuring his blood pressure to avoid
false-high BP
Electronic Vital Sign Monitor
1. An electronic vital signs monitor allows you to continually tract a patients
vital sign without having to reapply a blood pressure cuff each time.
2. Example: Dinamap VS monitor 8100
3. Lightweight, battery operated and can be attached to an IV pole
4. Before using the device, check the client7s pulse and BP manually using
the same arm youll using for the monitor cuff.
5. Compare the result with the initial reading from the monitor. If the results
differ call the supply department or the manufacturers representative.
Physiology of Arterial Blood Pressure
1. Pumping action of the heart
o Cardiac output is the volume of blood pumped into the arteries by
the heart. When the pumping action of the heart is weak, less
blood is pumped into arteries, and the blood pressure decreases.
When the hearts pumping action is strong and the volume of
blood pumped into the circulation increases, the blood pressure
increases. Cardiac output increases with fever and exercise.
2. Peripheral Vascular Resistance
o This can increase blood pressure. The diastolic pressure is
especially affected. The following are factors that create
resistance in the arterial system:
Size of the arterioles and capillaries. This determines in
great part the peripheral resistance to the blood in the
body pressure, whereas decreased vasoconstriction
lowers the blood pressure.
Compliance of the arteries. The arteries contain smooth
muscles that permit them to contract, thus decreasing
their compliance (distensibility). The major factor
reducing arterial compliance is pathologic change
affecting the arterial walls. The elastic and muscular
tissues of the arteries are replaced with fibrous tissues.
The condition, most common in middle-aged and elderly
adults, is known as arteriosclerosis.
Viscosity of the blood.
3. Blood volume
o When the blood volume decreases, the blood pressure decreases
because of decreased fluid in the arteries. Conversely, when the
volume increase, the blood pressure increases because of the
greater fluid volume within the circulatory system.
4. Blood viscosity
o This is a physical property that results from friction of molecules
in a fluid. The blood pressure is higher when the blood is highly
viscous, that is, when the proportion of RBCs to the blood plasma
is high. This ratio is referred to as the hematocrit is more than 60
to 65%
Factors Affecting Blood Pressure
1. Age. Newborn have a mean systolic pressure of 78mmHg. The pressure
rises with age. The pressure rises with age, reaching a peak at the onset of
puberty, and then tends to decline somewhat.
2. Exercise. Physical activity increase both the cardiac output and hence the
blood pressure. Thus, a rest of 20 to 30 minutes is indicated before the
blood pressure can be readily assessed.
3. Stress. Stimulation of the sympathetic nervous system increase cardiac
output and vasoconstriction of the arterioles, thus increasing the blood
4. Race. African American males over 35 years have higher blood pressure
than European American males of the same age.
5. Obesity. Pressure is generally higher in some overweight and obese people
than in people of normal weight.
6. Sex. After puberty, females usually have lower blood pressures than males
of the same age; this difference is thought to be due to hormonal
variations. After menopause, women generally have higher blood
pressures than before.
7. Medications. Many medications may increase or decrease the blood
pressure; nurses should be aware of the specific medications a client is
receiving and consider their possible impact when interpreting blood
pressure readings.
8. Diurnal variations. Pressure is usually lowest early in the morning, when
the metabolic rate is lowest, then rises throughout the day and peaks in
the late afternoon or early evening.
9. Disease process. Any conditions affecting the cardiac output, viscosity, and
or compliance of the arteries have a direct effect on the blood pressure.
Common Errors in Blood Pressure Assessment

Auscultatory gap is the temporary disappearance of sounds normally heard over
the brachial artery when the cuff pressure is high and the reappearance of the
sounds at a lower level.

Provide excellent clues to the physiological functioning of the body.
Alterations in body fxn are reflected in the body temp, pulse, respirations
and blood pressure.
These data provide part of the baseline info from which plan of care is
Any change from normal is considered to be an indication of the persons
state of health.
Also called Cardinal Signs.


How to Assess Pain
1. You must consider both the patients description and your observations on
his behavioral responses.
2. First, ask the client to rank his pain on a scale of 0-10, with 0 denoting lack
of pain and 10 denoting the worst pain imaginable.
3. Ask:
a. Where is the pain located?
b. How long does the pain last?
c. How often does it occur?
d. Can you describe the pain?
e. What makes the pain worse?
f. Observe the patients behavioral response to pain (body language, moaning,
grimacing, withdrawal, crying,restlessness muscle twitching and immobility)
g. Also note physiological response, which may be sympathetic or
Managing Pain
1. Giving medication as per MDs order
2. Giving emotional support
3. Performing comfort measures
4. Use cognitive therapy


Bladder cuff too narrow Erroneously high
Bladder cuff too wide Erroneously high
Arm unsupported Erroneously high
Insufficient rest before the
Erroneously high
repeating assessment too quickly Erroneously high
Cuff wrapped too loosely or
Erroneously high
Deflating cuff too quickly Erroneously low systolic and high diastolic
Deflating cuff too slowly Erroneously high diastolic reading
Failure to use the same arm
Inconsistent measurements
Arm above level of the heart Erroneously low
Assessing immediately after a meal
or while client smokes
Erroneously high
Failure to identify auscultatory gap
Erroneously low systolic pressure and
erroneously low diastolic
Theoretical Foundation of Nursing Overview
Differentiation of Terms
Conceptual framework
Abstract ideas or mental images of phenomena or reality
Often called the building blocks of theories
Examples: mass, energy, ego, id
A pattern of shared understanding and assumptions about reality and the
Include notions of reality that are largely unconscious or taken for granted
Derived from cultural beliefs
Examples: time, space
Concepts that can be superimposed on other concepts
Four major metaparadigms in nursing
o Person
o Environment
o Health
o Nursing
Supposition or system of ideas proposed to explain a given phenomenon
Attempt to explain relationships between concepts
Offer ways to conceptualize central interests of a discipline
Example: Freuds theory of the Unconscious

Purposes of Nursing Theory
1. Link among nursing theory, education, research, and clinical practice
2. Contributes to knowledge development
3. May direct education, research, and Practice

The Living Tree of Nursing Theories

Criteria for Evaluating Theoretical Work

Clarity- How clear is this theory?
Words often have multiple meanings within and across disciplines;
therefore words should be defined carefully and specifically to the
framework (philosophy, conceptual model, or theory) from which it is
Diagrams and examples may facilitate clarity and should be consistent.
Simplicity- How simple is the theory?
Theory should have as few concepts as possible with simplistic relations to
aid clarity.
The most useful theory provides the greatest sense of understanding.
Generality- How general is this theory?
To determine the generality of theory, the scope of concepts and goals
within the theory are examined.
The broader the scope, the greater the significance of the theory.
Empirical precision- How accessible is the theory?
Empirical precision is linked to the testability and ultimate use of a theory
and it refers to theextent that the defined concepts are grounded in
observable reality.
Derivable Consequences- How important is this theory?
Propose that if research, theory, and practice are to be meaningfully
related, then nursing theory should lend itself to research testing and
research testing should lead to knowledge that guides practice.
Indicates that to be considered useful, it is essential for theory to develop
and guide practice.
Care of the Dead
I. Purpose
1. To prepare the body for the morgue.
2. To prevent discoloration or deformity of the body.
3. To protect the body from post mortom discharge.

II. Equipments
Tray with:
Basin of warm water, a basin of lysol solution 2%
Soap in dish, pair of scissors, comb or brush
Bath towel and wash cloth
Surgical dressings p.r.n.
Mortuary pack: should, diaper sheet 2 death tags, non-absorbent cotton,
pins, bandages, forceps.
Bed screen
III. Points to Remember
1. Respect the dead body. Avoid unnecessary exposure and irrelevant
2. The body should be identified properly.
3. Clothings, jewelry and other valuables or belongings must be kept and
cared for properly.

IV. Procedure
1. The patient has pronounced dead by the doctor, place the body in dorsal
position with only a small pillow under the head. Straighten
2. See that dentures are placed in the mouth if patient has any
3. Remove all appliances; catheters, drainage tubings, Venoclysis sets, etc.
4. Close the eves and mouth when open.
5. Eyesbring upper lid down to the lower and apply gentle pressure over it
for a while.
6. Mouthbring the jaws together by placing a rolled towel under the chin.
7. Remove extra bed linen and camisa. Leave one sheet to cover the body.
8. Bathe the body using the Lysol solution to rinse.
9. Change surgical dressings p.r.n. Pack anus with cotton. Vagina (if female). If
there is any discharge from the nose and mouth, pack them too. Use
10. Place the diaper.
11. Full hands over the chest. Pad wrists with cotton and the tie the 2 wrists
together with bandage. Attach one tag to the wrist.
12. Pad the ankles and tie them together.
13. Put on the shroud. Wrap body with a sheet well. Attach the other tag at
the center
14. Cover the prepared body with a sheet and notify the head nurse or call for
the messenger to take the body to the morgue.
Central to all helping professions, and enables persons to create meaning
in their lives.
Means that people, relationships, and things matter

Nursing Theories of Caring

Culture Care Diversity and Universality Theory (Leininger)
Based on transcultural nursing model
Transcultural nursing: a learned branch of nursing that focuses on the
comparative study & analysis of cultures as they apply to nursing and
health-illness practices, beliefs, and values
Goal of Transcultural Nursing: to provide care that is congruent with
cultural values, beliefs, and practices
Cultures exhibit both diversity and universality
Diversity - perceiving, knowing, and practicing care in different ways
Universality - commonalities of care
Fundamental Theory Aspects - culture, care, cultural care, world view, folk
health or well-being systems
Theory of Bureaucratic Caring (Ray)
Rays theory focuses on caring in organizations (e.g. hospital) as cultures.
The theory suggests that caring in nursing is contextual and is influenced
by the organizational structure.
Example: ICU had a dominant value of technological caring (i.e., monitors,
ventilators, treatments), Oncology unit had a value of a more intimate,
spiritual caring (i.e., family focused, comforting, compassionate).
Furthermore, the meaning of caring was further influenced by the role and
position a person held. Staff nurses valued caring in terms of its
relatedness to client, while administrator valued caring as system related.
Spiritual ethical caring influences each of the aspects of the bureaucratic
system (political, legal, economic,, educational, physiologic, social-cultural,
and technological)
Caring, the Human Mode of Being (Roach)
Caring is the human mode of being, proposes that all persons are caring,
and develop their caring abilities by being true to self.
Develop the Six Cs of Caring in Nursing:
Six Cs of Caring in Nursing

Awareness of ones relationship to others, sharing their joys, sorrows, pain,
and accomplishments. Participation in the experience of another
Having the knowledge, judgment, skills, energy, experience, and
motivation to respond adequately to others within the demands of
professional responsibilities.
The quality that fosters trusting relationships. Comfort with self, client, and
Morals, ethics, and an informed sense of right and wrong. Awareness of
personal responsibility.
Convergence between ones desires and obligations and the deliberate
choice to act in accordance with them.
Appropriate bearing, demeanor, dress, and language, that is in harmony
with a caring presence. Presenting oneself as someone who respects
others and demands respect.

Nursing as Caring (Boykin and Schoenhofer)
Suggests that the purpose of the discipline and profession of nursing is to
know persons and nurture them as persons living in caring and growing in
Similar to Roach idea that all persons are caring.
Caring in nursing is an altruistic, active expression of love, and is the
intentional and embodied recognition of value and connectedness.
Theory of Human Care (Watson)
Human caring in nursing is not just an emotion, concern, attitude, or
benevolent desire. Caring is a moral ideal of nursing whereby the end is
protection, enhancement, and preservation of human dignity.
Theory of Caring (Swanson)
Caring involves 5 processes:
Process Definition Sub dimensions


Striving to understand an
event as it has meaning in
life of the other
Avoiding assumptions
Centering on the one cared
Assessing thoroughly
Seeing cues
Engaging the self of both

Being With

Being emotionally present
to other
Being there
Conveying ability
Sharing feelings
Not burdening

Doing For

Doing for the other as
he/she would do for the
self if it were at all
Preserving dignity


Facilitating the others
passage through life
transitions and unfamiliar
Alternative/thinking it
Validating/giving feedback


Sustaining faith in the
others capacity to get
through an event or
transition and face a
future meaning
Believing in/ holding in
Maintaining a hope-filled
Offering realistic optimism
Going the distance

The Primacy of Caring (Benner and Wrubel)
Caring is central to the essence of nursing. Caring creates the possibilities
for coping and creates possibilities for connecting with and concern for

Caring for Self

Caring for self means taking the time to nurture oneself. This involves initiating and
maintaining behaviors that promote healthy living and well-being.
A balanced diet
Regular exercise
Adequate rest and sleep
Recreational Activities
Meditation and prayer
Changing a Central Line Catheter Dressing
Sample Central Line Dressing Checklist
Critical Performance Elements YES NO
1. Gather all necessary equipment: roll of tape, label, and central line line dressing kit.
2. Wash hands. Explain procedure to the patient and/or significant others. Check for
providone-iodine or tape allergy.
3. Organize supplies and equipment at bedside to decrease the amount of time that site is
open to air.

4. *** Open central line kit. Don mask. (Don gown if soiling is likely).
5. Place patient in supine position with head turned away from catheter insertion site to
decrease potential for contamination by patients secretions. Place a mask over the
patients mouth and nose or sterile drape over ventilated or trached patient.

6. *** Don a pair of clean gloves.
7. Remove present dressing carefully to minimize trauma and prevent accidental
dislodgment of catheter. Discard soiled dressing in proper trash receptacle.

8. Visually inspect the skin and catheter site for signs of infection, leakage, or other
mechanical problems.

9. *** Remove soiled gloves and don sterile gloves.
10. *** Working in a circular motion from insertion site outward to edge of dressing border
cleanse skin, insertion site, and distal portion of catheter with :
a. Providone-iodine scrub swabsticks x 3 to remove bacteria and fungi.
b. Alcohol swabsticks x 3 to remove the betadine scrub.
c. Betadine solution swabsticks x 3 to cover a 3 x 6 area from site to periphery- to provide
protective barrier against pathogens. Blot excess or pooled solution. Allow to dry.
*** For patients with IODINE ALLERGY- If 4% chlorhexidine is used, remove it with alcohol
swabs after a two to five minute dwell time.

11. If a tubing change is necessary:
a. Instruct the patient to perform Valsalva maneuver or hold his/her breath (or immediately
after a ventilator delivers a breath).
b. Quickly disconnect and reconnect the IV tubing ensuring secure junction.

12. *** Dressing- may use elastoplast or occlusive dressing as follows:
a. Elastoplast:
place folded 22 over insertion site to include sutures to prevent the tape/
elastoplast from sticking to the line and sutures.
paint around the edges of the gauze with skin prep and allow to dry.
cut elastoplast to fit over insertion site and sutures.

apply elastoplast and secure edges with tape.
b. Occlusive Dressing- (Tegaderm):
do not use 22
skin prep is optional
apply occlusive dressing according to manufacturers guidelines.
13. *** Loop and secure IV tubing to dressing and arm or chest.
14. *** Label dressing with time, date of dressing change and insertion, and initials.
15. Discard supplies used. Wash hands.
17. *** Document the dressing change, the condition of the insertion site on nursing note
and flow sheet. Document any problems encountered in nursing progress notes on.

NOTE: If 22 gauze used after initial insertion under occlusive (Tegaderm) dressing, dressing
must be changed in 24 hours.

*** Must perform these critical elements for successful completion.

Changing and flushing a central line access cap
Check clients chart and care plan to determine time of last access cap
Identify client
Explain procedure to client and provide privacy
Gather equipment
Wash your hand and don gloves
Repeat procedure with the remaining access caps
Remove gloves and wash hands
Changing a Hospital Gown for a Client with an Intravenous Infusion
1. Slip the growth completely off the arm without the infusion and onto the tubing
connected to the arm with the infusion.
2. Holding the container above the clients arm, slide the sleeve up over the
container to remove the used gown.
3. Place the clean gown sleeve for the arm with the infusion over the container as if
it were an extension of the clients arm, from the inside of the gown to the sleeve
4. Rehang the container. Slide the gown carefully over the tubing toward the
clients hand.
5. Guide the clients arm and tubing into the sleeve, taking care not to pull on the
6. Assist the client to put the other arm into the second sleeve of the gown, and
fasten as usual.
7. Count the rate of flow of the infusion to make sure it is correct before leaving the
Changing Mainline IV Bag
Check physicians order.
Wash Hands.
Select correct solution (using 5 rights of drug administration).
Remove outer wrap.
Inspect bag carefully for tears or leaks by applying gentle pressure to the
Hold the bag up and examine for cloudiness, discoloration, or any foreign
Label bag with patients name, date, time or according to agency policy.
Tape bag based on hourly flow rate and initial.
Identify patient, explain procedure and asses IV site.
Asses IV site again.
Discard old bag according to agency policy
Record I&O and IV solution according to agency policy.
Check physicians order.
Wash Hands.
Select correct solution (using 5 rights of drug administration).
Remove outer wrap.
Inspect bag carefully for tears or leaks by applying gentle pressure to the
Hold the bag up and examine for cloudiness, discoloration, or any foreign
Label bag with patients name, date, time or according to agency policy.
Tape bag based on hourly flow rate and initial.
Identify patient, explain procedure and asses IV site.
Asses IV site again.
Discard old bag according to agency policy
Record I&O and IV solution according to agency policy.
I. In Dorsal Recumbent Position:
1. Arrange the pillows in the order to support the weight of the shoulders
and head.
2. Relieve strain on the muscles of the back by supporting it, fill in the
hollows with small pillows, small pads, or a hot water bottle partially filled
with warm water.
3. Relieve strain on the abdominal muscles and on tendons under the knees.
Support with the knee rest provided on the Gatch bed or with a pillow.

II. Turning to One Side:
A. To turn the patient toward you:
1. Move the patient to the side of the bed away from you by putting your
forearms under the body then sliding first the head and shoulders, next the
hips then legs across the bed.
2. Place one of your arms across the patients back reaching from the far side
to the side nearer you and the other arm across his hips on the same way.
3. Lift and turn him gently toward you to the middle of the bed.
4. See that the head, shoulders and hips are properly adjusted, that the neck
and shoulders are not cramped and the arms are not pinned under the
5. Flex the knees with the upper leg flexed a little more than the lower leg.
6. Support the legs by placing a pad or small pillow between them.
7. Support the whole length of the back with pillows so that the patient can
relax comfortably.
8. A small pillow placed against the abdomen gives relief and comfort
especially when the patient is suffering from gas pains.
B. To turn patient away from you:
1. From the side nearest you, slip one arm under the patients shoulder
reaching the far shoulder and place the other around the hips in the same
2. Lift and draw his far side slightly toward you so that he is gradually turned
away from you.
Purpose of Charting:

To make record of
1. The significant observation of the patients condition both mental and
2. The medication, treatment, diets and nursing care given and the reaction
of the patient to this care.
3. The incident which might have some bearing on the patients condition.

General Rules for Charting:
1. All recording on the chart must be printed, except the written signature of
the nurse.
2. The written signature of the nurse should consist of her initial of first name
and fill last name.
(a) The signature should stand alone on the line just below the notations
recorded by her.
(b) The signature of the nurse should be of a size that will insure legibility
without attracting attention.
3. A nurse making a series of statements or notations signs for the series and
not for each individual statement or notation.
4. The nurse should not go off duty without making the necessary notations
on the charts of each patient assigned to her to cover the time of the
5. All recording on the chart should be neat, legible, intelligent and
6. Statements must be accurate, relevant and concise.
(a) Terse statements instead of complete sentence are used.
(b) Correct spelling and only acceptable and official abbreviations are to be
7. Authentic recording is essential as a chart often plays an important part in
the presentation of court evidence.
8. Print the proper headings for all new pages or sheets to be added to the
chart using blue or black ink.
9. Keep all recordings within limits provided by the pale. Begin each separate
notation on the horizontal lines where it intersects the vertical limiting
10. Do not use ornamental lettering for recording on the chart.
11. Blue or black ink should be used for recording between the hours of
7:00am to 11:00pm.
12. Red ink should be used for recording between the hours of 11:00pm to
13. The midnight lines are to be drawn in red ink. Write the date and the day
of the new day between the midnight lines.
14. In the hour column, record the time of treatment, medication, appearance
of symptoms, doctors visit, etc.
15. In the observations column:
(a) Record any of all symptoms, complaints or change in the condition of
the patient.
(b) Record all start and p.r.n. treatments and medications given.
(c) Record the results and effects of the medications and treatments.
(d) Record routine nursing procedures involved in the care of the patient.
(e) Record each time the attending physician visits the patient.
16. Never print the word patient when charting. The chart in itself is a record
for the individual patient and all notations are in regard to the person for
whom the record is kept.
17. Do not write the orders of the doctor as Dr. Smith ordered backrest
elevated two inches.
18. Arrange the different sheets on the chart in correct order.
19. Errors in charting:
(a) Do not erase errors made in charting
(b) When an error has been made, draw a line through the error from the
upper left hand corner to the lower right hand corner to inchide the
necessary space containing the error and write the word ERROR under
which the nurse signs her name.
(c) An error in charting should not necessarily invoke recopying of the
entire page. Consult the supervisor or headnurse before copying a page on
which you have made an error. It is necessary to recopy, the original page
must be filed at the back of the chart.

General Rules for Printing:
1. Printing is the most consistently legible of all forms of writing for that
reason should be used for recording on hospital charts.
2. Print well formed, individual letters in each ward.
3. Properly space all printed letters and words.
4. Do not use more than one space for each letter, regardless of the shape of
that letter.
5. Separate printed words by a space the size of single letter.
6. Do not use unnecessary curves tails or fancy strokes in making the printed
7. Make all printed letters stand erect.
8. To avoid illegibility, do not make too much of a forward backward slant to
the letters.
9. Make all printed letters conform in appearance to those in the sample
10. Make each printed letter rest on the line.
11. Always make the small letter 2/3 the height of capital ones.
12. Make the letter U curved at the bottom, make the letter V with art
acute angle at the bottom.
13. Cross the letter t, horizontally at the upper third of its height.
14. Make the use of the word bed to remember on which side of the stem to
make the loop for the letters b and d.
15. For practice in printing use only those letters which are illustrated in the
sample alphabet.
16. Print numbers that are to be used in charting as well as letters.

Example of Data to be Charted:

1. All doctors orders.
(a) Medicines given, the time at which they are, and when, used to relieve a
condition that should respond to treatment within a short time.
(b) Inspections, or punctures done, time result, and by whom.
(c) Treatment given, time and effect on patients condition during or after the
treatment, or results of flow in cases or irrigations, etc.
(d) Operation delivery, kinds, time, TPR after.
2. When recording the dressing of wound, state condition of the letter, if there is
discharge, mention and change in the treatment or dressing by whom and time.
3. Symptoms
a. Subjective
b. Objectives:
(b1)All conditions that call for particularly careful attention to their record e.g.
following surgical operation or X-ray or other treatment that may-have harmful
effects, accidents, chills, convulsions and when patient is very ill.
(b3)Nature of excreta or order discharges, etc.
4. Amount of sleep.
5. Appetite and amount of food taken.
Cleaning Bedpans and Urinals
I. Equipment:
1. Tray with bedpan brush, bedpan swab
2. Short-sleeved gown
3. Can of disinfectant solution
4. Soap or any cleanser
5. Several pieces of dusting cloth

II. Procedure for Cleaning Bedpans and Urinals
1. Put on the short-sleeved gown
2. Collect the bedpans
3. Empty the contents one by one into the hoper. Wash with clean cold
water. Use brush p.r.n. Follow with hot water.
4. Put the bedpan in the scan of disinfectant
5. Remove after, wash inside and outside with warm soapy water. Remove
any stains using the cleanser
6. Rinse with hot water
7. Wipe to dry with the bedpan wiper and hang it at the bedpan rack.
Cleaning Sputum Cups
I. Equipment:
Tray with big basin of disinfectant solution. Creosol solution 5%.
Medicine glass
A pitcher of 1% creosol solution
Sputum cup brush
Several pieces of dusting cloth
Sapolio or Cleanser
Short-sleeved gown

II. Procedure:
1. Put on the gown.
2. Collect all the sputum cups in a tray.

3. Empty their contents into the hopper. Wash with cold water. Rinse with
hot water. Use brush p.r.n.
4. Place cup in basin of disinfectant solution of 5% Creosol solution for 2
5. Remove after, clean inside and out with soapy warm water. Remove stains.
6. Rinse with hot water and dry the outside.
7. Fill each sputum cup with 50 cc of 1% of Creosol solution and place in the
trays, distribute back to each patient.
8. For children and delirious patients, do not put Creosol solution inside their
sputum cups.

It is the process of exchanging information or feelings between two or
more people. It is a basic component of human relationship, including

The Communication process

Or stimulus motivates a person to communicate with another. It may be an
object, emotion, idea or act.
Also called the encoder, is the person who initiates the interpersonal
communication or message
The information that is sent or expressed by the sender.
It means, conveying messages such as through visual, auditory and tactile
Also called the decoder, is the person to whom the message is sent
Helps to reveal whether the meaning of the message is received

Modes of Communication

Verbal communication- uses the spoken or written word

1. Pace and Intonation
The manner of speech, as in the pace or rhythm and intonation, will modify
the feeling and impact of the message. For example, speaking slowly and
softly to an excited client may help calm the client.
2. Simplicity
Includes the use of commonly understood words, brevity, and
Nurses need to learn to select appropriate, understandable terms based
on the age, knowledge, culture and education of the client. For example,
instead of saying to a client, the nurses will be catheterizing you
tomorrow for a urinalysis, I would be more appropriate to say,
Tomorrow we need to get a sample of your urine, so we will collect it by
putting a small tube into your bladder.
3. Clarity and Brevity
A message that is direct and simple will be more effective. Clarity is saying
precisely what is meant, and brevity is using the fewest words necessary.
The goal is to communicate clearly so that all aspects of a situation or
circumstances are understood. To ensure clarity in communication, nurses
also need to speak slowly and enunciate carefully.
4. Timing and Relevance
No matter how clearly or simply words are stated or written, the timing
needs to be appropriate to ensure that words are heard.
This involves sensitivity to the clients needs and concerns. E.g., a client
who is enmeshed in fear of cancer may not hear the nurses explanations
about the expected procedures before and after gallbladder surgery.
5. Adaptability
What the nurse says and how it is said must be individualized and carefully
considered. E.g., a nurse who usually smiles, appears cheerful, and greets
his clients with an enthusiastic Hi, Mrs. Jones! notices that the client is
not smiling and appears distressed. It is important for the nurse to then
modify his tone of speech and express concern in his facial expression
while moving toward the client.
6. Credibility
Means worthiness of belief, trustworthiness, and reliability. Nurses foster
credibility by being consistent, dependable, and honest.
Nurses should convey confidence and certainly in what they are saying,
while being to acknowledge their limitations (e.g., I dont know the
answer to that, but I will find someone who does.
7. Humor
The use of humor can be a positive and powerful tool in nurse- client
relationship, but it must be used with care. When using humor, it is
important to consider the clients perception of what is considered
Non-verbal Communication- uses other forms, such as gestures or facial
expressions, and touch.

1. Personal Appearance
When the symbolic meaning of an object is unfamiliar the nurse can
inquire about its significance, which may foster rapport with the client.
How a person dresses is often an indicator of how person feels. E.g. For
acutely ill clients n hospital or home care settings, a change in grooming
habits may signal that the client is feeling better. A man may request a
shave, or a woman may request a shampoo and some makeup.
2. Posture and Gait
The ways people walk and carry themselves are often reliable indicators of
self-concept, current mood, and health. Erect posture and an active,
purposeful stride suggest a feeling of well being. Slouched posture and
slow, shuffling gait suggest depression or physical discomfort.
The nurse clarifies the meaning of the observed behavior, e.g. You look
like it really hurts you to move. Im wondering how your pain is and if you
might need something to make you more comfortable?
3. Facial Expression
No part of the body is as expressive as the face
Although he face may express the persons genuine emotions, it is also
possible to control these muscles so the emotion expresses does not
reflect what the person is feeling. When the message is not clear, it is
important to get feedback to be sure of the intent of expression.
Nurses need to be aware of their own expressions and what they are
communicating to others. It is impossible to control all facial expression,
but the nurse must learn to control expressions of feelings such as fear or
disgust in some circumstances.
Eye contact is another essential element of facial communication
4. Gesture
Hand and body gestures may emphasize and clarify the spoken word, or
they may occur without words to indicate a particular feeling or give a sign
Electronic Communication- many health care agencies are moving toward
electronic medical records where nurses document their assessments and nursing

Most common form of electronic communication.
Advantage: It is fast, efficient way to communicate and it is legible. It
provides a record of the date and time of the message that was sent or
Disadvantage: risk of confidentiality
When Not to Use Email:
a. When information is urgent
b. Highly confidential information (e.g. HIV status, mental health, chemical
c. Abnormal lab data
Agencies usually develop standards and guidelines in use of e-mail

Factors Influencing the Communication Process

1. Development
Language, psychosocial, and intellectual development move through
stages across the lifespan.
2. Gender
Girls tend to use language to seek confirmation, minimize differences, and
establish intimacy. Boys use language to establish independence and
negotiate status within a group.
3. Values and Perception
Values are the standards that influence behavior, and perceptions are the
personal view of event.
4. Personal Space
Personal space is the distance people prefer in interactions with others.
Proxemics is the study of distance between people in their interactions
Communication 4 distances:
a. Intimate: Touching to 1
b. Personal: 1 to 4 feet
c. Social: 4 to 12 feet
d. Public: 12 to 15 feet

5. Territoriality
Is a concept of the space and things that an individual considers as
belonging to the self
6. Roles and Relationships
Choice of words, sentence structure, and tone of voice vary considerably
from role to role. (E.g. nursing student to instructor, client and primary
care provider, or parent and child).
7. Environment
People usually communicate most effectively in a comfortable
8. Congruence
The verbal and nonverbal aspects of message match. E.g., when teaching a
client how to care for a colostomy, the nurse might say, You wont have
any problem with this. However, if the nurse looks worried or disgusted
while saying this, the client is less likely to trust the nurses words.
9. Interpersonal Attitudes
Attitudes convey beliefs, thoughts, and feelings about people and events.
Caring and warmth convey a feeling of emotional closeness
Respect is an attitude that emphasizes the other persons worth and
individuality. A nurse coveys respect by listening open mindedly even if the
nurse disagrees.Acceptance emphasizes neither approval nor disapproval
.The nurse willingly receives the clients honest feelings.

1. Is the means to establish a helping-healing relationship. All behavior
communication influences behavior.
2. Communication is essential to the nurse-patient relationship for the
following reasons:
3. Is the vehicle for establishing a therapeutic relationship.
4. It the means by which an individual influences the behavior of another,
which leads to the successful outcome of nursing intervention.

Basic Elements of the Communication Process
1. Sender is the person who encodes and delivers the message
2. Messages is the content of the communication. It may contain verbal,
nonverbal, and symbolic language.
3. Receiver is the person who receives the decodes the message.
4. Feedback is the message returned by the receiver. It indicates whether
the meaning of the senders message was understood.

Modes of Communication
1. Verbal Communication use of spoken or written words.
2. Nonverbal Communication use of gestures, facial expressions,
posture/gait, body movements, physical appearance and body language

Characteristics of Good Communication
1. Simplicity includes uses of commonly understood, brevity, and
2. Clarity involves saying what is meant. The nurse should also need to
speak slowly and enunciate words well.
3. Timing and Relevance requires choice of appropriate time and
consideration of the clients interest and concerns. Ask one question at a
time and wait for an answer before making another comment.
4. Adaptability Involves adjustments on what the nurse says and how it is
said depending on the moods and behavior of the client.
5. Credibility Means worthiness of belief. To become credible, the nurse
requires adequate knowledge about the topic being discussed. The nurse
should be able to provide accurate information, to convey confidence and
certainly in what she says.

Communicating With Clients Who Have Special Needs

1. Clients who cannot speak clearly (aphasia, dysarthria, muteness)
a. Listen attentively, be patient, and do not interrupt.
b. Ask simple question that require yes and no answers.
c. Allow time for understanding and response.
d. Use visual cues (e.g., words, pictures, and objects)
e. Allow only one person to speak at a time.
f. Do not shout or speak too loudly.
g. Use communication aid:Pad and felt-tipped pen, magic slate, pictures denoting
basic needs, call bells or alarm.

2. Clients who are cognitively impaired
a. Reduce environmental distractions while conversing.
b. Get clients attention prior to speaking
c. Use simple sentences and avoid long explanation.
d. Ask one question at a time
e. Allow time for client to respond
f. Be an attentive listener
g. Include family and friends in conversations, especially in subjects known to client.

3. Client who are unresponsive
a. Call client by name during interactions
b. Communicate both verbally and by touch
c. Speak to client as though he or she could hear
d. Explain all procedures and sensations
e. Provide orientation to person, place, and time
f. Avoid talking about client to others in his or her presence
g. Avoid saying things client should not hear

4. Communicating with hearing impaired client
a. Establish a method of communication (pen/pencil and paper, sign-language)
b. Pay attention to clients non-verbal cues
c. Decrease background noise such as television
d. Always face the client when speaking
e. It is also important to check the family as to how to communicate with the client
f. It may be necessary to contact the appropriate department resource person for
this type of disability

5. Client who do not speak English
a. Speak to client in normal tone of voice (shouting may be interpreted as anger)
b. Establish method for client o signal desire to communicate (call light or bell)
c. Provide an interpreter (translator) as needed
d. Avoid using family members, especially children, as interpreters.
e. Develop communication board, pictures or cards.
f. Have dictionary (English/Spanish) available if client can read.

Are oral, written, or audiotape exchanges of information between
Common reports
1. Change-in-shift report
2. Telephone report
3. Telephone or verbal orders only RNs are allowed to accept telephone orders.
4. Transfer report
5. Incident report

1. Is anything written or printed that is relied on as record or proof for
authorized person.
2. Nursing documentation must be:
o accurate
o comprehensive
o flexible enough to retrieve critical data, maintain continuity of
care, track client outcomes, and reflects current standards of
nursing practice
3. Effective documentation ensures continuity of care saves time and
minimizes the risk of error.
4. As members of the health care team, nurses need to communicate
information about clients accurately and in timely manner
5. If the care plan is not communicated to all members of the health care
team, care can become fragmented, repetition of tasks occurs, and
therapies may be delayed or omitted.
6. Data recorded, reported, or communicated to other health care
professionals are CONFIDENTIAL and must be protected.

1. Nurses are legally and ethically obligated to keep information about clients
2. Nurses may not discuss a clients examination, observation, conversation,
or treatment with other clients or staff not involved in the clients care.
3. Only staff directly involved in a specific clients care has legitimate access
to the record.
4. Clients frequently request copies of their medical record, and they have
the right to read those records.
5. Nurses are responsible for protecting records from all unauthorized
6. When nurses and other health care professionals have a legitimate reason
to use records for data gathering, research, or continuing education,
appropriate authorization must be obtained according to agency policy.
7. Maintaining confidentiality is an important aspect of profession behavior.
8. It is essential that the nurse safe-guard the client right to privacy by
carefully protecting information of a sensitive, private nature.
9. Sharing personal information or gossiping about others violates nursing
ethical codes and practice standards.
10. It sends the message that the nurse cannot be trusted and damages the
interpersonal relationships.

Guidelines of Quality Documentation and Reporting

1. Factual
a. A record must contain descriptive, objective information about what a nurse
sees, hears, feels, and smells.
b. The use of vague terms, such as appears, seems, and apparently, is not
acceptable because these words suggest that the nurse is stating an opinion.

The client seems anxious (the phrase seems anxious is a conclusion without
supported facts.)
2. Accurate
a. The use of exact measurements establishes accuracy. (example: Intake of 350 ml
of water is more accurate than the client drank an adequate amount of fluid
b. Documentation of concise data is clear and easy to understand.
c. It is essential to avoid the use of unnecessary words and irrelevant details

3. Complete

a. The information within a recorded entry or a report needs to be complete,
containing appropriate and essential information.
The client verbalizes sharp, throbbing pain localized along lateral side of right ankle,
beginning approximately 15 minutes ago after twisting his foot on the stair. Client
rates pain as 8 on a scale of 0-10.

4. Current
a. Timely entries are essential in the clients ongoing care. To increase accuracy and
decrease unnecessary duplication, many healthcare agencies use records kept near
the clients bedside, which facilitate immediate documentation of information as it
is collected from a client

5. Organized

a. The nurse communicates information in a logical order.

An organized note describes the clients pain, nurses assessment, nurses
interventions, and the clients response

Legal Guidelines for Recording
1. Draw single line through error, write word error above it and sign your
name or initials. Then record note correctly.
2. Do not write retaliatory or critical comments about the client or care by
other health care professionals.
o Enter only objective descriptions of clients behavior; clients
comments should be quoted.
3. Correct all errors promptly
o Errors in recording can lead to errors in treatment
o Avoid rushing to complete charting, be sure information is
4. Do not leave blank spaces in nurses notes.
o Chart consecutively, line by line; if space is left, draw line
horizontally through it and sign your name at end.
5. Record all entries legibly and in blank ink
o Never use pencil, felt pen.
o Blank ink is more legible when records are photocopied or
transferred to microfilm.
o Legal Guidelines for Recording
6. If order is questioned, record that clarification was sought.
o If you perform orders known to be incorrect, you are just as liable
for prosecution as the physician is.
7. Chart only for yourself
o Never chart for someone else.
o You are accountable for information you enter into chart.
8. Avoid using generalized, empty phrases such as status unchanged or
had good day.
o Begin each entry with time, and end with your signature and title.
o Do not wait until end of shift to record important changes that
occurred several hours earlier. Be sure to sign each entry.
9. For computer documentation keep your password to yourself.
o Maintain security and confidentiality.
o Once logged into the computer do not leave the computer screen

D5LRS (Lactated Ringers Solution) IV Fluid
The Dextrose 5% in Lactated Ringers Solution (D5LRS) is useful for daily
maintenance of body fluids and nutrition, and for rehydration.
Type of Solution
Nonpyrogenic, parenteral fluid, electrolyte and nutrient replenisher

Parenteral fluid
Nutrient replenisher

Electrolytes 1000ml
Sodium 130 mmol
Potassium 4 mmol
Calcium 1.4 mmol
Chloride 109 mmol
Lactate 28 mmol
Osmolality 406 mOsm

Mechanism of Action
Hypertonic solutions are those that have an effective osmolarity greater
than the body fluids. This pulls the fluid into the vascular by osmosis
resulting in an increase vascular volume. It raises intravascular osmotic
pressure and provides fluid, electrolytes and calories for energy.

Indications of D5NM
Treatment for persons needing extra calories who cannot tolerate fluid
Treatment of shock.

Hypersensitivity to any of the components.

D5LRs is supplied in single-dose 500 and 1000 mL flexible plastic
1000 mL @ 30 gtts/min or as prescribed by the physician.

Nursing Responsibilities
Do not administer unless solution is clear and container is undamaged.
Caution must be exercised in the administration of parenteral fluids,
especially those containing sodium ions to patients receiving
corticosteroids or corticotrophin.
Solution containing acetate should be used with caution as excess
administration may result in metabolic alkalosis.
Solution containing dextrose should be used with caution in patients with
known subclinical or overt diabetes mellitus.
Discard unused portion.
In very low birth weight infants, excessive or rapid administration of
dextrose injection may result in increased serum osmolality and possible
intracerebral hemorrhage.
Properly label the IV Fluid
Observe aseptic technique when changing IV fluid
D5NM (Normosol-M) IV Fluid
Type of Solution
Dextrose 5% in Normosol M Solution
Hypertonic solution of balanced maintenance electrolytes and 5% dextrose
injection in water for injection


Parenteral fluid
Nutrient replenisher

Each 1000 mL contains 5g of Dextrose Monohydrate,
234 mg of sodium chloride
128 mg of potassium acetate tetrahydrate and
30mg (approximately 1.6 mmol/L) of sodium Metabisulfate.

Mechanism of Action
When administered intravenously, Normosol-M and 5% Dextrose Injection
provides water and electrolytes (with dextrose as a readily available source
of carbohydrate) for maintenance of daily fluid and electrolyte
requirements, plus minimal carbohydrate calories.
The electrolyte composition approaches that of the principal ions of
normal plasma (extracellular fluid).
The electrolyte concentration is hypotonic (112 mOsmol/liter) in relation
to the extracellular fluid (280 mOsmol/liter).
One liter provides approximately one-third of the average adult daily
requirement for water and principal electrolytes in balanced proportions,
with acetate as a bircarbonate alternate,plus 170 calories from dextrose.

Indications of D5NM
D5NM is indicated for parenteral maintenance of routine daily fluid and
electrolyte requirements with minimal carbohydrate calories from
Magnesium in the formula may help to prevent iatrogenic magnesium
deficiency in patients receiving prolonged parenteral therapy.

Hypersensitivity to any of the components.

D5NM is supplied in single-dose 500 and 1000 mL flexible plastic
1000 mL @ 30 gtts/min.

Nursing Responsibilities
Do not administer unless solution is clear and container is undamaged.
Caution must be exercised in the administration of parenteral fluids,
especially those containing sodium ions to patients receiving
corticosteroids or corticotrophin.
Solution containing acetate should be used with caution as excess
administration may result in metabolic alkalosis.
Solution containing dextrose should be used with caution in patients with
known subclinical or overt diabetes mellitus.
Discard unused portion.
In very low birth weight infants, excessive or rapid administration of
dextrose injection may result in increased serum osmolality and possible
intracerebral hemorrhage.
Properly label the IV Fluid
Observe aseptic technique when changing IV fluid

D5W (Dextrose 5% Water) IV Fluid
Dextrose 5% in Water (D5W) raises total fluid volume it is also helpful in rehydrating
and excretory purposes.

Type of Solution
Dextrose 5% Water

Isotonic then hypotonic (once inside the body)

Isotonic then hypotonic
Parenteral fluid
Nutrient replenisher

Dextrose Hydrous 50gm/L

Mechanism of action
Dextrose provides a source of calories. Dextrose is readily metabolized,
may decrease losses of body protein and nitrogen, promotes glycogen
deposition and decreases or prevents ketosis if sufficient doses are

Lactated Ringers and 5% Dextrose Injection, is indicated as a source of
water, electrolytes and calories or as an alkalinizing agent.

solutions containing dextrose may be contraindicated in patients with
allergy to corn or corn products.

As directed by a physician. Dosage is dependent upon the age, weight and
clinical condition of the patient as well as laboratory determinations.
Parenteral drug products should be inspected visually for particulate
matter and discoloration prior to administration whenever solution and
container permit.
All injections in VIAFLEX plastic containers are intended for intravenous
administration using sterile equipment.
As reported in the literature, the dosage and constant infusion rate of
intravenous dextrose must be selected with caution in pediatric patients,
particularly neonates and low weight infants, because of the increased risk
of hyperglycemia/hypoglycemia.
Additives may be incompatible. Complete information is not available.
Those additives known to be incompatible should not be used. Consult
with pharmacist, if available. If, in the informed judgement of the
physician, it is deemed advisable to introduce additives, use aseptic
technique. Mix thoroughly when additives have been introduced. Do not
store solutions containing additives

Nursing Responsibilities
Suspend container from eyelet support.
Remove plastic protector from outlet port at bottom of container.
Attach administration set. Refer to complete directions accompanying set
Clinical evaluation and periodic laboratory determinations are necessary to
monitor changes in fluid balance, electrolyte concentrations, and acid base
balance during prolonged parenteral therapy or whenever the condition of
the patient warrants such evaluation.
Lactated Ringers and 5% Dextrose Injection, USP should be used with
caution. Excess administration may result in metabolic alkalosis.
Caution must be exercised in the administration of parenteral fluids,
especially those containing sodium ions to patients receiving
corticosteroids or corticotrophin.
Solution containing acetate should be used with caution as excess
administration may result in metabolic alkalosis.
If an adverse reaction does occur, discontinue the infusion, evaluate the
patient, institute appropriate therapeutic countermeasures

Diagnostic Tests
PPD test
1. Read result 48 72 hours after injection.
2. For HIV positive clients, in duration of 5 mm is considered positive

1. Secure consent
2. Check for allergies to seafood or iodine or anesthesia
3. NPO 6-8 hours before the test
4. NPO until gag reflex return to prevent aspiration

Thoracentesis (Aspiration of fluid in the pleural space.)
1. Secure consent, take V/S
2. Position upright leaning on over bed table
3. Avoid cough during insertion to prevent pleural perforation
4. Turn to unaffected side after the procedure to prevent leakage of fluid in
the thoracic cavity
5. Check for expectoration of blood. This indicate trauma and should be
reported to MD immediately.

Holter Monitor
1. It is continuous ECG monitoring, over 24 hours period
2. The portable monitoring is called telemetry unit

1. Ultrasound to assess cardiac structure and mobility
2. Client should remain still, in supine position slightly turned to the left side,
with HOB elevated 15-20 degrees

1. If the patients skin is oily, scaly, or diaphoretic, rub the electrode with a
dry 4x4 gauze to enhance electrode contact.
2. If the area is excessively hairy, clip it
3. Remove client`s jewelry, coins, belt or any metal
4. Tell client to remain still during the procedure

Cardiac Catheterization
1. Secure consent
2. Assess allergy to iodine, shellfish
3. V/S, weight for baseline information
4. Have client void before the procedure
5. Monitor PT, PTT, and ECG prior to test
6. NPO for 4-6 hours before the test
7. Shave the groin or brachial area
8. After the procedure : bed rest to prevent bleeding on the site, do not flex
9. Elevate the affected extremities on extended position to promote blood
supply back to the heart and prevent thrombophlebitis
10. Monitor V/S especially peripheral pulses
11. Apply pressure dressing over the puncture site
12. Monitor extremity for color, temperature, tingling to assess for impaired

1. Secure consent,
2. The procedure will last 45-60 minute
3. Assess client for claustrophobia
4. Remove all metal items
5. Client should remain still
6. Tell client that he will feel nothing but may hear noises
7. Client with pacemaker, prosthetic valves, implanted clips, wires are not
eligible for MRI.
8. Client with cardiac and respiratory complication may be excluded
9. Instruct client on feeling of warmth or shortness of breath if contrast
medium is used during the procedure

UGIS Barium Swallow
1. Instruct client on low-residue diet 1-3 days before the procedure
2. Administer laxative evening before the procedure
3. NPO after midnight
4. Instruct client to drink a cup of flavored barium
5. X-rays are taken every 30 minutes until barium advances through the small
6. Film can be taken as long as 24 hours later
7. Force fluid after the test to prevent constipation/barium impaction

LGIS Barium Enema
1. Instruct client on low-residue diet 1-3 days before the procedure
2. Administer laxative evening before the procedure
3. NPO after midnight
4. Administer suppository in AM
5. Enema until clear
6. Force fluid after the test to prevent constipation/barium impaction

Liver Biopsy
1. Secure consent,
2. NPO 2-4 hrs before the test
3. Monitor PT, Vitamin K at bedside
4. Place the client in supine at the right side of the bed
5. Instruct client to inhale and exhale deeply for several times and then
exhale and hold breath while the MD insert the needle
6. Right lateral post procedure for 4 hours to apply pressure and prevent
7. Bed rest for 24 hours
8. Observe for S/S of peritonitis

1. Secure consent, check V/S
2. Let the patient void before the procedure to prevent puncture of the
3. Check for serum protein. Excessive loss of plasma protein may lead to
hypovolemic shock.

Lumbar Puncture
1. Obtain consent
2. Instruct client to empty the bladder and bowel
3. Position the client in lateral recumbent with back at the edge of the
examining table
4. Instruct client to remain still
5. Obtain specimen per MDs order
Cleansing Enemas

Stimulate peristalsis through irrigation of colon and rectum and by distention
1. Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa.
Dilute 5 ml of castile soap in 1000 ml of water
2. Tap water: Give caution o infants or to adults with altered cardiac and
renal reserve
3. Saline: For normal saline enemas, use smaller volume of solution
4. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-
lubricate and does not require further preparation

Oil-Retention Enemas
Lubricates the rectum and colon; the feces absorb the oil and become
softer and easier to pass

Carminative Enema
Provides relief from gaseous distention

Astringent Enema
Contracts tissue to control bleeding

Key Points: Administering Enema
1. Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or
less for children, 250 cc or less fro an infant), 99 degrees F to 102 degrees
F. Solutions that are too hot or too cold, or solutions that are instilled too
quickly, can cause cramping and damage to rectal tissues
2. Allow solution to run through the tubing so that air is removed
3. Place client on left side in Sims position
4. Lubricate the tip of the tubing with water-soluble lubricant
5. Gently insert tubing into clients rectum (3 to 4 inches for adult, 1 inch for
infants, 2 to 3 inches for children), past the external and internal sphincters
6. Raise the water container no more than 12 to 18 inches above the client
7. Allow solution to flow slowly. If the flow is slow, the client will experience
fewer cramps. The client will also be able to tolerate and retain a greater
volume of solution
8. After you have instilled the solution, instruct client to hold solution for
about 10 to 15 minutes
9. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas
are retained 10 to 15 minutes.
Ethico-Moral Aspects in Nursing
Ethos - comes from Greek work w/c means character/culture
- Branch of Philosophy w/c determines right and wrong
Moral - personal/private interpretation from what is good and bad.

Ethical Principles:
1. Autonomy the right/freedom to decide (the patient has the right to
refuse despite the explanation of the nurse) Example: surgery, or any
2. Nonmaleficence the duty not to harm/cause harm or inflict harm to
others (harm maybe physical, financial or social)
3. Beneficence- for the goodness and welfare of the clients
4. Justice equality/fairness in terms of resources/personnel
5. Veracity - the act of truthfulness
6. Fidelity faithfulness/loyalty to clients

Moral Principles:
1. Golden Rule
2. The principle of Totality The whole is greater than its parts
3. Epikia There is always an exemption to the rule
4. One who acts through as agent is herself responsible (instrument to the
5. No one is obliged to betray herself You cannot betray yourself
6. The end does not justify the means
7. Defects of nature maybe corrected
8. If one is willing to cooperate in the act, no justice is done to him
9. A little more or a little less does not change the substance of an act.
10. No one is held to impossible
Law - Rule of conduct commanding what is right and what is wrong. Derived from
an Anglo-Saxon term that meansthat which is laid down or fixed

Court - Body/agency in government wherein the administration of justice is

Plaintiff - Complainant or person who files the case (accuser)

Defendant - Accused/respondent or person who is the subject of complaint

Witness- Individual held upon to testify in reference to a case either for the accused
or against the accused.

Written orders of court

Writ legal notes from the court

1. Subpoena

a. Subpoena Testificandum a writ/notice to an individual/ordering him to
appear in court at a specific time and date as witness.
b. Subpoena Duces Tecum- notice given to a witness to appear in court to
testify including all important documents

Summon notice to a defendant/accused ordering him to appear in court to
answer the complaint against him

Warrant of Arrest - court order to arrest or detain a person

Search warrant - court order to search for properties.

Private/Civil Law - body of law that deals with relationships among private

Public law - body of law that deals with relationship between individuals and the
State/government and government agencies. Laws for the welfare of
the general public.

Private/Civil Law :
1. Contract law involves the enforcement of agreements among private
individuals or the payment of compensation for failure to fulfill the
o Ex. Nurse and client nurse and insurance
o Nurse and employer client and health agency
An agreement between 2 or more competent person to
do or not to do some lawful act.
It maybe written or oral= both equally binding
Types of Contract:

1. Expressed when 2 parties discuss and agree orally or in writing the terms and
conditions during the creation of the contract.
Example: nurse will work at a hospital for only a stated length of time (6
months),under stated conditions (as volunteer, straight AM shift, with
food/transportation allowance)
2. Implied one that has not been explicitly agreed to by the parties, but that the
law considers to exist.
Example: Nurse newly employed in a hospital is expected to be competent
and to follow hospital policies and procedures even though these
expectations were not written or discussed.
Likewise: the hospital is expected to provide the necessary supplies,
equipment needed to provide competent, quality nursing care.
Feature/Characteristics/Elements of a lawful contract:

1. Promise or agreement between 2 or more persons for the performance of an
action or restraint from certain actions.
2. Mutual understanding of the terms and meaning of the contract by all.
3. A lawful purpose activity must be legal
4. Compensation in the form of something of value-monetary

Persons who may not enter into a contract: minor, insane, deaf, mute and ignorant

Tort law
Is a civil wrong committed against a person or a persons property.
Person/persons responsible for the tort are sued for damages
Is based on:
o ACT OF COMMISSION something that was done incorrectly
o ACT OF OMMISION something that should have been done but
was not.

Classification of Tort

Unintentional Tort

1. Negligence
Misconduct or practice that is below the standard expected of ordinary,
reasonable and prudent person
Failure to do something due to lack of foresight or prudence
Failure of an individual to provide care that a reasonable person would
ordinarily use in a similar circumstance.
An act of omission or commission wherein a nurse fails to act in
accordance with the standard of care.
Doctrines of Negligence:
a. Res ipsa loquitor the thing speaks for itself the injury is enough proof of
b. Respondeat Superior let the master answer command responsibility
c. Force majuere unforeseen event, irresistible force

2. Malpractice
stepping beyond ones authority
6 elements of nursing malpractice:

a. Duty the nurse must have a relationship with the client that involves
providing care and following an acceptable standard of care.

b. Breach of duty
the standard of care expected in a situation was not observed by the nurse
is the failure to act as a reasonable, prudent nurse under the
something was done that should not have been done or nothing was done
when it should have been done
c. Foreseeability a link must exist between the nurses act and the injury

d. Causation it must be proved that the harm occurred as a direct result of the
nurses failure to follow the standard of care and the nurse should or
could have known that the failure to follow the standard of care could result
in such harm.

e. harm/injury physical, financial, emotional as a result of the breach of duty to
the client Example: physical injury, medical cost/expenses, loss of wages, pain
and suffering

f. damages amount of money in payment of damage/harm/injury

Intentional Tort
Unintentional tort do not require intent bur do require the element of
Intentional tort the act was done on PURPOSE or with INTENT
o No harm/injury/damage is needed to be liable
o No expert witnesses are needed
An attempt or threat to touch another person unjustifiably
o A person who threatens someone with a club or closed fist.
o Nurse threatens a client with an injection after refusing to take
the meds orally.
Willful touching of a person, persons clothes or something the person is
carrying that may or may not cause harm but the touching was done
without permission, without consent, is embarrassing or causes injury.
o A nurse threatens the patient with injection if the patient refuses
his meds orally. If the nurse gave the injection without clients
consent, the nurse would be committing battery even if the client
benefits from the nurses action.
False Imprisonment
Unjustifiable detention of a person without legal warrant to confine the
Occurs when clients are made to wrongful believe that they cannot leave
the place
o Telling a client no to leave the hospital until bill is paid
o Use of physical or chemical restraints
o False Imprisonment Forceful Restraint=Battery
Invasion of Privacy
intrusion into the clients private domain
right to be left alone
Types of Invasion the client must be protected from:
1. use of clients name for profit without consent using ones name,
photograph for advertisements of HC agency or provider without clients
2. Unreasonable intrusion observation or taking of photograph of the client
for whatever purpose without clients consent.
3. Public disclosure of private facts private information is given to others who
have no legitimate need for that.
4. Putting a person in a false/bad light publishing information that is normally
considered offensive but which is not true.
communication that is false or made with a careless disregard for the truth
and results in injury to the reputation of a person
1. Libel defamation by means of print, writing or picture
o Example:
1. o writing in the chart/nurses notes that doctor A is
incompetent because he didnt respond immediately to a
2. Slander defamation by the spoken word stating unprivileged (not legally
protected) or false word by which a reputation is damaged
o Example:
Nurse A telling a client that nurse B is incompetent
Person defamed may bring the lawsuit
The material (nurses notes) must be communicated to a
3rd party in order that the persons reputation maybe
Public Law:

Criminal Law deals with actions or offenses against the safety and welfare of the
1. homicide self-defense
2. arson- burning or property
3. theft stealing
4. sexual harassment
5. active euthanasia
6. illegal possession of controlled drugs
Homicide killing of any person without criminal intent may be done as self-

Arson willful burning of property

Theft act of stealing

Evening Care of Patient
I. Purpose
1. To refresh the patient and prepare line him for sleep
2. To promote muscular relaxation
3. To prevent bedsore

II. Preparation of Patient and Environment
A try containing:
Basin of warm water
Alcohol 70%
Soap in soap dish
Talcum powder
Hair comb or brush
Bath towel & wash cloth
Pitcher of warm water
Mouth wash tray with
Mouth wash solution
Tooth brush
Kidney basin
Linen required

III. Procedure
1. Allow patient to brush his teeth, wash his face, hands and forearms. If
patient is unable to help himself do it for him.
2. Turn patient to her side, unfasten her camisa and bath her back. Massage
back with alcohol 700/0 or (skin lotion) paying particular attention to the
bony prominences and other reddish pots on the back. Dust with powder
3. If the patient is wearing a binder, remove it when giving care to the back.
Inspect dressing for bleeding or discharge and changes or reinforce p.r.n.
Return the binder in place.
4. Brush and comb hair. Protect back and camisa with towel
5. Fasten patients camisa Move patient to one side brush crumbs or dirt
from the bed.
6. Tighten beddings.
7. Fluff up pillows and replace
8. Replace ice cap or hot water bag p.r.n
9. Give bedtime medicine if any. Attend to all patients request
10. Place signal cord or bell within the reach of the patient.
11. Remove all unnecessary things from the room: trays, dishes, etc. Empty
waste basket.
12. Adjust screen or blinds and light.
Family Structure
Traditional Family
It is composed of a father, a mother and their children. These people,
married and living together in one house make up the nuclear family.
Relatives, such as aunts, uncles, cousins and grandparents, who may or
may not live with the nuclear family, are part of the extended family. This
family group usually live in close geographic proximity to members of the
extended family, who provided a sense of stability and belonging.

Single Parent Families
Single parents may be never married, separated, divorced or widowed.
Most often, the single parent is divorced or widowed, but increasing
numbers of never married men and women are choosing to become

Alternate Family Structure
Cohabiting Families
It includes those individuals who choose to live together for a variety of
reasons: relationships, financial need, changing values
Although the single person is not living with others, he or she is a part of a family of
origin, usually has a social network with significant others. Majority of single adults
living alone are found in to age groups: the young adult who has achieved
independence and enters the work force and the elderly person, left alone through
death of a spouse. (Taylor,, 1989)
Hair Care
I. Purpose
1. To ass to the comfort of the patient.
2. To remove tangles from the hair.
3. To preserve or keep the hair in good condition during illness.
4. To observe the presence of lice without the patients being aware of it.
5. To prevent infection.

II. Equipment
Patients bath towel
Hair comb
Rubber bands or tapes

III. Procedure
1. Move the patients head near the edge of the bed, her face turned away
from you.
2. Place towel under the head of the patient extending down the chest rind
3. Loose the hair and part of the middle.
4. Brush hair thoroughly.
5. In combing or brushing, comb small stands at a time. Hold the strand at a
time wrapping around the forefinger. Hold the stand above the part being
combed so that the pull comes on your baud, not on the hair roots and
comb the tangles from the end first.
6. Comb gently. But remove all tangles. If the hair is badly tangled, apply
vaseline or oil or wet hair with alcohol but time, patience and skill are
7. If the hair is long, part down and middle and plaid into two braids shirting
towards the front so that a patient lying on her back will not be conscious
of this coronet across the front of the head or let them freely down helding
the ends with ribbon or tape or rubber bands.
8. Gather all used articles. Clean and disinfect brush and comb and return
them into their proper places.

IV. Instructions
1. Never allow an ill patient to comb her hair.
2. If the hair is too tangled, alcohol or vaseline may be use to remove the
3. The nurse should never cut the patients hair without the patients
Hand Washing Technique
Purpose of Hand Washing Technique
1. To avoid infection
2. For cleanliness
3. As an example to patents.

Solutions Common Used for Hand Washing
1. Lysol or Cresol solution P/a and 2%
2. Diphen solution % to Gb.
3. Bichloride of Mercury 1:10000
4. Zephiran Cloride 1:10,000
5. Rocall solution 800 parts per milliliter (3 0cc. of Rocall per gallon of water)

Method A
Running water (foot or knee control of faucet preferable)
Soap in soap dish
Hand towel (paper towel preferable)
Waste container
Procedure for Hand Washing
1. Stand well away from the sink and let water run.
2. Moisten hands, apply soap and with enough friction. Sect a good father.
Pay particular attention to surface between the fingers, around and under
the nails.
3. Rinse well
4. Repeat #2 & 3
5. Dry hands thoroughly
6. Use hand lotion if necessary.

Method B
Wash stand
Hand towel
2 basins
Waste container
Toilet soap in soap dish
Running water or faucet
Nail file
Procedure for Hand Washing
1. Make the hand solution for the two basins. (Any of the solutions in #11).
2. Soak both hands in Solution 1 for 1 to 3 minutes.
3. Scrub both hands with soap and water using hand brush. Use nail file p.r.n.
Scrub for 1 to 3 minutes. (For communicable diseases 5 minutes).
4. Soak both hands in Solution II.
5. Rinse hands well.
6. Wipe to dry.
7. Alcohol is used after handling infections cases.
When to Wash Hands
1. Before and after meals.
2. Before leaving the ward.
3. Before handling clean articles.
4. After handling contaminated things.
5. After using the toilet.
6. Before commencing a procedure.
Hanging Main Line IV and Tubing
Wash hands.
Compare type and amount of solution with physicians order.
Check pharmacy label for clients identification, solution type, additives
and expiration date.
Select appropriate IV tubing.
Obtain needle-less cannula or adapter for the established infusion site.
Remove the outer wrapper around the IV bag.
Inspect the bag carefully for tears or leaks by applying gentle pressure to
Examine for discoloration, cloudiness or foreign matter.
Time-tape and label bag.
History of Nursing Periods
Intuitive Nursing
From Prehistoric times up to the early Christian Era
Untaught and Instinctive
Nursing performed out of compassion
Nursing belonged to women

Apprentice Nursing
From the founding of the Religious orders in the 11th century up to 1836
with the establishment of the Kaiserwerth Institute for training of
Period of on-the-job training
Nursing performed without any formal education and by people who were
directed by more experienced nurses
Important personalities in this period:
o St. Clare-gave nursing care to the sick and the afflicted
o St. Elizabeth of Hungary- Patrones of nurses
o St. Catherine of Siena- First lady with a lamp
Dark period of Nursing
From the 17th century up to 19th century
Nursing became the work of the least desirable of women

Educated Nursing
Began on June 15, 1860 when Florence Nightingale School of nursing
opened St. Thomas Hospital in London
Development of nursing was strongly influenced by trends resulting from
wars, from an arousal of social consciousness, from the increased
educational opportunities offered to women

Contemporary Nursing
Covers the period after the world war II to the present
Marked by scientific and technological developments as well as social
Hygiene and Comfort
Factor Influencing Individual Hygienic Practices
Factor Variables
Culture North American culture places a high value on
cleanliness. Many North Americans bathe or shower once
or twice a day, whereas people from some other cultures
bathe once a week. Some cultures consider privacy
essential for bathing, whereas others practice communal
bathing. Body odor is offensive in some cultures and
accepted normal in others.
Religion Ceremonial washings are practiced by some religion
Environment Finances may affect the availability f facilities for bathing.
For example, homeless people may not have warm water
available; soap, shampoo, shaving lotion, and deodorants
may be too expensive for people who have limited
Children learn hygiene in home. Practices vary according
to the individuals age; for example, preschoolers can
carry out most tasks independently with encouragement.
Health and Ill people may not have the motivation or energy to
Energy attend to hygiene. Some clients who have neuromuscular
impairments may be unable o perform hygienic care.
Some people prefer a shower to tub bath. People have
different preferences regarding the time of bathing (e.g.
morning versus evening)

Skin Care

General Guidelines for Skin Care
1. An intact, healthy skin is the bodys first line of defense
2. The degree to which the skin protects the underlying tissues from injury
depends on the amount of subcutaneous tissue and the dryness of the
3. Moisture in contact with the skin can result in increased bacterial growth
and irritation.
4. Body odors are caused by resident skin bacteria acting on the body
secretions. Cleanliness is the best deodorant.
5. Skin sensitivity to irritation and injury varies among individuals and in
accordance with their health.
6. Agents used for skin care have selective actions and purposes. E.g. soap,
detergent, bath oil, cream, lotion, powder, deodorant, and antiperspirant.
Common Skin Problem
Problem and
Nursing Implication
Superficial layers of
the skin are scraped
or rubbed away. Area
is reddened and may
have localized
bleeding or serous

1. Prone to infection; therefore, wound
should be kept clean and dry.
2. Do not wear rings or jewelry when
providing care to avoid causing abrasions
to clients.
3. Lift, do not pull, a client across a bed.
4. Use two or more people for assistance.
Excessive Dryness
Skin can appear flaky
and rough.

1. Prone to infection if the skin cracks;
therefore, provide alcohol-free lotions to
moisturize the skin and prevent cracking.
2. Bathe client less frequently; use no soap,
or use nonirritating soap and limit its use.
Rinse skin thoroughly because soap can
be irritating and drying.
3. Encourage increased fluid intake if health
permits to prevent dehydration.
Ammonia Dermatitis
(Diaper Rash)
Caused by skin
bacteria reacting with
urea in the urine. The
skin becomes
reddened and is sore.

1. Keep skin dry and clean by applying
protective ointments containing zinc
oxide to areas at risk (e.g., buttocks and
2. Boil an infants diaper or wash them with
an antibacterial detergent to prevent
infection. Rinse diapers well because
detergent is irritating to an infants skin.
condition with
papules and pustules.

1. Keep the skin clean to prevent secondary
2. Treatment varies widely.
Redness associated
with a variety of
conditions, such as
rashes, exposure to
sun, elevated body

1. Wash area carefully to remove excess
2. Apply antiseptic spray or lotion to
prevent itching, promote healing, and
prevent skin breakdown.
Excessive hair on a
persons body and
face, particularly in

1. Remove unwanted hair by using
depilatories, shaving, electrolysis, or
2. Enhance clients self concept.

Bathing removes accumulated oil, perspiration, dead skin cells, and some
Excessive bathing, can interfere with the intended lubricating effect of
sebum, causing dryness of the skin.
Bathing stimulates circulation
Bathing offers an excellent opportunity for the nurse to assess all clients.
Cleaning baths

Given chiefly for hygiene purposes and include these types:
Complete bed bath. The nurse washes the entire body of a dependent
client in bed.
Self- help bed bath. Clients confined to bed are able to bathe themselves
with help from the nurse for washing the back and perhaps the feet.
Partial bath (abbreviated bath). Only the parts of the clients body that
might cause discomfort or odor, if neglected, are washed: the face, hands,
axillae, perineal area and back.
Bag bath. This bath is a commercially prepared product that contains 10 to
12 presoaked disposable washcloths that contain no- rinse cleanser
Tub bath. Tub baths are often preferred to bed baths because it is easier
to wash and rinse in a tub.
Shower. Many ambulatory clients are able to use shower facilities and
require only minimal assistance from the nurse.

Ear Care

Nursing Interventions
Cleanse the pinna with moist wash cloth
Remove visible cerumen by retracting the ears downward. If this is
ineffective, irrigate the ear as ordered.
Do not use bobby pins, toothpicks or cotton-tipped applicators to remove
cerumen. These can rupture the tympanic membrane or traumatize the
ear canal. Cotton- tipped applicators can push wax into the ear canal,
which can cause blockage.

Eye Care

Nursing Interventions
Cleanse the eyes from the inner cantus to the outer cantus. Use a new
cotton ball for each wipe. To prevent contamination of the nasolacrimal
If the client is comatose, cover the ayes with sterile moist compresses. To
prevent dryness and irritation of the cornea.
Eyeglass should be cleaned with warm water and soap; dried with soft
Clean contact lens as directed by the manufacturer
To remove artificial eyes, wear clean gloves, depress the clients lower
Hold the artificial eye with thumb and index finger
Clean the artificial eye with warm normal saline, then place in a container
with water or saline solution.
Avoid rubbing the eyes. This may cause infection.
Maintain adequate lighting when reading.
Avoid regular use of eye drops
If dirt/ foreign bodies get into eyes, clean them with copious, clean, tepid
water as an emergency treatment.

Nose Care

Nursing Interventions
Clean nasal secretions by blowing the nose gently into the soft tissue.
Both nares should be open when blowing the nose to prevent forcing
debris into the middle ear, via Eustachian tube.
May use cotton tipped applicator moistened with saline or water to
remove encrusted, dried secretions. Insert only up to cotton tip.

Oral Cavity Care

Measures to Prevent Tooth Decay
Brush the teeth thoroughly after meals and at bedtime.
Floss the teeth daily.
Ensure adequate intake of food rich in calcium, phosphorous, Vit. A, C and
D and fluoride.
Avoid sweet foods and drinks between meals
Eat coarse, fibrous foods (cleansing foods) such as fresh fruits ant raw
Have dental check up every 6 months.
Have topical fluoride applications as prescribed by the dentists.
Brushing and Flossing the Teeth

1. To remove food particles from around and between the teeth.
2. To remove dental plaque.
3. To enhance the clients feelings of well- being
4. To prevent sordes and infection of the oral tissues.
Nursing Interventions When Providing Oral Care for Conscious Patient
Inform the client and explain purpose of the procedure.
Provide privacy.
Assist in sitting or side-lying position.
Place towel under the clients chin.
Moisten bristles of toothbrush and apply dentifrice.
Hold kidney basin under the chin.
Allow the client to brush his teeth, if possible.
Use downward strokes fro upper front teeth; upward strokes for lower
front teeth; back and forth strokes for the biting surfaces of the teeth; and
hold the brush against the teeth with bristles at 45 degrees angle to
penetrate and clean under the gingival margins.
Rinse the mouth with adequate amount of water. Floss the teeth.
Keep the client comfortable.
Do after-care of the equipment and articles.
Document relevant data.
For Unconscious Client
Place in side-lying position to prevent aspiration.
Have suction apparatus readily available.
Use padded tongue blade to open the mouth.
Brush teeth and gums, using toothbrush or soft sponge-ended swab.
Apply thin layer of petroleum jelly to lips to prevent drying or cracking.
Note: Lemon glycerin swabs can be drying to the oral mucosa if used for extended

Care of Artificial Dentures
Wear gloves when handling and cleansing dentures.
Place a washcloth in a basin or bowl of sink when brushing dentures to
prevent damage if the dentures are dropped.
Store the dentures in a container with water.
Common Problems of the Mouth
1. Plaque. An invisible soft film of bacteria, saliva, epithelial cells and
leukocytes that adhere to the enamel surface of the teeth.
2. Tatar. A visible, hard deposit of plaque and bacteria that forms at the gum
3. Halitosis. Bad breath.
4. Glossitis. Inflammation of the tongue.
5. Gingivitis. Inflammation of the gums.
6. Stomatitis. Inflammation and dryness of oral mucosa.
7. Parotitis. Inflammation of the parotid salivary glands (mumps).
8. Sordes. Accumulation of foul matter (food, microorganisms, and epithelial
elements) on the gums and teeth.
9. Periodontal disease. Gums appear spongy and bleeding (pyorrhea).
10. Cheilosis. Cracking of the lips.
11. Dental Caries. Teeth have darkened area, may be painful (cavities).

Hair Care
The appearance of the hair may reflect a persons sense of well being and
health status.
Brushing and combing the hair stimulate circulation of blood in the scalp;
distribute the oil along the hair shaft; help to arrange the hair.
Hair shampoo

1. To stimulate the circulation of the blood in the scalp through massage.
2. To clean the hair and improve the clients sense of well-being.
Nursing Interventions during Hair Shampoo
Determine if the institution requires doctors order for hair shampoo.
Place client diagonally in bed.
Remove pins from hair. Comb and brush hair thoroughly. This is to remove
Place Kelly pad under the head, with neck hyper extended.
The trough of the Kelly pad should be directed to a pail. To prevent spillage
of the water onto the floor.
Cover the eyes with wash cloth. To protect them from irritation.
Plug the ears with cotton balls. To prevent entry of the water into the
external auditory canal.
Apply small amount of shampoo.
Massage the scalp with the fat pads of the fingers and make a rich lather.
Massage promotes circulation on the scalp. Rich lather ensures through
cleansing of the hair.
Rinse the hair thoroughly. Soap residue in hair may cause irritation of the
scalp and may dry hair.
Dry the hair thoroughly.
Keep he client comfortable.
Do after-care of equipment and articles.
Make relevant documentation.
Common Hair and Scalp Problems
1. Dandruff. Is a chronic diffuse scaling of the scalp, with pruritus (seborrheic
2. Alopecia. Lair loss or baldness.
3. Pediculosis. Infestation with lice.
Padiculosis capitis is head louse
Pediculosis corporis is body louse
Pediculosis pubis is crab louse

4. Scabies. Contagious skin infestation by the itch mite. The characteristic of the
lesion is the burrow produced by the female mite as it penetrates the skin. The
burrows are short, wavy, brown, or black threadlike lesions.
5. Hirsutism. Excessive growth of body hair.

Foot Care
Wash the feet daily, and dry them well especially the interdigital spaces.
Use warm water for foot soak, to soften the nails and loosen debris under
them. Caution: soaking the feet of diabetic clients is no longer encouraged
because excessive moisture can contribute to skin breakdown.
Use cream or lotion to moisten the skin and soften calluses.
Use deodorant sprays or foot powder to prevent or control unpleasant
File toe nails straight across. To prevent nail splitting and tissue injury
around nail.
Change socks or stocking daily.
Wear comfortable, well-fitted pair of shoes
Do not go bare footed
Exercise the feet to improve circulation
Avoid using constricting clothing or round garters which may decrease
Avoid crossing the legs
Avoid self-treatment for corns or calluses
Common Foot Problems
1. Callus. Painless, flat, thickened epidermis, a mass of keratotic material.
Often caused by pressure from the shoe on bony prominence.
2. Corn. Keratosis caused by friction and pressure from a shoe. It commonly
affects the fourth and fifth toe. It appears circular and raised.
3. Unpleasant odors. This results from perspiration and its interaction with
4. Plantar warts. Caused by virus papova-virus hominis . They appear on the
sole of the foot and are moderately contagious. They are painful and make
walking difficult.
5. Fissures. Caused by dryness and cracking of the skin.
6. Tinea pedis. Characterized by scaling and cracking of the skin, particularly
between the toes, caused by a fungus. There may be blisters. (also
Athletes foot, ringworm of the foot.)
7. Ingrown Toenail. Inward growth of the nail, causing trauma into soft
tissues. It is usually due to trimming the lateral edges of the toenails.

Nail Care
Trim nails straight across, or follow the contour of the fingers.
File nails to have smooth edges.
Do not trim nails at the lateral corners to prevent ingrowns.
- The usual treatment for pediculosis is gamma benzene hexachloride (Kwell),
which comes in lotion, cream and shampoo. Pubic lice are difficult to remove, so
the shampoo may be applied and left on 12 to 24 hours.
- Linens and clothing used by clients should be washed in hot water.
Diabetic clients are advised against cutting hangnails or cuticles.
Ingrown is also called unguis incarnate.
Separation of the nail from the nail bed is onycholysis.
Inflammation of the skin fold at the nail margin is paronychia.

Perineal- Genital Care

Purposes of Perineal-Genital Care
1. To remove normal perineal secretions and odor.
2. To prevent infection.
3. To promote comfort.
Nursing Intervention during Perineal- Genital Care
Inform the client and explain purpose of the procedure.
Provide privacy. To maintain client dignity.
Position and drape the client as follows:
o Female: dorsal recumbent position; drape the client diagonally.
o Male: supine position
o For female clients, use forceps to hold cotton balls for cleansing
the perineum.
o For male clients, wear clean gloves.
For Female Clients
1. Use anterior to posterior (front to back) stroke to prevent contamination
of urethral meatus and vagina with microorganisms from the anus.
2. Use one cotton ball for each stroke.
3. Cleanse perineum with soap/ antiseptic solution. Include the inner thigh.
4. Rinse the area with copious amount of water. To remove soap adequately
and prevent irritation of the perineal area.
5. Dry perineum thoroughly. Moisture supports microbial growth.
For Male Clients
1. Wash and dry penis using firm strokes, to prevent erection of the penis.
2. Use circular motion, from the tip of glans penis towards the penile shaft.
3. If the client is uncircumcised, retract the prepuce (foreskin). This is to
remove smegma that collects under the foreskin and facilitates bacterial
4. Wash and dry the scrotum and buttocks.
For post-delivery or menstruating females, apply a perineal pad as needed
from front to back. This prevents contamination of urethra and vagina
from anal area.
Keep the client comfortable
Do the after-care of equipment and articles
Document relevant data
Historical Evolution of Nursing
Period of Intuitive Nursing/Medieval Period
Nursing was untaught and instinctive. It was performed of compassion
for others, out of the wish to help others.
Nursing was a function that belonged to women. It was viewed as a natural
nurturing job for women. She is expected to take good care of the children,
the sick and the aged.
No caregiving training is evident. It was based on experience and
Primitive men believed that illness was caused by the invasion of the
victims body of evil spirits. They believed that the medicine man, Shaman
or witch doctor had the power to heal by using white magic, hypnosis,
charms, dances, incantation, purgatives, massage, fire, water and herbs as
a mean of driving illness from the victim.
Trephining drilling a hole in the skull with a rock or stone without
anesthesia was a last resort to drive evil spirits from the body of the

Period of Apprentice Nursing/Middle Ages
Care was done by crusaders, prisoners, religious orders
Nursing care was performed without any formal education and by people
who were directed by more experienced nurses (on the job training). This
kind of nursing was developed by religious orders of the Christian Church.
Nursing went down to the lowest level
o Wrath/anger of Protestantism confiscated properties of hospitals
and schools connected with Roman Catholicism.
o Nurses fled their lives; soon there was shortage of people to care
for the sick
o Hundreds of Hospitals closed; there was no provision for the sick,
no one to care for the sick
o Nursing became the work of the least desirable of women
prostitutes, alcoholics, prisoners
Pastor Theodore Fliedner and his wife, Frederika established the
Kaiserswerth Institute for the training of Deaconesses (the 1st formal
training school for nurses) in Germany.
o This was where Florence Nightingale received her 3-month course
of study in nursing.

Period of Educated Nursing/Nightingale Era 19th-20th century
The development of nursing during this period was strongly influenced by:
1. trends resulting from wars Crimean, civil war
2. arousal of social consciousness
3. Increased educational opportunities offered to women.
Florence Nightingale was asked by Sir Sidney Herbert of the British War
Department to recruit female nurses to provide care for the sick and
injured in the Crimean War.
In 1860, The Nightingale Training School of Nurses opened at St. Thomas
Hospital in London.
o The school served as a model for other training schools. Its
graduates traveled to other countries to manage hospitals and
institute nurse-training programs.
o Nightingale focus vision of nursing Nightingale system was more
on developing the profession within hospitals. Nurses should be
taught in hospitals associated with medical schools and that the
curriculum should include both theory and practice.
o It was the 1st school of nursing that provided both theory-based
knowledge and clinical skill building.
Nursing evolved as an art and science
Formal nursing education and nursing service begun
Facts about Florence Nightingale
Mother of modern nursing. Lady with the Lamp because of her
achievements in improving the standards for the care of war casualties in
the Crimean war.
Born may 12, 1800 in Florence, Italy
Raised in England in an atmosphere of culture and affluence
Not contended with the social custom imposed upon her as a Victorian
Lady, she developed her self-appointed goal: To change the profile of
She compiled notes of her visits to hospitals and her observations of the
sanitary facilities, social problems of the places she visited.
Noted the need for preventive medicine and god nursing
Advocated for care of those afflicted with diseases caused by lack of
hygienic practices
At age 31, she entered the Deaconesses School at Kaiserswerth in spite of
her familys resistance to her ambitions. She became a nurse over the
objections of society and her family.
Worked as a superintendent for Gentlewomen Hospital, a charity hospital
for ill governesses.
Disapproved the restrictions on admission of patients and considered this
unchristian and incompatible with health care
Upgraded the practice of nursing and made nursing an honorable
profession for women.
Led nurses that took care of the wounded during the Crimean war
Put down her ideas in 2 published books: Notes on Nursing, What It Is and
What It Is Not and Notes on Hospitals.
She revolutionized the publics perception of nursing (not the image of a
doctors handmaiden) and the method for educating nurses.

Period of Contemporary Nursing/20th Century
Licensure of nurses started
Specialization of Hospital and diagnosis
Training of Nurses in diploma program
Development of baccalaureate and advance degree programs
Scientific and technological development as well as social changes marks
this period.
1. Health is perceived as a fundamental human right
2. Nursing involvement in community health
3. Technological advances disposable supplies and equipments
4. Expanded roles of nurses was developed
5. WHO was established by the United Nations
6. Aerospace Nursing was developed
7. Use of atomic energies for medical diagnosis, treatment
8. Computers were utilized-data collection, teaching, diagnosis,
inventory, payrolls, record keeping, and billing.
9. Use of sophisticated equipment for diagnosis and therapy
Health Promotion Guidelines Across Lifespan

To meet the fetal demands for oxygen, the pregnant mother gradually
increases her normal blood flow by about one-third, peaking at about 8
Respiratory rate and cardiac output increase significantly during this
Feta circulation travels from the placenta through umbilical arteries, which
caries deoxygenated blood away from the fetus.
Nutrition and Fluids
The fetus obtains nourishment from the placental circulation and by
swallowing amniotic fluid.
Nutritional needs are met when the mother eats a well-balanced diet
containing sufficient calories and nutrients to meet both her needs and
those of the fetus.
Adequate folic acid, one of the B vitamins, is important in order to prevent
neural tube defects
Folic rich foods are green leafy vegetables, oranges, dried beans and
suggest she take a vitamin supplement that contain folic acid.
Rest and Activity
The fetus sleeps most of the time and develops a pattern of sleep and
wakefulness that usually persist after birth.
Fetal activity can be felt by the mother at about the fifth lunar month of
Fetal feces are formed in the intestines from swallowed amniotic fluid
throughout the pregnancy, but are normally not excreted until after birth.
Urine normally is excreted into the amniotic fluid when the kidneys mature
(16 to 20 weeks).
Temperature Maintenance
Amniotic fluid usually provides a safe and comfortable temperature for the
Significant changes in the maternal temperature can alter the temperature
of the amniotic fluid and the fetus.
Significant alter in temperature increases due to illness, hot whirlpool
baths, or saunas may result in birth defects.
In the last weeks of gestation, the fetus develops subcutaneous fatty tissue
stores that will help maintain body temperature at birth.
The body systems form during the embryonic period. As a result, the
embryo is particularly vulnerable to damage from teratogen, which is
anything that adversely affects normal cellular development in the embryo
or fetus.
It is important for the nurse to inquire about possible pregnancy when
giving medications that are known teratogens and also ask when the
woman is scheduled for tests that involve radiography (x-ray).
Smoking, alcohol, and drugs can affect the environment for the fetus.
Smoking has been associated with preterm labor, spontaneous abortion,
low-birth weight infants, and sudden infant death syndrome and learning
Fetal alcohol syndrome (FAS), a result of impaired mitochondrial
development, leads to microcephaly, mental retardation, learning
disorders, and other central nervous system defects.


Health Examinations
Screening of newborns for hearing loss; follow-up at 3 months and early
intervention by 6 months if appropriate
At 2 weeks and at 2,4,6, and 12 months
Protective Measures
Immunizations: diptheria,tetanus, acellular pertussis (DTaP), inactivated
poliovirus vaccine (IVP), pneumococcal, measles-mumps-rubella (MMR),
Haemophilus influenzae type B (HIB), hepatitis B (HepB), varicella and
influenza vaccines as recommended
Fluoride supplements if there is adequate water fluoridation (less than 0.7
part per million)
Screening for tuberculosis
Screening for phenylketonuria (PKU) and other metabolic conditions
Prompt attention for illnesses
Appropriate skin hygiene and clothing
Infant Safety
Importance of supervision
Car seat, crib, playpen, bath, and home environment safety ,measures
Feeding measures (e.g., avoid propping bottle)
Provide toys with no small parts or sharp edges
Eliminate toxins in the environment (e.g., chemicals, radon, lead, mercury)
Use smoke and carbon monoxide (CO) detectors in home
Breast-feeding to age 12 months
Breast-feeding and bottle feeding techniques
Formula preparation
Feeding schedule
Introduction of solid foods
Need for iron supplements at 4 to 6 months
Characteristics and frequency of stool and urine elimination
Diarrhea and its effects
Rest/ Sleep
Establish routine for sleep and rest patterns
Sensory Stimulation
Touch: holding, cuddling, rocking
Vision: colorful, moving toys
Hearing: soothing voice tones, music, singing
Play: toys appropriate for development


Health Examinations
At 15 and 18 months and then as recommended by the primary care
Dental visit starting at age of 3 or earlier
Protective Measures
Immunizations: continuing DTaP, IPV series, pneumococcal, MMR,
Haemophilus influenzae type B, hepatitis, hepatitis A, and influenza
vaccines as recommended
Screenings for tuberculosis and lead poisoning
Fluoride supplements if there is inadequate water fluoridation (less than
0.7 part per million)
Toddler Safety
Importance of constant supervision and teaching child to obey commands
Home environment safety measures (e.g., lock medicine cabinet)
Outdoor safety measures (e.g., close supervision near water)
Appropriate toys
Eliminate toxins in environment (e.g., pesticides, herbicides, mercury, lead,
arsenic in playground materials)
Use smoke and carbon monoxide (CO) detectors in home
Importance of nutritious meals and snacks
Teaching simple mealtime manners
Dental care
Toilet training techniques
Dealing with sleep disturbances
Providing adequate space and variety of activities
Toys that allow acting on behaviors and provide motor and sensory


Health Examinations
Every 1 to 2 years
Protective Measures
Immunizations: continuing DTaP, IPV series, MMR, hepatitis,
pneumococcal, influenza, and other immunizations as recommended
Screenings for tuberculosis
Vision and hearing screening
Regular dental screenings and fluoride treatment
Preschooler Safety
Educating child about simple safety rules (e.g., crossing the street)
Teaching child to play safely (e.g., bicycle and playground safety)
Educating to prevent poisoning; exposure to toxic materials
Importance of nutritious meals and snacks
Teaching proper hygiene (e.g., washing hands after using bathroom)
Rest/ Sleep
Dealing with sleep disturbances (e.g., night terrors, sleepwalking)
Providing times for group play activities
Teaching child simple games that require cooperation and interaction
Providing toys and dress-ups for role-playing

School-Age Children

Health Examinations
Annual physical examination or as recommended
Protective Measures
Immunizations as recommended (e.g., MMR, meningococcal, tetanus-
diphtheria, adult preparation [Td])
Screening for tuberculosis
Periodic vision, speech, and hearing screenings
Regular dental screenings and fluoride treatment
Providing accurate information about sexual issues (e.g., reproduction,
School-Age Child Safety
Using proper equipment when participating in sports and other physical
activities (e.g., helmets, pads)
Encouraging child to take responsibility for own safety (e.g., participating in
bicycle and water safety courses)
Importance of child not skipping meals and eating balance diet
Experiences with food that may lead to obesity
Utilizing positive approaches for elimination problems (e.g., enuresis)
Play and Social Interactions
Providing opportunities for a variety of organized group activities
Accepting realistic expectations of childs abilities
Acting as role models in acceptance of other persons who may be different
Providing a home environment that limits TV viewing and video games and
encourages completion of homework and healthy exercise


Health Examinations
As recommended by the primary care provider
Protective Measures
Immunizations as recommended, such as adult tetanus diphtheria
vaccine, MMR, pneumococcal, and hepatitis B vaccine
Screening for tuberculosis
Periodic vision and hearing screenings
Regular dental assessments
Obtaining and providing accurate information about sexual issues
Adolescent Safety
Adolescents taking responsibility for using motor vehicles safely (e.g.,
completing a drivers education course, wearing seat belt and helmet)
Making certain that proper precautions are taken during all athletic
activities (e.g., medical supervision, proper equipment)
Parents keeping lines of communication open and being alert to signs of
substance abuse and emotional disturbances in the adolescent
Nutrition and Exercise
Importance of healthy snacks and appropriate patterns of food intake and
Factors that may lead to nutritional problems (e.g., obesity , anorexia
nervosa, bulimia)
Balancing sedentary activities with regular exercise
Social Interactions
Encouraging and facilitating adolescent success in school
Encouraging adolescent to establish relationships that promote discussion
of feelings, concerns, and fears.
Parents encouraging adolescent peer group activities that promote
appropriate moral and spiritual values
Parents acting as role models for appropriate social interactions
Parents providing a comfortable home environment for appropriate
adolescent peer group activities
Parents expecting adolescents to participate in and contribute to family

Young Adults

Health Test and Screenings
Routine physical examination (every 1 to 3 years for females; every 5 years
for males)
Immunizations as recommended, such as tetanus-diphtheria boosters
every 0 years, meningococcal vaccine if not given in early adolescence, and
hepatitis B vaccine
Regular dental assessments (every 6 months)
Periodic vision and hearing screenings
Professional breast examination every 1 to 3 years
Papanicolaou smear annually within 3 years of onset of sexual activity
Testicular examination every year
Screening for cardiovascular disease (e.g., cholesterol test every 5 years if
results are normal; blood pressure to detect hypertension; baseline
electrocardiogram at age 35)
Tuberculosis skin test every 2 years
Smoking: history and counseling if needed
Motor vehicle safety reinforcement (e.g., using designated drivers when
drinking, maintaining brakes and tires)
Sun protection measures
Workplace safety measures
Water safety reinforcement (e.g., no diving in shallow water)
Nutrition and Exercise
Importance of adequate iron intake in diet
Nutritional and exercise factors that may lead to cardiovascular disease
(e.g., obesity, cholesterol, and fat intake, lack of vigorous exercise)
Social Interactions
Encouraging personal relationship that promote discussion of feelings,
concerns, and fears
Setting short-and long- term goals for work and career choices

Middle-Aged Adults

Health Test and Screening
Physical examination (every 3 to 5 years until age 40, then annually)
Immunizations as recommended, such as a tetanus booster every 10 years,
and current recommendations for influenza vaccine.
Regular dental assessments (e.g., every 6 months)
Tonometry for signs of glaucoma and other eye diseases every 2 to 3 years
or annually if indicated
Breast examination annually by primary care provider
Testicular examination annually by primary care provider
Screenings for cardiovascular disease (e.g., blood pressure measurement;
electrocardiogram and cholesterol test as directed by the primary care
Screenings for colorectal, breast, cervical, uterine, and prostate cancer
Screening for tuberculosis every 2 years
Smoking: history and counseling, if needed
Motor vehicle safety reinforcement, especially when driving at night
Workplace safety measures
Home safety measures: keeping hallways and stairways lighted and
uncluttered, using smoke detector, using nonskid mats and handrails in the
Nutrition and Exercise
Importance of adequate protein, calcium, and vitamin D in diet
Nutritional and exercise factors that may lead to cardiovascular disease
(e.g., obesity, cholesterol and fat intake, lack of vigorous exercise)
An exercise program that emphasizes skill and coordination
Social Interactions
The possibility of a middle crisis: encourage discussion of feelings,
concerns, and fears
Providing time to expand and review previous interests
Retirement planning (financial and possible diversional activities), with
partner if appropriate


Health Test and Screening
Total cholesterol and high density lipid protein measurement every 3 to 5
years until age 75
Aspirin, 81 mg daily, if in high- risk group
Diabetes mellitus screen every 3 years, if in high-risk group
Smoking cessation
Screening mammogram every 1 to 2 years (women)
Clinical breast exam annually (women)
Pap smear annually if there is a history of abnormal smears or previous
hysterectomy of malignancy (United States Preventive Services Task Force,
o Older women who have regular, normal Pap smear or
hysterectomy for nonmalignant causes do NOT need Pap smear
beyond the age of 65
Annual digital rectal exam
Annual prostate-specific antigen (PSA)
Annual fecal occult blood test (FOBT)
Sigmoidoscopy every 5 years; colonoscopy every 10 years
Visual acuity screen annually
Hearing screen annually
Depression screen periodically
Family violence screen periodically
Height and weight measurements annually
Sexually transmitted disease testing, if high- risk group
Annual flu vaccine if over 65 or in high-risk group
Pneumococcal vaccine at 65 and every 10 years thereafter
Td vaccine every 10 years
Home safety measures to prevent falls, fire, burns, scalds, and
Working smoke detectors and carbon monoxide detectors in the home
Motor vehicle safety reinforcement, especially when driving at night
Elder driver skills evaluation (some states require for license renewal)
Precautions to prevent pedestrian accidents
Nutrition and Exercise
Importance of a well-balanced diet with fewer calories to accommodate
lower metabolic rate and decreased physical activity
Importance of sufficient amounts of vitamin D and calcium to prevent
Nutritional and exercise factors that may lead to cardiovascular disease
(e.g., obesity, cholesterol and fat intake, lack of exercise)
Importance of 30 minutes of moderate physical activity daily; 20 minutes
of vigorous physical activity 3 times per week
Importance of adequate roughage in the diet, adequate exercise, and at
least six 8-once glasses of fluid daily to prevent constipation
Social Interaction
Encouraging intellectual and recreational pursuits
Encouraging personal relationships that promote discussion of feelings,
concerns, and fears
Assessment of risk factors for maltreatment
Availability of social community centers and programs for seniors
Indwelling Catheter Insertion
Inserting an Indwelling Catheter to a Female
Check physicians order.

Check clients identaband and if able have client state name.
Explain procedure to client.
Provide privacy.
Gather equipment.
Assist client to position, knees up and out.
o *Be careful to not contaminate sterile field
Cleanse clients perineum of antiseptic solution.
Remove drapes.
Reposition client for comfort; put bed in low position.
Remove and discard disposable supplies in appropriate container.
Wash hand.
Document procedure, measure and record urine output on I&O bedside

Inserting an Indwelling Catheter to a Male
Check physicians order.
Check clients identaband and if able have client state name.

Explain procedure to client.
Provide privacy.
Gather equipment.
Prepare client by placing client in supine position with knees slightly apart.
Fan fold top linen down to lower extremities exposing only perineal area.
Prepare equipment in the same manner as demonstrated for female
Tape catheter to abdomen with 1 inch tape.
Attach drainage bag to bed frame, not side rails.
Cleanse clients perineum of antiseptic solution.
Remove drapes.
Reposition client for comfort; put bed in low position with side rails up.
Remove all equipment, including gloves & discard trash in the appropriate
Wash hand.
Document procedure.
Measure and record urine output on I&O bedside record.

Intramuscular (IM) Administration
Here are the steps needed to accomplish administering IM injections. Feel free to
read through the steps and watch the accompanying video if necessary.
1. You will be needing all these supplies. Prepare the medication to be given,
syringe, alcohol prep pad, gauze, band-aid and needle. The needles are
usually 21g or 22g, and 1 1/2 long.
2. Wash your hands.
3. Prepare/Mix the medication accordingly and put it into the syringe.
4. Attach the new needle into the syringe.
5. Medication can be given into the:
o Ventrogluteal Patient may lie on back or side with hip and knee
o Vastus lateralis Patient may lie on the back or may assume a
sitting position.
o Deltoid Patient may sit or lie with arm relaxed.
o Dorsogluteal Patient may lie prone with toes pointing inward or
on side with upper leg flexed and placed in front of lower leg.
6. The site should be free of bumps and scars.
7. Clean the site with an alcohol pad. Allow the alcohol to dry. Do not use a
blower or fan to quicken the drying process.
8. Spread the skin with your fingers and inject the needle straight down in a
dart-like motion all the way.
9. Pull back on the plunger a little. If you see blood enter the syringe, pull the
needle out a little and inject the medication. If you do not see blood,
simply inject.
10. Pull the needle out and dispose of properly in a sharps container. Do not
put medical or sharp waste in the regular garbage.
11. Use the gauze to dab up any blood, if necessary, and cover with a bandage.
12. Wash your hands.

IV Fluid/Solution Quick Reference Guide
Intravenous Solutions are used in fluid replacement therapy by changing the
composition of the serum by adding fluids and electrolytesh

Type Description Osmolality Use Miscellaneous
Saline (NS)
0.9% NaCl in
id Solution
(308 mOsm)
Increases circulating plasma
volume when red cells are
Replaces losses without altering
fluid concentrations.
Helpful for Na+ replacement
1/2 Normal
Saline (1/2
0.45% NaCl in
id Solution
(154 mOsm)
Raises total fluid volume Useful for daily maintenance of
body fluid, but is of less value for
replacement of NaCldeficit.
Helpful for establishing renal
Fluid replacement for clients
who dont need extra glucose
Ringers (LR)
Normal saline
and buffer
(275 mOsm)
Replaces fluid and buffers pH Normal saline with K+, Ca++, and
lactate (buffer)
Often seen with surgery
W Dextrose 5% in
Isotonic (in the
y hypotonic
(260 mOsm)
Raises total fluid
volume.Helpful in rehydrating
and excretory purposes.
Provides 170-200
calories/1,000cc for energy.
Physiologically hypotonic -the
dextrose is metabolized quickly
so that only water remains a
hypotonic fluid
NS Dextrose 5% in
0.9% saline
(560 mOsm)
Replaces fluid sodium,
chloride, and calories.
Watch for fluid volume overload
1/2 NS Dextrose 5% in
0.45% saline
(406 mOsm)
Useful for daily maintenance
of body fluids and nutrition,
and for rehydration.
Most common postoperative
LR Dextrose 5% in
(575 mOsm)
Same as LR plus provides
about 180 calories per
Watch for fluid volume overload
Normosol-R Normosol Isotonic
(295 mOsm)
Replaces fluid and buffers pH pH 7.4
Contains sodium, chloride,
calcium, potassium and
Common fluid for OR and PACU

Laboratory and Diagnostic Examination
Urine Specimen

1. Clean-Catch mid-stream urine specimen for routine urinalysis, culture and
sensitivity test

a. Best time to collect is in the morning, first voided urine
b. Provide sterile container
c. Do perineal care before collection of the urine
d. Discard the first flow of urine
e. Label the specimen properly
f. Send the specimen immediately to the laboratory
g. Document the time of specimen collection and transport to the lab.
h. Document the appearance, odor, and usual characteristics of the specimen.

2. 24-hour urine specimen

a. Discard the first voided urine.
b. Collect all specimens thereafter until the following day
c. Soak the specimen in a container with ice
d. Add preservative as ordered according to hospital policy

3. Second-Voided urine required to assess glucose level and for the presence of
albumen in the urine.

a. Discard the first urine
b. Give the patient a glass of water to drink
c. After few minutes, ask the patient to void

4. Catheterized urine specimen

a. Clamp the catheter for 30 min to 1 hour to allow urine to accumulate in the
bladder and adequate specimen can be collected.
b. 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

a. Secure a sterile specimen container
b. Ask the pt. to defecate into a clean, dry bed pan or a portable commode.
c. 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
a. Hematest- (an Orthotolidin reagent tablet)
b. Hemoccult slide- (filter paper impregnated with guaiac)
*Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours.
c. Colocare a newer test, requires no smear

1. Advise client to avoid ingestion of red meat for 3 days
2. Patient is advice on a high residue diet
3. Avoid dark food and bismuth compound
4. If client is on iron therapy, inform the MD
5. Make sure the stool in not contaminated with urine, soap solution or toilet
6. Test sample from several portion of the stool.


1. Never collect a venous sample from the arm or a leg that is already being
use d for I.V therapy or blood administration because it mat affect the
2. Never collect venous sample from an infectious site because it may
introduce pathogens into the vascular system
3. Never collect blood from an edematous area, AV shunt, site of previous
hematoma, or vascular injury.
4. Dont wipe off the povidine-iodine with alcohol because alcohol cancels
the effect of povidine iodine.
5. If the patient has a clotting disorder or is receiving anticoagulant coagulant
therapy, maintain pressure on the site for at least 5 min after withdrawing
the needle.
Arterial puncture for ABG test
1. Before arterial puncture, perform Allens test first.
2. If the patient is receiving oxygen, make sure that the patients therapy has
been underway for at least 15 min before collecting arterial sample
3. Be sure to indicate on the laboratory request slip the amount and type of
oxygen therapy the patient is having.
4. If the patient has just received a nebulizer treatment, wait about 20
minutes before collecting the sample.

Blood specimen
1. No fasting for the following tests:
o CBC, Hgb, Hct, clotting studies, enzyme studies, serum
2. Fasting is required:
o FBS, BUN, Creatinine, serum lipid (cholesterol, triglyceride)

Sputum Specimen

1. Gross appearance of the sputum

a. Collect early in the morning
b. Use sterile container
c. Rinse the mount with plain water before collection of the specimen
d. Instruct the patient to hack-up sputum

2. Sputum culture and sensitivity test

a. Use sterile container
b. Collect specimen before the first dose of antibiotic

3. Acid-Fast Bacilli

a. To assess presence of active pulmonary tuberculosis
b. Collect sputum in three consecutive mornings

4. Cytologic sputum exam

a. To assess for presence of abnormal or cancer cells.
Loss and Grief
Absence of an object, person, body part, emotion, idea or function that
was valued
1. Actual loss is identified and verified by others
2. Perceived Loss cannot be verified by others
3. Maturational Loss occurs in normal development
4. Situational Loss occurs without expectations
5. Ultimate Loss (Death) results in a lost for a dying person as well as for
those left behind, can be viewed as a time of growth for all who
experienced it

Grieving Process (Theories of Grief, Dying and Mourning)

1. 3 Phases of Grief
Protest- lack of acceptance, concerning the loss, characterized by anger,
ambivalence and crying
Despair- denial and acceptance occurs simultaneously causing disorganized
behavior, characterized by crying and sadness
Detachment- loss is realized; characterized by hopelessness, accurately
defining the relationship with the lost individual and energy to move
forward in life.
2. Kubler-5 Stages of Grieving
Denial characterized by shock and disbelief, serves as a buffer to
mobilize defense mechanism
Anger- resistance of the loss occurs, anger is typically directed toward
Bargaining - deals are sought with God or other higher power in an effort
to postpone the loss
Depression- loss is realized; may talk openly or withdraw.
Acceptance- recognition of the loss occurs disinterest may occur; future
thinking may occur.

3. Wordens 4 Tasks of Mourning
Accept the reality of the loss, the loss is accepted
Experience the pain of grief, healthy behaviors are accomplished to assist
in the grieving process.
Adjust to the environment without the deceased, task are accomplished to
reorient the environment, i.e. removing the clothes of the deceased from
the closet.
Emotionally relocate the deceased and move forward with life, correctly
align the past, the present & look towardsthe future

Anticipatory Grief
Expression of the symptoms of grief prior to the actual loss, grief period
following the lost may be shortened and the intensity lessened because of
the previous of grief; for example, a child told that a family move is
expected may grieve about losing friends prior to actually living

Complications of Bereavement
1. Chronic Grief symptoms of grief occur beyond the expected time frame
and the severity of symptoms is greater; depression may result.
2. Delayed Grief when symptoms of grief are not expressed and are
suppressed, a delayed reaction of grief occurs, the nurse should discuss the
normal process of grieving with the client and give permission to express
these symptoms

Symptoms of Normal Grief
1. Feelings include sadness, exhaustion, numbness, helplessness, loneliness,
and disorganization, preoccupation with the lost object or person, anxiety,
2. Thought patterns include fear, guilt, denial, ambivalence, anger
3. Physical sensations include nausea, vomiting, anorexia, weight loss or gain,
constipation or diarrhea, Diminished hearing or sight, chest pain, shortness
of breath, tachycardia
4. Behaviors include crying, difficulty carrying out activities of daily living and

Nursing Health Promotion (to facilitate mourning)
1. Help client accept that the loss is real by providing sensitive, factual
information concerning the loss
2. Encourage the expression of feelings to support people; this build
relationships and enhances the grief process
3. Support efforts to live without the diseased person or in the face of
disability; this promotes a clients sense of control as well as a healthy
vision of the future
4. Encourage establishment with new relationships to facilitate healing.
5. Allow time to grief, the work of grief may take longer for some; observe for
a healthy progression of symptoms.
6. Interpret normal behavior by teaching thoughts, feelings, and behaviors
that can be expected in the grief process
7. Provide continuing support in the form of the presence for therapeutic
communication and resource information.
8. Be alert for signs of ineffective coping such as inability to carry out
activities of daily living, signs of depression, or lack of expression of grief.
9. Intradermal Injection (Test for Drug Sensitivity) Lifting and Moving
Patient from Bed
To introduce drugs, bacteria or their toxins and other organic preparations to test
whether the body is sensitive to the preparation to be injected.

Site of Injection:
Inner aspect of forearm or upper arm

Points to Remember:
1. A positive test consists of a wheal formation with redness which appears in
10-15 minutes.
2. Precaution in all patients being injected with penicillin for the first or
second time even if the sensitivity test is negative.

3. Watch patient for at least 30 minutes after the injection for signs of
reaction. At all times the following must be available for emergency
treatment of penicillin anaphylaxis or generalized reactions:
o Epinephrine Hcl 1:10 00 for immediate IM
o I.V. antihistaminics
o 50/0 Dextrose in Water 1 liter and venosel.

Hype tray:
Alcohol sponge
Sterile tuberculin syringe
2 sterile needles gauge 25-27
Drug to be tested diluted to the strength which will be injected to the

1. Prepare the drug in the same manner as for hypodermic injection.
2. Explain to the patient. Make him comfortable. Support forearm on a firm
3. Cleanse the skin area about 3 inches (diameter) on the inner aspect of the
forearm midway between the wrist, and the elbow with alcohol sponge.
(Preferably swab with other, and allow to dry.)
4. Insert the needle, into the skin as superficially as possible by the needle
only as far as the level edge to be sure that the injection is intradermal.
5. Inject the solution enough to make a wheal or circumscribed elevation of
the skin. Inject no more than 0.1 cc.
6. Withdraw the needle gently, do not press. Do not cleanse or massage site
of injection.
7. Wait for 10-15 minutes. Evaluate results.

Record drug, time injected, reaction observed, and usually by whom it was
1. Stand facing patient at the side of the bed.
2. Assume a broad stance, one leg forward of the other with knees and hips
flexed, bring arms to the level of the bed.
3. Place one arm under shoulders and neck pf patient and another arm under
small of patients back.
4. Shift body weight from front to back foot, rock backward to a crouch
position, bringing patients towards his side. Nurses hips come downwards
as he rocks backwards. Patient should be pulled.
1. Stand at the side of the bed towards which patient is to be turned. Place
patients far arm across his chest and far leg over near leg, near arm is
lateral to and away from his body.
2. Stand opposite to the patients waist and face side of the bed with one
foot a step in front of the other.
3. Place one hand on patients far shoulder and one hand on his far hip.
4. Shift weight from forwarded leg to rear leg, patient is turned towards the
nurse hips come downward.
5. Patient is stopped by nurses elbows, which come to rest on mattress at
the edge of the bed.
1. Stand at side of the side of the bed and face patient head.
2. Assume a wide stance with foot next to bed behind the other foot.
3. Pass arm over the patients near shoulders and rest hand between
patients shoulder blades.
4. Rock backward, shift weight from forwarded foot to rear foot, hips coming
straight down.
1. Stand at one side of the bed facing the head of the patient. Foot next to
bed is to rear and the other foot forward. Provide wide base of support.
2. Bend knees to bring arm next to bed down to a level with a surface of the
3. With elbow on the patients bed grasps the nurses arm in the same
4. Rock forward, shift weight from forwarded foot to rear foot to bring hips
downward. Elbow remains on bed, which serves as fulcrum.
1. Stand at the side of the bed and face the far corner of the foot of the bed.
2. Flex knees so that arms are leveled with the bed. Put arm under patient,
one arm under patients head and shoulders, one hand under small of his
3. Rock forward. Shift weight from forwarded foot to rear foot, hips coming
downward. Patient will slide diagonally across the bed towards the head
and side of the bed.
4. Repeat from tuck and legs of patient.
5. Go to the other side of the bed and repeat number 1 3. Continue this
process until patient is satisfactorily positioned.
1. Patient flexes knees, bringing heels up to his buttocks.
2. Stand at the side of the bed, turn slightly towards patients head. One foot
is stepped in front of the other foot closer to bed. Feet are directed
towards the head of the bed.
3. Place one arm under patients shoulders, one arm under thighs. Flex knees
to bring arms to the level of the surface of the bed.
4. Patient places chin on his chest and pushes with his feet. Nurse shifts
weight from rear foot to forwarded foot. Patient grasps the head of the
bed with his hands to pull on his own weight.
1. Patient flexes knees and brings heels towards the buttocks.
2. Nurse faces the side of the bed and stands opposite to the patients
buttocks. Assume a board stance.
3. Flex knees to bring arms to the level of the bed, place one hand under
sacral area of the patient. The elbow is resting firmly on the 3 bed.
4. As the patient raises his hips, the nurse comes to a crouching position by
bending his knees while his arms act as a lever to help support the
patients buttocks. Nurses hips come straight down. While supporting
patient in this position, free hand can place bedpan under the patients
sacral area.
1. Patient is turned to the side towards the edge of the bed.
2. The nurse ensures that the patient does not fall out of the bed by raising
the head of the bed.
3. Face the far bottom corner of the bed, support the shoulders of the
patient with one arm and the other arm helps patient extend lower legs
over the side of the bed top the rear of the other foot.
4. Bring patient to a natural sitting position on the bed; support the patients
shoulders and legs over the side of the bed. Pivot body to lower legs of the
patient. Patients legs are swung downward. Nurses weight is shifted form
front to rear leg.
1. The patient assumes a suiting position on the edge of the bed, put on
shoes/slipper and gown.
2. Place the chair at the side of the bed with back towards foot of the bed.
3. Stand facing patient with foot closer to the chair and a step in front of the
other to give the nurse a wide base of support.
4. Place patients hands on the nurses shoulders and the nurse grasps
patients waist.
5. Patient steps on the floor and the nurse flexes her knees, forwarded knee
is against the patient knee. This provides patients knees bending
6. Turn with the patient while maintaining a wide base of support. Bend
knees as the patient sits on chair.
Making a Recovery or Anesthetic Bed (Post-Operative Bed)
I. Purpose
1. To provide warmth and comfort for the patient.
2. To provide protection for the bed.
3. To arrange the bed and other furniture in order to facilitate the transfer of
the patient from stretcher to bed.

II. Equipment
The same linen as those used for making on occupied bed plus the
Bath towel
Small robber sheet
Woolen blanket
3 hot water bags w/cover p.r.n.
On the Bedside Table:
Kidney basin
Padded tongue depressor
Observation Sheet
In the Room
Oxygen tank with complete
Tubbings, humidifier and nassal catheter
Suction apparatus
Drainage bottles

III. Procedure:
1. Strip on the bed and turn the mattress.
2. Make an ordinary bed with the top sheet untucked at the foot part. (If
weather is cold, place bath blanket over the top sheet.) Fold back lop side
of the sheet about 14 inches and the bottom side folded back even with
the foot of the mattress.
3. Fanfold together the top sheet and blanket towards the side away from
the door.
4. Place the small rubber sheet across the hood part of the bed.
5. Place the bath towel over the small rubber sheet.
6. Slip the pillowcase and put the pillow upright against the bars of the head
of the bed.
7. Put the hot water bags at the foot and center of the bed if the weather is
8. Place the necessary articles on the bedside table and the irrigating stand,
suction machine and oxygen set-up adjacent to the bed.
9. Arrange unit

Making an Occupied Bed
1. To change the linen with the least possible disturbance to the patient.
2. To draw or fix the sheets under the patients very firmly so that it would not
3. To remove crumbs from the bed.
4. To make patient feel comfortable.

Necessary linen.
Tray for stripping and airing.
Laundry bag or hamper

1. Do the medical handwashing.
2. Gather equipments at bed side and arrange according to use. Explain
procedure to patient and screen.
3. Loosen the linens starting at the foot part, then to the sides and around.
Remove pillows unless contraindicated.
4. Place clean top sheet over dirty top sheet wider hem, wrong side out at
the head part of bed. Spread, then remove the dirty linen without exposing
the patient.
5. Turn patient towards one side of the bed.
6. Work on the unoccupied side of the bed. Roll dirty linens toward the
patient (except rubber sheet).
7. Place bottom sheet following the principles, tuck head part miter corner
tuck. Roll used rubber sheet towards you. Replace with a new one.
8. Place draw sheep over rubber sheet. Tuck together.
9. Turn patient towards made bed.
10. Work on the other side. Remove dirty linens.
11. Spread clean linens, tuck head part of the bottom sheet, miter at side, tuck
all together. Do the same with rubber sheet and draw sheet.
12. Turn patient to the center of the bed.
13. Arrange top sheet, fold head part up to the patients chest.
14. Make a toe pleat.
15. Tuck foot part, miter corner.
16. Time limit, check features of a good bed and proper body mechanics.

1. Provision for privacy as situation requires.
2. Carefully turning the patient. So as to prevent over exertion and feeling or
3. Provision of opportunity for patient to Participate.
4. Placement of top bedding so that shoulder may be covered and the
necessary adjustments made over toes.
5. Careful observation of skin areas of the patient.
Medication Administration
Principles of Medication Administration

I. Six Rights of drug administration

1. The Right Medication when administering medications, the nurse compares
the label of the medication container with medication form.

The nurse does this 3 times:
a. Before removing the container from the drawer or shelf
b. As the amount of medication ordered is removed from the container
c. Before returning the container to the storage

2. Right Dose when performing medication calculation or conversions, the nurse
should have another qualified nurse check the calculated dose

3. Right Client an important step in administering medication safely is being sure
the medication is given to the right client.
a. To identify the client correctly:
b. The nurse checks the medication administration form against the clients
identification bracelet and asks the client to state his or her name to ensure the
clients identification bracelet has the correct information.

4. Right Route if a prescribers order neither does nor designates a route of
administration, the nurse consult the prescriber. Likewise, if the specified route is
not recommended, the nurse should alert the prescriber immediately.

5. Right Time
a. The nurse must know why a medication is ordered for certain times of the day
and whether the time schedule can be altered
b. Each institution has are commended time schedule for medications ordered at
frequent interval
c. Medication that must act at certain times are given priority (e.g insulin should be
given at a precise interval before a meal)

6. RIGHT DOCUMENTATION Documentation is an important part of safe
medication administration
a. The documentation for the medication should clearly reflect the clients name,
the name of the ordered medication, the time, dose, route and frequency
b. Sign medication sheet immediately after administration of the drug

Clients Right Related to Medication Administration

A client has the following rights:
1. To be informed of the medications name, purpose, action, and potential
undesired effects.
2. To refuse a medication regardless of the consequences
3. To have a qualified nurses or physicians assess medication history,
including allergies
4. To be properly advised of the experimental nature of medication therapy
and to give written consent for its use
5. To received labeled medications safely without discomfort in accordance
with the six rights of medication administration
6. To receive appropriate supportive therapy in relation to medication
7. To not receive unnecessary medications
II. Practice Asepsis
Wash hand before and after preparing the medication to reduce transfer
of microorganisms.
III. Nurse who administers the medications is responsible for their own action
Question any order that you considered incorrect (may be unclear or
IV. Be knowledgeable about the medication that you administer
A fundamental rule of safe drug administration is: Never administer an
unfamiliar medication
V. Keep the Narcotics in locked place

VI. Use only medications that are in clearly labeled containers. Relabeling of drugs
is the responsibility of the pharmacist.

VII. Return liquid that is cloudy in color to the pharmacy.

VIII. Before administering medication, identify the client correctly

IX. Do not leave the medication at the bedside. Stay with the client until he
actually takes the medications.

X. The nurse who prepares the drug administers it. Only the nurse prepares the
drug knows what the drug is. Do not accept endorsement of medication.

XI. If the client vomits after taking the medication, report this to the nurse in
charge or physician.

XII. Preoperative medications are usually discontinued during the postoperative
period unless ordered to be continued.

XIII. When a medication is omitted for any reason, record the fact together with
the reason.

XIV. When the medication error is made, report it immediately to the nurse in
charge or physician
To implement necessary measures immediately. This may prevent any
adverse effects of the drug.

Oral Administration

1. The easiest and most desirable way to administer medication
2. Most convenient
3. Safe, does nor break skin barrier
4. Usually less expensive
1. Inappropriate if client cannot swallow and if GIT has reduced motility
2. Inappropriate for client with nausea and vomiting
3. Drug may have unpleasant taste
4. Drug may discolor the teeth
5. Drug may irritate the gastric mucosa
6. Drug may be aspirated by seriously ill patient.
Drug Forms for Oral Administration
1. Solid- tablet, capsule, pill, powder
2. Liquid- syrup, suspension, emulsion, elixir, milk, or other alkaline
3. Syrup- sugar-based liquid medication
4. Suspension- water-based liquid medication. Shake bottle before use of
medication to properly mix it.
5. Emulsion- oil-based liquid medication
6. Elixir- alcohol-based liquid medication. After administration of elixir, allow
30 minutes to elapse before giving water. This allows maximum absorption
of the medication.
Never crush Enteric-Coated or Sustained Release Tablet
Crushing enteric-c-coated tablets allows the irrigating medication to
come in contact with the oral or gastric mucosa, resulting in mucositis or
gastric irritation.
Crushing sustained-released medication allows all the medication to be
absorbed at the same time, resulting in a higher than expected initial level
of medication and a shorter than expected duration of action

Sublingual Administration
A drug that is placed under the tongue, where it dissolves.
When the medication is in capsule and ordered sublingually, the fluid must
be aspirated from the capsule and placed under the tongue.
A medication given by the sublingual route should not be swallowed, or
desire effects will not be achieved
1. Same as oral
2. Drug is rapidly absorbed in the bloodstream
1. If swallowed, drug may be inactivated by gastric juices.
2. Drug must remain under the tongue until dissolved and absorbed

Buccal Administration
A medication is held in the mouth against the mucous membranes of the
cheek until the drug dissolves.
The medication should not be chewed, swallowed, or placed under the
tongue (e.g sustained release nitroglycerine, opiates, antiemetic,
tranquilizer, sedatives)
Client should be taught to alternate the cheeks with each subsequent dose
to avoid mucosal irritation
1. Same as oral
2. Drug can be administered for local effect
3. Ensures greater potency because drug directly enters the blood and bypass
the liver
If swallowed, drug may be inactivated by gastric juice

Topical Administration
Application of medication to a circumscribed area of the body.
1. Dermatologic includes lotions, liniment and ointments, powder.
a. Before application, clean the skin thoroughly by washing the area gently with
soap and water, soaking an involved site, or locally debriding tissue.
b. Use surgical asepsis when open wound is present
c. Remove previous application before the next application
d. Use gloves when applying the medication over a large surface. (e.g. large area of
e. Apply only thin layer of medication to prevent systemic absorption.

2. Ophthalmic - includes instillation and irrigation
a. Instillation to provide an eye medication that the client requires.
b. Irrigation To clear the eye of noxious or other foreign materials.
c. Position the client either sitting or lying.
d. Use sterile technique
e. Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile
normal saline from the inner to the outer canthus
f. Instill eye drops into lower conjunctival sac.
g. Instill a maximum of 2 drops at a time. Wait for 5 minutes if additional drops
need to be administered. This is for proper absorption of the medication.
h. Avoid dropping a solution onto the cornea directly, because it causes discomfort.
i. Instruct the client to close the eyes gently. Shutting the eyes tightly causes
spillage of the medication.
j. For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for
at least 30 seconds to prevent systemic absorption of the medication.

3. Otic Instillation to remove cerumen or pus or to remove foreign body
a. Warm the solution at room temperature or body temperature, failure to do so
may cause vertigo, dizziness, nausea and pain.
b. Have the client assume a side-lying position (if not contraindicated) with ear to
be treated facing up.
c. Perform hand hygiene. Apply gloves if drainage is present.
d. Straighten the ear canal:
0-3 years old: pull the pinna downward and backward
Older than 3 years old: pull the pinna upward and backward
e. Instill eardrops on the side of the auditory canal to allow the drops to flow in and
continue to adjust to body temperature
f. Press gently bur firmly a few times on the tragus of the ear to assist the flow of
medication into the ear canal.
g. Ask the client to remain in side lying position for about 5 minutes
h. At times the MD will order insertion of cotton puff into outermost part of the
canal. Do not press cotton into the canal. Remove cotton after 15 minutes.

4. Nasal Nasal instillations usually are instilled for their astringent effects (to
shrink swollen mucous membrane), to loosen secretions and facilitate drainage or
to treat infections of the nasal cavity or sinuses. Decongestants, steroids, calcitonin.
a. Have the client blow the nose prior to nasal instillation
b. Assume a back lying position, or sit up and lean head back.
c. Elevate the nares slightly by pressing the thumb against the clients tip of the
nose. While the client inhales, squeeze the bottle.
d. Keep head tilted backward for 5 minutes after instillation of nasal drops.
e. When the medication is used on a daily basis, alternate nares to prevent

5. Inhalation use of nebulizer, metered-dose inhaler
a. Semi or high-fowlers position or standing position. To enhance full chest
expansion allowing deeper inhalation of the medication
b. Shake the canister several times. To mix the medication and ensure uniform
dosage delivery
c. Position the mouthpiece 1 to 2 inches from the clients open mouth. As the client
starts inhaling, press the canister down to release one dose of the
medication. This allows delivery of the medication more accurately into the
bronchial tree rather than being trapped in the oropharynx then swallowed
d. Instruct the client to hold breath for 10 seconds to enhance complete absorption
of the medication.
e. If bronchodilator, administer a maximum of 2 puffs, for at least 30 second
interval. Administer bronchodilator before other inhaled medication. This opens
airway and promotes greater absorption of the medication.
f. Wait at least 1 minute before administration of the second dose or inhalation of a
different medication by MDI
g. Instruct client to rinse mouth, if steroid had been administered. This is to prevent
fungal infection.

6. Vaginal drug forms: tablet liquid (douches), jelly, foam and suppository.
a. Close room or curtain to provide privacy.
b. Assist client to lie in dorsal recumbent position to provide easy access and good
exposure of vaginal canal, also allows suppository to dissolve without escaping
through orifice.
c. Use applicator or sterile gloves for vaginal administration of medications.
Vaginal Irrigation is the washing of the vagina by a liquid at low pressure.
It is also called douche.
i. Empty the bladder before the procedure
ii. Position the client on her back with the hips higher than the shoulder (use
iii. Irrigating container should be 30 cm (12 inches) above
iv. Ask the client to remain in bed for 5-10 minute following administration of
vaginal suppository, cream, foam, jelly or irrigation

Rectal Administration
Can be use when the drug has objectionable taste or odor.
1. Need to be refrigerated so as not to soften.
2. Apply disposable gloves.
3. Have the client lie on left side and ask to take slow deep breaths through
mouth and relax anal sphincter.
4. Retract buttocks gently through the anus, past internal sphincter and
against rectal wall, 10 cm (4 inches) in adults, 5 cm (2 in) in children and
infants. May need to apply gentle pressure to hold buttocks together
5. Discard gloves to proper receptacle and perform hand washing.
6. Client must remain on side for 20 minute after insertion to promote
adequate absorption of the medication.

Parenteral Administration
Administration of medication by needle.
Intradermal under the epidermis.
1. The site are the inner lower arm, upper chest and back, and beneath the
2. Indicated for allergy and tuberculin testing and for vaccinations.
3. Use the needle gauge 25, 26, 27: needle length 3/8, 5/8 or
4. Needle at 1015 degree angle; bevel up.
5. Inject a small amount of drug slowly over 3 to 5 seconds to form a wheal or
6. Do not massage the site of injection. To prevent irritation of the site, and
to prevent absorption of the drug into the subcutaneous.
Subcutaneous- Vaccines, heparin, preoperative medication, insulin, narcotics.

outer aspect of the upper arms
anterior aspect of the thighs
Scapular areas of the upper back
1. Only small doses of medication should be injected via SC route.
2. Rotate site of injection to minimize tissue damage.
3. Needle length and gauge are the same as for ID injections
Use 5/8 needle for adults when the injection is to administer at 45 degree
angle; is use at a 90 degree angle.
1. For thin patients: 45 degree angle of needle
2. For obese patient: 90 degree angle of needle
3. For heparin injection: do not aspirate.
4. Do not massage the injection site to prevent hematoma formation
5. For insulin injection: Do not massage to prevent rapid absorption which
may result to hypoglycemic reaction.
6. Always inject insulin at 90 degrees angle to administer the medication in
the pocket between the subcutaneous and muscle layer. Adjust the length
of the needle depending on the size of the client.
7. For other medications, aspirate before injection of medication to check if
the blood vessel had been hit. If blood appears on pulling back of the
plunger of the syringe, remove the needle and discard the medication and
Needle length is 1, 1 , 2 to reach the muscle layer
Clean the injection site with alcoholized cotton ball to reduce
microorganisms in the area.
Inject the medication slowly to allow the tissue to accommodate volume.

1. Ventrogluteal site
a. The area contains no large nerves, or blood vessels and less fat. It is farther from
the rectal area, so it less contaminated.
b. Position the client in prone or side-lying.
c. When in prone position, curl the toes inward.
d. When side-lying position, flex the knee and hip. These ensure relaxation of
gluteus muscles and minimize discomfort during injection.
e. To locate the site, place the heel of the hand over the greater trochanter, point
the index finger toward the anterior superior iliac spine, and then abduct the
middle (third) finger. The triangle formed by the index finger, the third finger and
the crest of the ilium is the site.

2. Dorsogluteal site
a. Position the client similar to the ventrogluteal site
b. The site should not be use in infant under 3 years because the gluteal muscles
are not well developed yet.
c. To locate the site, the nurse draw an imaginary line from the greater
d. trochanter to the posterior superior iliac spine. The injection site id lateral and
superior to this line.
e. Another method of locating this site is to imaginary divide the buttock into four
quadrants. The upper most quadrant is the site of injection. Palpate the crest of
the ilium to ensure that the site is high enough.
f. Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site

3. Vastus Lateralis
a. Recommended site of injection for infant
b. Located at the middle third of the anterior lateral aspect of the thigh.
c. Assume back-lying or sitting position.

4. Rectus femoris site located at the middle third, anterior aspect of thigh.

5. Deltoid site
a. Not used often for IM injection because it is relatively small muscle and is very
close to the radial nerve and radial artery.
b. To locate the site, palpate the lower edge of the acromion process and the
midpoint on the lateral aspect of the arm that is in line with the axilla. This is
approximately 5 cm (2 in) or 2 to 3 fingerbreadths below the acromion process.

* IM injection Z tract injection
a. Used for parenteral iron preparation. To seal the drug deep into the muscles and
prevent permanent staining of the skin.
b. Retract the skin laterally, inject the medication slowly. Hold retraction of skin
until the needle is withdrawn
c. Do not massage the site of injection to prevent leakage into the subcutaneous.

The nurse administers medication intravenously by the following method:
1. As mixture within large volumes of IV fluids.
2. By injection of a bolus, or small volume, or medication through an
existing intravenous infusion line or intermittent venous access
(heparin or saline lock)
3. By piggyback infusion of solution containing the prescribed
medication and a small volume of IV fluid through an existing IV
Most rapid route of absorption of medications.
Predictable, therapeutic blood levels of medication can be obtained.
The route can be used for clients with compromised gastrointestinal
function or peripheral circulation.
Large dose of medications can be administered by this route.
The nurse must closely observe the client for symptoms of adverse
The nurse should double-check the six rights of safe medication.
If the medication has an antidote, it must be available during
When administering potent medications, the nurse assesses vital signs
before, during and after infusion.
Nursing Interventions in IV Infusion
1. Verify the doctors order
2. Know the type, amount, and indication of IV therapy.
3. Practice strict asepsis.
4. Inform the client and explain the purpose of IV therapy to alleviate clients
5. Prime IV tubing to expel air. This will prevent air embolism.
6. Clean the insertion site of IV needle from center to the periphery with
alcoholized cotton ball to prevent infection.
7. Shave the area of needle insertion if hairy.
8. Change the IV tubing every 72 hours. To prevent contamination.
9. Change IV needle insertion site every 72 hours to prevent
10. Regulate IV every 15-20 minutes. To ensure administration of proper
volume of IV fluid as ordered.
11. Observe for potential complications.
Types of IV Fluids
1. Isotonic solution has the same concentration as the body fluid
o D5 W
o Na Cl 0.9%
o Plain Ringers lactate
o Plain Normosol M
2. Hypotonic has lower concentration than the body fluids.
o NaCl 0.3%
3. Hypertonic has higher concentration than the body fluids.
o D10W
o D50W
o D5LR
o D5NM
Complication of IV Infusion

1. Infiltration the needle is out of nein, and fluids accumulate in the subcutaneous

Pain, swelling, skin is cold at needle site; pallor of the site, flow rate has
decreases or stops.
Nursing Intervention:
Change the site of needle
Apply warm compress. This will absorb edema fluids and reduce swelling.
2. Circulatory Overload - Results from administration of excessive volume of IV

Flushed skin
Rapid pulse
Increase BP
Weight gain
Syncope and faintness
Pulmonary edema
Increase volume pressure
SOB (shortness of breath)
Nursing Interventions:
Slow infusion to KVO
Place patient in high fowlers position. To enhance breathing
Administer diuretic, bronchodilator as ordered
3. Drug Overload the patient receives an excessive amount of fluid containing

Nursing Intervention:
Slow infusion to KVO.
Take vital signs
Notify physician
4. Superficial Thrombophlebitis it is due to o0veruse of a vein, irritating solution
or drugs, clot formation, large bore catheters.

Pain along the course of vein
Vein may feel hard and cordlike
Edema and redness at needle insertion site.
Arm feels warmer than the other arm
Nursing Intervention:
Change IV site every 72 hours
Use large veins for irritating fluids.
Stabilize venipuncture at area of flexion.
Apply cold compress immediately to relieve pain and inflammation; later
with warm compress to stimulate circulation and promotion absorption.
Do not irrigate the IV because this could push clot into the systemic
5. Air Embolism Air manages to get into the circulatory system; 5 ml of air or
more causes air embolism.

Chest, shoulder, or back pain
Increase venous pressure
Loss of consciousness
Nursing Intervention
Do not allow IV bottle to run dry
Prime IV tubing before starting infusion.
Turn patient to left side in the trendelenburg position. To allow air to rise
in the right side of the heart. This prevent pulmonary embolism.
6. Nerve Damage may result from tying the arm too tightly to the splint.

Numbness of fingers and hands
Nursing Interventions
Massage the are and move shoulder through its ROM
Instruct the patient to open and close hand several times each hour.
Physical therapy may be required
Note: apply splint with the fingers free to move.

7. Speed Shock may result from administration of IV push medication rapidly.
To avoid speed shock, and possible cardiac arrest, give most IV push
medication over 3 to 5 minutes.
General Principles of Parenteral Administration
1. Check doctors order.
2. Check the expiration for medication drug potency may increase or
decrease if outdated.
3. Observe verbal and non-verbal responses toward receiving injection.
Injection can be painful; client may have anxiety, which can increase the
4. Practice asepsis to prevent infection. Apply disposable gloves.
5. Use appropriate needle size to minimize tissue injury.
6. Plot the site of injection properly to prevent hitting nerves, blood vessels,
and bones.
7. Use separate needles for aspiration and injection of medications to
prevent tissue irritation.
8. Introduce air into the vial before aspiration. To create a positive pressure
with in the vial and allow easy withdrawal of the medication.
9. Allow a small air bubble (0.2 ml) in the syringe to push the medication that
may remain.
10. Introduce the needle in quick thrust to lessen discomfort.
11. Either spread or pinch muscle when introducing the medication.
Depending on the size of the client.
12. Minimized discomfort by applying cold compress over the injection site
before introduction of medicati0n to numb nerve endings.
13. Aspirate before the introduction of medication. To check if blood vessel
had been hit.
14. Support the tissue with cotton swabs before withdrawal of needle. To
prevent discomfort of pulling tissues as needle is withdrawn.
15. Massage the site of injection to haste absorption.
16. Apply pressure at the site for few minutes. To prevent bleeding.
17. Evaluate effectiveness of the procedure and make relevant

Medication Calculation
D = Desired Dose
Q = Quantity of Solution
H = Strength on Hand
X = Unknown quantity of Drug

Sample: Physician orders 500 mg of ibuprofen (desired Dose) for a patient
and you have 250 mg (Quantity on Hand) tablets (Quantity of solution) on
Solution: D H x Q = X 500mg 250 mg x 1 tablet = 2 tablets Answer: 2 tablets.

Sample: Physician orders 1500 mg of liquid ibuprofen for a patient.
Quantity of Ibuprofen is 500 mg in 1 cc, how much will you administer?
Solution: 1500 mg 500 mg x 1cc = 3 cc Answer: 3 cc

Dosage and Conversions
Sample: MD orders 300 mg of Ibuprophen to be taken by a 6 kg infant
every 4 hours. Label shows 75 150 mg/kg per day. Is the physicians order
within normal range?
Solution: 6 x 75 = 450 mg (minimum dosage per day); 150 X6 = 900 (maximum
dosage per day)
24 4 = 6 dosages : 300 x 6 = 1800

Answer: Dosage is not within range

IV Calculations
[amount of fluid to be infused] x [drop factor] minutes to infuse =
Sample: Dr. A. orders your patient to receive 125 ml of D5W an hour for the
next 8 hours. The nursing unit uses tubing with a drop factor of 10. What is the
drip rate per minute?

Solution: Convert 1 hour to 60 minutes: 1250 x 10 gtts 60 minutes = 20.83 or
21 gtts/min

Answer: 21 gtts/min

Sample: Dr. B. orders a liter of D5W to run this 8-hour shift. The drop
factor is 15. What is the drip rate per minute?
Solution: 1 liter = 1000 cc of solution, next convert 8 hours to minutes (8 X 60
minutes) = 480 minutes
1000 cc x 15 gtts 480 minutes = 31.25 or 31 gtts/min
Answer: 31 gtts/min
Sample: Your patient weighs 200 lb and the order is to infuse 250 mg
dobutamine in 500 ml NS at 10 mcg/kg/min. How many milligrams of
dobutamine will infuse per hour?
Solution: 2002.2= 90.90kg: 60 minutes = 1 hour: 10 mcg x 90.90kg x 60
min=5454.54 mcg/hour 1000 = 54.54mg/hr or 54.5mg/hr

The 7 Rights of Medication Administration
1. Right Patient
2. Right Drug
3. Right Dose
4. Right Route
5. Right Time
6. Right Documentation
7. Right to Refuse

Conversion Table
1 kilogram (kg) = 1000 grams (g)
1 gram (g) = 1000 milligrams (mg)
o Convert Grams to Milligrams by Multiplying grams by 1,000
o Convert Milligrams to grams by dividing milligrams by 1,000
1 milligram (mg) = 1000 micrograms (mcg)
Grains (gr.) 15 = 1 Gram (g) or 1000 milligrams (mg)
o To convert g. to gr multiply by 15
o To convert gr to g divide by 15.
1 Grain (gr.) = 60 Milligrams (mg)
o To convert gr. to mg multiply gr. by 60
o To convert mg to gr. divide mg. by 60
1ml = 1 cc
1 ounce = 30 ml
1 tablespoon (T or tbsp) = 15 ml
1 teaspoon (t or tsp) = 5 ml
2.2 lb = 1 kg
To convert pounds to kg divide pounds by 2.2
To convert kg to pounds multiply by 2.2
Metro Manila Development Screening Test (MMDST)
Simple and clinically useful tool
To determine early serious developmental delays
Dr. William K. Frankenburg
Modified and standardized by Dr. Phoebe D. Williams DDST to MMDST
Developed for health professionals (MDs, RNs, etc) It is not an
intelligence test
It is a screening instrument to determine if childs development is within
Children 6 years and below

Measures developmental delays
Evaluates 4 aspects of development

Aspects of development
In the care of pediatric clients, growth and development are not in
isolation. Nurses being competent in the aspects of growth and development
particularly principles, theories and milestones are in best position to counsel
clients on these aspects. Having background knowledge on growth and
development, nurses are equipped with assessment skills to determine
developmental delays through the aid of screening tests.
The Metro Manila Developmental Screening Test (MMDST) is a screening test to
note for normalcy of the childs development and to determine any delays as well in
children 6 years old and below. Modified and standardized by Dr. Phoebe
Williams from the original Denver Developmental Screening Test (DDST) by Dr.
William K. Frankenburg, MMDST evaluates 4 sectors of development:
Personal-Social tasks which indicate the childs ability to get along with
people and to take care of himself
Fine-Motor Adaptive tasks which indicate the childs ability to see and
use his hands to pick up objects and to draw
Language tasks which indicate the childs ability to hear, follow
directions and to speak
Gross-Motor tasks which indicate the childs ability to sit, walk and jump
MMDST KIT. Preparation for test administration involves the nurse ensuring the
completeness of the test materials contained in the MMDST Kit. These materials
should be followed as specified:
MMDST manual
test Form
bright red yarn pom-pom
rattle with narrow handle
eight 1-inch colored wooden blocks (red, yellow, blue green)
small clear glass/bottle with 5/8 inch opening
small bell with 2 inch-diameter mouth
rubber ball 12 inches in circumference
cheese curls
EXPLAINING THE PROCEDURE. Once the materials are ready, the nurse explains the
procedure to the parent or caregiver of the child. It has to be emphasized that this
is not a diagnostic test but rather a screening test only. When conducting the test,
the parents or caregivers of the child under study should be informed that it is not
an IQ test as it may be misinterpreted by them. The nurse should also establish
rapport with the parent and the child to ensure cooperation.
AGE & THE AGE LINE. To proceed in the administration of the test, the nurse is to
compute for the exact age of the child, meaning the age of the child during the test
date itself. The age is the most crucial component of the test because it determines
the test items that will be applicable/ administered to the child. The exact age is
computing by subtracting the childs birth date with the test date. After computing,
draw the age line in the test form.
TEST ITEMS. There are 105 test items in MMDST but not all are administered. The
examiner prioritizes items that the age line passes through. It is however
imperative to explain to the parent or caregiver that the child is not expected to
perform all the tasks correctly. If the sequence were to be followed, the examiner
should start with personal-social then progressing to the other sectors. Items that
are footnoted with R can be passed by report.
SCORING. The test items are scored as either Passed (P), Failed (F), Refused (R), or
Nor Opportunity (NO). Failure of an item that is completely to the left of the childs
age is considered a developmental delay. Whereas, failure of an item that is
completely to the right of the childs age line is acceptable and not a delay.
Manner in which each test is administered must be exactly the same as
stated in the manual, words or direction may not be changed
If the child is premature, subtract the number of weeks of
prematurity. But if the child is more than 2 years of age during the test,
subtracting may not be necessary
If the child is shy or uncooperative, the caregiver may be asked to
administer the test provided that the examiner instructs the caregiver to
administer it exactly as directed in the manual
If the child is very shy or uncooperative, the test may be deferred

Making an Unoccupied BedObjectives of Making an Unoccupied Bed
1. To meet the patients need by providing a safe comfortable bed.
2. For neatness and tidiness.

Principles of Bedmaking: (Techniques vary but principles are the same).
1. Have everything ready on hand before starting.
2. Remember that the bed is made for use, for durability and comfort and
that it should have a finished appearance.
3. Place all linen on perfectly straight line on the bed, otherwise , it would be
impossible to make bed tight and free from wrinkles.
4. All comes should look neat, smooth and firm.
5. Throughout the procedure, the nurse should study her movements so as to
avoid waste of time and energy
6. When finished inspect the bed and see if it measures to the highest
standard of health and comfort of the patient economy of time, effort and
materials and smooth finished appearance
Note: Do not use torn linen and in private rooms avoid stained linen.

Equipments Needed:
2 large sheets
Rubber sheet
Draw sheet
Pillow case
Bath towel & wash cloth
Pillow & mosquito net p.r.n
Additional for private rooms
Woolen blanket top sheet
Extra pillow with pillow case
Hand towel
Bedspread or coverlet

1. Gather all equipment and place at the bedside table and arrange them in
the order of their use.
2. Get bottom sheet and spread it lengthwise on mattress with the center
fold at center of bed, with right side up and with narrow them even with
foot of mattress. Tuck the head part and miter the corner nearest to you
by bring the side of the sheet at night angle to the side of the mattress.
Then tuck from the head part making a boxlike appearance going down to
the foot part.
3. Place the rubber sheet 15 to 18 inches from the edge of the mattress. Put
the draw sheet over the rubber sheet giving an allowance of one inch
longer than the rubber sheet at the head part and luck both together.
4. Place the top sheet with the wrong side up wider harm at the head part in
line with the upper edge of the mattress and with the centerfold along the
middle of the bed. Tuck the foot part and miter the corner. Leave the side
5. Go to the other side of the bed.
6. Full the bottom sheets firmly, tuck at head part miter the corner and tuck
the sides working towards the foot.
7. Adjust the rubber sheet and draw sheet, pull them firmly and tuck them in
8. Tuck top sheet at food part and miter the corner. Leave side free. Fold
back top part about 14 inches.
9. Put the pillowcase and lay pillow flat on bed with the open and of case
away from the main door.
10. In the private room fold down the top sheet 18 inches away from the head
part of the bed. Place a bedspread on top.
11. Hang the bath towel, hand towel and washcloth on rack
12. Straighten bed, bedside table and replace chair

1. Wash hands before proceeding.
2. All beddings must be clean.
3. Protect mattress, pillows and rubber sheets from getting in contact with
patients body.
4. Avoid contact of beddings with floor and other patients Unit.
5. Remove each piece of linen separately so that valuables will not be
accidentally discarded.
1. Make under-bedding smooth, tight and securely tucked in.
2. Place upper bedding high enough to cover patients shoulder comfortably.
3. Secure to bedding at foot so that it will stay in well and be loose over the
Resources: (time, energy and materials)
1. Bring all equipment to bed at one time.
2. Remove all used equipment at one time.
3. Avoid unnecessary trips around the bed by placing each piece on bed
before going to far aide of bed.
4. Sure accurate movements will make it unnecessary to pat and straighten
1. Smooth tight bed with well-made corners.
2. Smooth flat pillows with cases evenly fitted.
3. Keep unit orderly during procedure.
4. Check unit for standard equipment and see that patients personal effects
are in good order.
5. Place hand bell or signal cord within easy reach of patient.
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 childs feeling
of aggression or attachment toward the model parent rather than on the
actual standards of the parent.

Erikson (1964)
Eriksons 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 egostrength or virtue emerges.

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.
1. At first level called the premolar or the preconventional 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.
2. 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.
3. At the third level, people make postconventional, 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 human and belief that relationships
are based on mutual trust.

Peter (1981)
Proposed a concept of rational morality based on principles. Moral
development is usually considered to involve three separate components:
moral emotion (what one feels), moral judgment (how one reason), and
moral behavior (how one act).
In addition, Peters believed that the development of character traits or
virtues is an essential aspect or moral development. And that virtues or
character traits can be learned from others and encouraged by the
example of others.
Also, Peters believed that some can be described as habits because they
are in some sense automatic and therefore are performed habitually, such
as politeness, chastity, tidiness, thrift and honesty.

Gilligan (1982)
Included the concepts of caring and responsibility. She described three
stages in the process of developing an Ethic of Care which are as follows.
1. Caring for oneself.
2. Caring for others.
3. Caring for self and others.
She believed the human see morality in the integrity of relationships and
caring. For women, what is right is taking responsibility for others as self-
chosen decision. On the other hand, men consider what is right to be what
is just.

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 persons 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.
Mouth and Teeth CareI. Purpose
1. To prevent bacterial infection.
2. To prevent formation of sores.
3. To promote cleanliness, comfort and health.
4. To enable the patient to articulate distinctly thus requiring less effort make
himself understood.

II. When to wash the Mouth
1. After waking up in the morning.
2. After meals.
3. At bed time.
4. In accordance with doctors order.

III. Mouth Wash Commonly Used
1. Listerine with water.
2. Beric acid solution 2%.
3. Antiseptic solution1 tbsp. to a glass of water.
4. Dobells solution1 tbsp. to a glass of water
5. Hydrogen peroxide1 tbsp. to a glass of water.
6. Potassium chlorate S grins to every 1 Oz. of water.
7. NSS or 1 tsp. table sale to a glass of water.
8. Equal parts of sodium bicarbonate 10% solution and sodium chloride
9. Potassium permanganate1:10, 000 units.
Note: Many patient with artificial dentures are sensitive about them, so be careful
to guard against offending them in any way.

IV. Equipment
Tooth brush
Kidney basin
Mouth wash solution
Special mouth care tray with the following:
Cotton applicators
Dressing sponges
Tongue depressor
Mineral Oil or vaseline
Paper bag
Drinking Glass tube
Asepto syringe or irrigating bulb

V. Procedure
A. With patient who is able to carry out oral hygiene procedure:
1. Place the patient in the sitting position with the kidney basin before him on
the table. 11 ambulatory, he will take his toilet articles along with him to
the bathroom.
2. Arrange articles conveniently for us~ and instruct him.
3. Remove equipment promptly when finished.
B. With patient requiring assistance:
1. Wash your hands, tell the patient what you are going to do.
2. Turn the patient on his side with his face along the pillow and her head
near the edge of the bed in upright position if possible: Place towel and
kidney basin under the patients chin.
3. Wet brush and apply dentifrice.
4. Offer water or mouth wash to patient to rinse his mouth.
5. Have patient separate teeth or open mouth so that the teeth are
6. Brush upper, teeth from gums down over teeth. Brush lower teeth from
gums up over the teeth. Brush upper and lower lingual surface. Brush
tongue from back forward.
7. Rinse brush frequently while working.
8. Offer mouth wash or water and let him rinse his mouth well holding kidney
basin under his chain.
9. Make patient comfortable and take equipment away.
C. With patient comfortable unable to care for mouth and teeth:
1. Turn patients head to one side near the edge of the bed.
2. Place towel under patients mouth and chin and put kidney basin place to
catch rinsing water.
3. Moisten applicator with mouth wash and sponge all surface of mouth and
teeth. Change applicator as often as necessary. Insert tongue depressor
between teeth to keep mouth open as necessary.
4. Clean tongue if coated with dressing wrapped in a tongue depressor and
dipped in mouth wash solution.
5. Have patient rinse mouth by drawing some of the solution through
drinking tube or by irrigating with the bulb syringe. Rinse well directing
solution to side or mouth.
6. Wipe lips well. If cracked or dry apply mineral oil or vaseline (Lemon juice
may be added to the glycerine)
7. Make patient comfortable and remove equipments.
D. With patient with artificial dentures:
1. Have patient remove dentures and put in a kidney basin.
2. Bring to lavatory, and brush them using a special brush with polydant or
any dentifice
3. Rinse well under running and table to patient.
4. Brush gums and tongue with ordinary toothbrush. Have patient rinse his
mouth and have or assist her place the dentures.

VI. After Care of Equipments
1. Rinse toothbrush and shake water off. Replace it in the bedside table.
2. Fold towel and hang at head part of the bed or towel rack.
3. Empty, wash and dry kidney basin and glass return to bedside table.
4. Make mouth care tray to lavatory. Clean and replace needed articles. Put
back tray in cabinet.
Nasogastric and Intestinal Tubes
Nasogastric Tubes

1. Levin Tube single lumen

a. Suctioning gastric contents
b. Administering tube feedings

2. Salem Sump Tube double lumen (smaller blue lumen vents the tube & prevents
suction on the gastric mucosa, maintains intermittent suction regardless of suction

a. Suctioning gastric contents
b. Maintaining gastric decompression

Key Points
1. Prior to insertion, position the client in High-Fowlers position if possible.
2. Use a water-soluble lubricant to facilitate insertion
3. Measure the tube from the tip of the clients nose to the earlobe and from
the nose to the xiphoid process to determine the approximate amount of
tube to insert to reach the stomach
4. Flex the clients head slightly forward; this will decrease the chance of
entry into the trachea
5. Insert the tube through the nose into the nasopharyngel area; ask the
client to swallow, and as the swallow occurs, progress the tube past the
area of the trachea and into the esophagus and stomach. Withdraw tube
immediately if client experiences respiratory distress
6. Secure the tube to the nose; do not allow the tube to exert pressure on the
upper inner portion of the nares
7. Validating placement of tube.
o Aspirate gastric contents via a syringe to the end of the tube
o Measure ph of aspirate fluid
o Place the stethoscope over the gastric area and inject a small
amount of air through the NGT. A characteristic sound of air
entering the stomach from the tube should be heard
8. Characteristics of nasogastric drainage:
o Normally is greenish-yellowish, with strands of mucous
o Coffee-ground drainage old blood that has been broken down in
the stomach
o Bright red blood bleeding from the esophagus, the stomach or
swallowed from the lungs
o Foul-smelling (fecal odor) occurs with reverse peristalsis in
bowel obstruction; increase in amount of drainage with

Intestinal Tubes
Provide intestinal decompression proximal to a bowel obstruction.
Prevent/decrease intestinal distention. Placement of a tube containing a
mercury weight and allowing normal peristalsis to propel tube through the
stomach into the intestine to the point of obstruction where
decompression will occur
1. Types of Intestinal Tubes

a. Cantor and Harris Tubes

i. Approximately 6-10 feet long
ii. Single lumen
iii. Mercury placed in rubber bag prior to tube insertion

b. Miller-Abbot Tubes

i. Approximately 10 feet long
ii. Double lumen
iii. One lumen utilized for aspiration of intestinal contents
iv. Second lumen utilized to instill mercury into the rubber bag after the tube
has been inserted into the stomach

2. Nursing Implications

a. Maintain client on strict NPO
b. Initial insertion usually done by physician and progression of the tube may be
monitored via an X-ray
c. After the tube has been placed in the stomach, position client on the right side
to facilitae passage through the pyloric valve
d. Advance the tube 2 to 4 inches at regular intervals as indicated by the
e. Encourage activity, to facilitate movement of the tube through the intestine
f. Evaluate the type of gastric secretions being aspirated
g. Do not tape or secure the tube until it has reached the desired position
h. Tubes may attached to suction and left in place for several days
i. Offer the client frequent oral hygiene, if possible offer hard candy or gum to
reduce thirst
j. Removal of the tube depends on the relief of the intestinal obstruction

k. May be removed by gradual pulling back (4-6 inches per hour) and eventual
removal via the nose or mouth
l. May be allowed to progress through the intestines and expelled via the rectum.

How to Insert a Nasogastric (NG) Tube
Check physicians order.
Check clients identaband and if able have client state name.
Discuss procedure to client.
Provide privacy.
Gather equipment.
Position client at 45 degree angle or higher with head elevated.
Wash hands and don clean gloves.
Provide regular oral and nasal hygiene.
Remove gloves and wash hands.
Position client for comfort.
Document procedure.
Nasal Gavage
I. Definition:
In this method of feeding, liquid is introduced into the stomach through a
rubber catheter which is passed through the anterior and posterior nose
and the pharynx into the esophagus. When forced feeding is necessary,
this method is less exhausting as the mouth does not have to be forced or
kept open.

II. Therapeutic Uses:
1. When a patient is weakened and cannot swallow food.

2. Sometimes in the operation of the mouth such as carcinoma of the tongue,
a cleft palate or fracture of the jaw etc.
3. In the operation of the throat and sometimes after tracheotomy.
4. In tetanus or meningitis with a locked jaw.
5. In forced feeding for irrational and violet patients.
6. In very weak patient who cannot swallow food vary well.

III. Equipment:
Tray with:
Medium size rubber catheter
Sterile (No.2 French catheter for adult)
Sterile glass syringe or a small glass funnel attached
Kidney basin
Dressing rubber
Draw sheet
A flask containing the nourishment ordered at temperature of 104 to 105F

IV. Procedure
Food consists of any liquid for which will readily pass through the tube.
The temperature should be warm, not hot, as the lining of the nose is
much sensitive than that of the mouth.
The danger of burning the patient is greater when feeding by this method
1. The position of the patient may be lying down with the head turned to one
side or sitting up with the head titled forward. An Infant should lie across
knees of the nurse with head turned away from the nurse.
2. Expel the air and lubricate the tube.
3. Insert the curve thru the nose and backward inward the septum. Instruct
the patient to make motion of swallowing till about 3 inches of the
catheter is introduced.
4. Tell patient to open the mouth and look if the catheter has passed if
patient coughs, wait before moving down the catheter.
5. Introduce 6 to 8 inches. Wait until the patient is accustomed to the
presence of the tube.
6. Connect the funnel to the catheter; then pour the liquid slowly at the
sides. Raise 3 to 4 inches above the nostril and release food slowly.
7. Wait for a few minutes then pinch the tube and withdraw. In some cases
the tube is left and hold in place by adhesive.

VI. Precautionary Measures While Doing the Nasal Gavage
The following precautions should be strictly observe during a nasal gavage:
1. The catheter should first be lubricated and in inserting it should be
directed toward the septum of the nose. If there is difficulty in passing it,
the tube should be removed and inserted again in the other nostril.
2. As the catheter is small, there is considerable danger of its passing into the
larynx therefore the patients color and breathing should be observed
closely before pouring in the solution which if the tube should be in the
larynx would down the patient.
3. Even a small amount of food in the lungs would cause a severe irritation,
and dyspnea and if, allowed to remain (that is if not cough up) would
decompose and probably lead to a lung abscess or septic pneumonia, if the
tube is in the trachea a whistling sound will be heard when the funnel is
hold to ear, while if in the esophagus probably a gurgling sound will be
4. As the tube is soft it may become coiled upon itself in the mouth or in the
throat. If the fluid, is poured in while the tube is in this position it will cause
gagging, checking and gasping. And will almost certainly enter the larynx
causing dyspnea, cyanosis and later a possible abscess and septic
pneumonia. Look in the mouth or pass the finger to the back of the throat
to sea the tube is in position.
5. Before pouring in the solution, wait until the patient is at rest, until all
distress has subsided and normal breathing is established and to make
sure that the tube is in the esophagus.
6. Pour in only few drops at first, then pour the balance in very slowly, if
there are not symptoms of checking
7. After all the fluid has left the funnel, pinch the catheter and quickly
8. Normal Values

Nursing as a Profession

Is a calling that requires special knowledge, skill and preparation.
An occupation that requires advanced knowledge and skills and that it
grows out of societys needs for special services.

Professional Nursing
Is an art and a science, dominated by an ideal of service in which certain
principles are applied in the skillful care of the well and the ill, and through
relationship with the client/ patient, significant others, and other members
of the health team.

Criteria of Profession
1. To provide a needed service to the society.
2. To advance knowledge in its field.
3. To protect its members and make it possible to practice effectively.

Characteristics of a Profession
1. Education. A profession requires an extended education of its members, as
well as basic liberal foundation.
2. Theory. A profession has a theoretical body of knowledge leading to
defined skills, abilities and norms.
3. Service. A profession provides basic service.
4. Autonomy. Members of a profession have autonomy in decision making
and in practice.
5. Code of Ethics. The profession as a whole has a code of ethics for practice.
A profession has sufficient self-impelling power o retain its members
throughout life. It must not be a mere steppingstone to other occupations.
6. Caring. The most unique characteristic of nursing as a profession is that, it
is a CARING profession.

Bleeding time

1-9 min

Prothrombin time

10-13 sec


Male 42-52% ;
Female 36-48%


Male 13.5-16 g/dl;
Female 12-16 g/dl


150,000- 400,000


Male 4.5-6.2 million/L;
Female 4.2-5.4 million/L


80-180 IU/L


direct 0-0.4 mg/dl;
indirect 0.2-0.8 mg/dl;
total 0.3-1.0mg/dl


7.35- 7.45
Is a disciplined involved in the delivery of health care to the society.
Is a helping profession
Is service-oriented to maintain health and well-being of people.
Is an art and a science.
Nurse - originated from a Latin word NUTRIX, to nourish.

Characteristics of Nursing
1. Nursing is caring.
2. Nursing involves close personal contact with the recipient of care.
3. Nursing is concerned with services that take humans into account as
physiological, psychological, and sociological organisms.
4. Nursing is committed to promoting individual, family, community, and
national health goals in its best manner possible.
5. Nursing is committed to personalized services for all persons without
regard to color, creed, social or economic status.
6. Nursing is committed to involvement in ethical, legal, and political issues in
the delivery of health care.

Personal Qualities of a Nurse
1. Must have a Bachelor of Science degree in nursing.
2. Must be physically and mentally fit.
3. Must have a license to practice nursing in the country.
A professional nurse therefore, is a person who has completed a basic nursing
education program and is licensed in his country to practice professional nursing.

Roles of a Professional

1. Caregiver/ Care provider
the traditional and most essential role
functions as nurturer, comforter, provider
mothering actions of the nurse
provides direct care and promotes comfort of client
activities involves knowledge and sensitivity to what matters and what is
important to clients
show concern for client welfare and acceptance of the client as a person
2. Teacher
provides information and helps the client to learn or acquire new
knowledge and technical skills
Encourages compliance with prescribed therapy.
promotes healthy lifestyles
interprets information to the client
3. Counselor
helps client to recognize and cope with stressful psychologic or social
problems; to develop an improve interpersonal relationships and to
promote personal growth
provides emotional, intellectual to and psychologic support
Focuses on helping a client to develop new attitudes, feelings and
behaviors rather than promoting intellectual growth.
Encourages the client to look at alternative behaviors recognize the
choices and develop a sense of control.
4. Change agent
Initiate changes or assist clients to make modifications in themselves or in
the system of care.
5. Client advocate
Involves concern for and actions in behalf of the client to bring about a
Promotes what is best for the client, ensuring that the clients needs are
met and protecting the clients right.
Provides explanation in clients language and support clients decisions.
6. Manager
makes decisions, coordinates activities of others, allocate resource
evaluate care and personnel
Plans, give direction, develop staff, monitor operations, give the rewards
fairly and represent both staff and administrations as needed.
7. Researcher
participates in identifying significant researchable problems
participates in scientific investigation and must be a consumer of research
Must be aware of the research process, language of research, a sensitive to
issues related to protecting the rights of human subjects.

Expanded role as of the nurse

1. Clinical Specialists
Is a nurse who has completed a masters degree in specialty and has
considerable clinical expertise in that specialty. She provides expert care to
individuals, participates in educating health care professionals and
ancillary, acts as a clinical consultant and participates in research.
2. Nurse Practitioner
Is a nurse who has completed either as certificate program or a masters
degree in a specialty and is also certified by the appropriate specialty
organization. She is skilled at making nursing assessments, performing P.
E., counseling, teaching and treating minor and self- limiting illness.
3. Nurse-midwife
A nurse who has completed a program in midwifery; provides prenatal and
postnatal care and delivers babies to woman with uncomplicated
4. Nurse anesthetist
A nurse who completed the course of study in an anesthesia school and
assess, prescribe, deliver, and manage care during the preoperative,
perioperative, and postoperative phases of a patients
operative/interventional procedure(s). (Visit ANAA for more details.)
5. Nurse Educator
A nurse usually with advanced degree, who beaches in clinical or
educational settings, teaches theoretical knowledge, clinical skills and
conduct research.
6. Nurse Entrepreneur
A nurse who has an advanced degree, and manages health-related
7. Nurse administrator
A nurse who functions at various levels of management in health settings;
responsible for the management and administration of resources and
personnel involved in giving patient care.

Fields and Opportunities in Nursing

1. Hospital/Institutional Nursing
A nurse working in an institution with patients
Example: rehabilitation, lying-in, etc.
2. Public Health Nursing/Community Health Nursing
Usually deals with families and communities. (no confinement, OPD only)
Example: Barangay, Health Center
3. Private Duty/special Duty Nurse
Privately hired
4. Industrial/Occupational Nursing
A nurse working in factories, office, companies
5. Nursing Education
Nurses working in school, review center and in hospital as a CI.
6. Military Nurse
Nurses working in a military base.
7. Clinic Nurse
Nurses working in a private and public clinic.
8. Independent Nursing Practice
Private practice, BP monitoring, home service.
Independent Nurse Practitioner.
Nursing Care of the Dying
Routine Procedures to be done as Symptoms of Approaching Death Develop:
1. Notify the doctor.
2. Notify relatives and friends.
3. Call for priest or minister.
4. Call supervisor and Headnurse.
5. Provide privacy (by screening if in the ward).

1. Warm the cooling extremities by the application of blankets and prevent
2. See that the bedding is light in weight and when the gown is wet with
perspiration should be changed.
3. Rub the skin gently with alcohol 70%
4. Place patient in a comfortable position preferably on his side and support
back with pillows with head part elevated.
5. Turn him toward the light. Never, darken the room.
6. Make the room airy.
7. Give special care to the mouth. Relieve excessive dryness of the lips by
applying mineral oil with cotton applicator.
8. Give water on some refreshing liquid in Small amount at short interval.
9. Speak distinctly and stand near the patient because the hearing become
less acute.
10. Place bedpan or urinal in position periodically. Protect beddings well.
11. Avoid disagreeable odor.
12. The nurse should stay with the patient as long as he shows signs of lie,
except for short periods when he may want to be left with a friend,
member of the family physician or minister.
Nursing Jurisprudence


It embraces:
1. All laws enacted by the legislative body.
2. All regulations promulgated by those in authority.
3. Court decisions.
4. Formal principles upon which laws are based.

Nursing Jurisprudence
Defined as the department of law that comprises all the legal rules and
principles affecting the practice of nursing. It includes not only the study
but also the interpretation of all these rules and principles and their
application in the regulation of the practice of nursing.
It deals with:
1. All laws, rules and regulations.
2. Legal principles and doctrines governing and regulating the practice of
3. Legal opinions and decisions of competent authority in cases involving
nursing practice.

Sources of Nursing Jurisprudence in the Philippines

The sources are the following:
1. The Constitution of the Republic of the Philippines, particularly the Bill of
2. Republic Act No. 7164 otherwise known as the Philippine Nursing Law of
3. Rules and regulations promulgated by the Board of Nursing and/or
Professional Regulation Commission pertaining to nursing practice.
4. Decisions of the Board of Nursing and/or Professional Regulation
Commission on nursing cases.
5. Decisions of the Supreme Court on matters relevant to nursing.
6. Opinions of the Secretary of Justice in like cases.
7. The Revised Penal Code.
8. The New Civil Code of the Philippines.
9. The Revised Rule of Courts.
10. The National Internal Revenue Code as amended
Nursing Theorist


As defined by the INTERNATIONAL COUNCIL OF NURSES as written by Virginia
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 would perform unaided if he had the
necessary strength, will or knowledge.
Help the client gain independence as rapidly as possible.

Nursing Theory

Over the years, nursing has incorporated theories from non-nursing sources,
including theories of systems, human needs, change, problem solving, and decision
making. Barnum defines theory as a construct that accounts for or organizes some
phenomenon. A nursing theory, then, describes or explains nursing.

With the formulation of different theories, concepts, and ideas in nursing it:
It guides nurses in their practice knowing what is nursing and what is not
It helps in the formulations of standards, policies and laws.
It will help the people to understand the competencies and professional
accountability of nurses.
It will help define the role of the nurse in the multidisciplinary health care

Four Major Concepts

Nurses have developed various theories that provide different explanations of the
nursing discipline. All theories, however, share four central concepts: Person refers
to all human beings. People are the recipients of nursing care; they include
individuals, families, communities, and groups. Environment includes factors that
affect individuals internally and externally. It means not only in the everyday
surroundings but all setting where nursing care is provided. Health generally
addresses the persons state of well-being. The concept of Nursing is central to all
nursing theories. Definitions of nursing describe what nursing is, what nurses do,
and how nurses interact with clients. Most nursing theories address each of the
four central concepts implicitly or explicitly.

Betty Neuman
(1972, 1982, 1989, 1992)
Health Care System Model

The Neuman System Model or Health Care System Model
Stress reduction is a goal of system model of nursing practice. Nursing
actions are in primary, secondary or tertiary level of prevention.
To address the effects of stress and reactions to it on the development and
maintenance of health. The concern of nursing is to prevent stress
invasion, to protect the clients basic structure and to obtain or maintain a
maximum level of wellness. The nurse helps the client, through primary,
secondary, and tertiary prevention modes, to adjust to environmental
stressors and maintain client stability.

A client system that is composed of physiologic, psychological,
sociocultural, and environmental variables.
Internal and external forces surrounding humans at any time.
Health or wellness exists if all parts and subparts are in harmony with the
whole person.
Nursing is a unique profession in that it is concerned with all the variables
affecting an individuals response to stressors.

Dorothea Orem
(1970, 1985)
Self-Care Deficit Theory

Self-Care Deficit Theory
Defined Nursing: The act of assisting others in the provision and
management of self-care to maintain/improve human functioning at
home level of effectiveness.
Focuses on activities that adult individuals perform on their own behalf to
maintain life, health and well-being.
Has a strong health promotion and maintenance focus.
Identified 3 related concepts:
1. Self-care - activities an Individual performs independently
throughout life to promote and maintain personal well-being.
2. Health - results when self-care agency (Individuals ability) is not
adequate to meet the known self-care needs.
3. Nursing System - nursing interventions needed when Individual is
unable to perform the necessary self-care activities:
Wholly compensatory - nurse provides entire self-care
for the client.
Example: care of a new born, care of client
recovering from surgery in a post-anesthesia
care unit
Partial compensatory - nurse and client perform care;
client can perform selected self-care activities, but also
accepts care done by the nurse for needs the client
cannot meet independently.
Example: Nurse can assist post operative client
to ambulate, Nurse can bring a meal tray for
client who can feed himself
Supportive-educative - nurses actions are to help the
client develop/learn their own self-care abilities through
knowledge, support and encouragement.
Example: Nurse guides a mother how to
breastfeed her baby, Counseling a psychiatric
client on more adaptive coping strategies.

Dorothy E. Johnson
Behavioral System Model

Behavioral System Model
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.
Viewed the patients behavior as a system, which is a whole with
interacting parts.
The nursing process is viewed as a major tool.
To reduce stress so the client can recover as quickly as possible. According
to Johnson, each person as a behavioral system is composed of seven
subsystems namely:
1. Ingestive. Taking in nourishment in socially and culturally
acceptable ways.
2. Eliminated. Riddling the body of waste in socially and culturally
acceptable ways.
3. Affiliative. Security seeking behavior.
4. Aggressive. Self protective behavior.
5. Dependence. Nurturance seeking behavior.
6. Achievement. Master of oneself and ones environment according
to internalized standards of excellence.
7. Sexual role identity behavior
In addition, she viewed that each person strives to achieve balance and
stability both internally and externally and to function effectively by
adjusting and adapting to environmental forces through learned pattern of
response. Furthermore, She believed that the patient strives to become a
person whose behavior is commensurate with social demands; who is able
to modify his behavior in ways that support biologic imperatives; who is
able to benefit to the fullest extent during illness from the health care
professionals knowledge and skills; and whose behavior does not give
evidence of unnecessary trauma as a consequence of illness.

A system of interdependent parts with patterned, repetitive, and
purposeful ways of behaving.
All forces that affect the person and that influence the behavioral system
Focus on person, not illness. Health is a dynamic state influenced by
biologic, psychological, and social factors
Promotion of behavioral system, balance and stability. An art and a science
providing external assistance before and during balance disturbances

Ernestine Wiedenbach
The Helping Art of Clinical Nursing

The Helping Art of Clinical Nursing
Developed the Clinical Nursing A Helping Art Model.
She advocated that the nurses individual philosophy or central purpose
lends credence to nursing care.
She believed that nurses meet the individuals need for help through the
identification of the needs, administration of help, and validation that
actions were helpful. Components of clinical practice: Philosophy, purpose,
practice and an art.

Any individual who is receiving help from a member of the health
profession or from a worker in the field of health.
Not specifically addressed
Concepts of nursing, client, and need for help and their relationships imply
health-related concerns in the nurseclient relationship.
The nurse is a functional human being who acts, thinks, and feels. All
actions, thoughts, and feelings underlie what the nurse does.

Faye Glenn Abdellah
Twenty One Nursing Problems

Twenty One Nursing Problems
Nursing is broadly grouped into 21 problem areas to guide care and
promote the use of nursing judgement.
Introduced Patient Centered Approaches to Nursing Model She defined
nursing as service to individual and families; therefore the society.
Furthermore, she conceptualized nursing as an art and a science that
molds the attitudes, intellectual competencies and technical skills of the
individual nurse into the desire and ability to help people, sick or well, and
cope with their health needs.
21 Nursing Problems
1. To maintain good hygiene.
2. To promote optimal activity; exercise, rest and sleep.
3. To promote safety.
4. To maintain good body mechanics
5. To facilitate the maintenance of a supply of oxygen
6. To facilitate maintenance of nutrition
7. To facilitate maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic response of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory functions
12. To identify and accept positive and negative expressions, feelings and
13. To identify and accept the interrelatedness of emotions and illness.
14. To facilitate the maintenance of effective verbal and non-verbal
15. To promote the development of productive interpersonal relationship
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying needs.
19. To accept the optimum possible goals
20. To use community resources as an aid in resolving problems arising from
21. To understand the role of social problems as influencing factors

The recipients of nursing care having physical, emotional, and sociologic
needs that may be overt or covert.
Not clearly defined. Some discussion indicates that clients interact with
their environment, of which nurse is a part.
A state when the individual has no unmet needs and no anticipated or
actual impairment.
Broadly grouped in 21 nursing problems, which center around needs for
hygiene, comfort, activity, rest, safety, oxygen, nutrition, elimination,
hydration, physical and emotional health promotion, interpersonal
relationships, and development of self-awareness. Nursing care is doing
something for an individual

Florence Nightingale
Environmental Theory

Environmental Theory
Defined Nursing: The act of utilizing the environment of the patient to
assist him in his recovery.
Focuses on changing and manipulating the environment in order to put the
patient in the best possible conditions for nature to act.
Identified 5 environmental factors: fresh air, pure water, efficient drainage,
cleanliness/sanitation and light/direct sunlight.
Considered a clean, well-ventilated, quiet environment essential for
Deficiencies in these 5 factors produce illness or lack of health, but with a
nurturing environment, the body could repair itself.
Developed the described the first theory of nursing. Notes on Nursing:
What It Is What It Is Not. She focused on changing and manipulating the
environment in order to put the patient in the best possible conditions for
nature to act.

An individual with vital reparative processes to deal with disease.
External conditions that affect life and individuals development.
Focus is on the reparative process of getting well
Goal is to place the individual in the best condition for good healthcare

Evelyn Tomlin, Helen Erickson, and Mary Ann Swain
Modeling and Role Modeling Theory

Modeling and Role Modeling Theory
Developed Modeling and Role Modeling Theory. The focus of this theory
is on the person. The nurse models (assesses), role models (plans), and
intervenes in this interpersonal and interactive theory.
They asserted that each individual unique, has some self-care knowledge,
needs simultaneously to be attached to the separate from others, and has
adaptive potential. Nurses in this theory, facilitate, nurture and accept the
person unconditionally.

A differentiation is made between patients and clients in this theory. A
patient is given treatment and instruction; a client participates in his or her
own care. Our goal is for nurses to work with clients. A client is one who
is considered to be a legitimate member of the decision-making team, who
always has some control over the planned regimen, and who is
incorporated into the planning and implementation of his or her own care
as much as possible.
Environment is not identified in the theory as an entity of its own. The
theorist see environment in the social subsystems as the interaction
between self and others both cultural and individual. Biophysical stressors
are seen as part of the environment.
Health is a state of physical, mental and social well-being, not merely the
absence of disease or infirmity. It connotates a state of dynamic
equilibrium among the various subsystems *of a holistic person+.
The nurse is a facilitator, not an effector. Our nurse-client relationship is
an interactive, interpersonal process that aids the individual to identify,
mobilize, and develop his or her own strengths.

Hildegard Peplau
Interpersonal Relations Theory

Interpersonal Relations Theory
Defined Nursing: An interpersonal process of therapeutic interactions
between an Individual who is sick or in need of health services and a nurse
especially educated to recognize, respond to the need for help.
Nursing is a maturing force and an educative instrument
Identified 4 phases of the Nurse - Patient relationship:
1. Orientation - individual/family has a felt need and seeks professional
assistance from a nurse (who is a stranger). This is the problem identification
2. Identification - where the patient begins to have feelings of belongingness
and a capacity for dealing with the problem, creating an optimistic attitude
from which inner strength ensues. Here happens the selection of
appropriate professional assistance.
3. Exploitation - the nurse uses communication tools to offer services to the
patient, who is expected to take advantage of all services.
4. Resolution - where patients needs have already been met by the
collaborative efforts between the patient and the nurse. Therapeutic
relationship is terminated and the links are dissolved, as patient drifts away
from identifying with the nurse as the helping person.

An organism striving to reduce tension generated by needs
The interpersonal process is always included, and psychodynamic milieu
receives attention, with emphasis on the clients culture and mores.
Ongoing human process that implies forward movement of personality and
other ongoing human processes in the direction of creative, constructive,
productive, personal, and community living.
Interpersonal therapeutic process that functions cooperatively with
others human processes that make health possible for individuals in
communities. Nursing is an educative instrument, a maturing force that
aims to promote forward movement of personality.

Ida Jean Orlando
The Dynamic Nurse-Patient Relationship

The Dynamic Nurse-Patient Relationship
Conceptualized The Dynamic Nurse Patient Relationship Model.
She believed that the nurse helps patients meet a perceived need that the
patient cannot meet for themselves. Orlando observed that the nurse
provides direct assistance to meet an immediate need for help in order to
avoid or to alleviate distress or helplessness.
She emphasized the importance of validating the need and evaluating care
based on observable outcomes.
To interact with clients to meet immediate needs by identifying client
behaviors, nurses reactions, and nursing actions to take

Unique individual behaving verbally nonverbally. Assumption is that
individuals are at times able to meet their own needs and at other times
unable to do so
Not defined
Not defined. Assumption is that being without emotional or physical
discomfort and having a sense of well-being contribute to a healthy state.
Professional nursing is conceptualized as finding out and meeting the
clients immediate need for help.
Imogene King
(1971, 1981)
Goal Attainment Theory

Goal Attainment Theory
Nursing process is defined as dynamic interpersonal process between
nurse, client and health care system.
Postulated the Goal Attainment Theory. She 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.
In addition, King viewed nursing as an interaction process between client
and nurse whereby during perceiving, setting goals, and acting on them
transactions occurred and goals are achieved.

Biopsychosocial being
Internal and external environment continually interacts to assist in
adjustments to change.
A dynamic life experience with continued goal attainment and adjustment
to stressors.
Perceiving, thinking, relating, judging, and acting with an individual who
comes to a nursing situations

Jean Watson
The Philosophy and Science of Caring

The Philosophy and Science of Caring
Nursing is concerned with promotion health, preventing illness, caring for
the sick, and restoring health.
Nursing is a human science of persons and human health-illness
experiences that are mediated by professional, personal, scientific,
esthetic and ethical human care transactions
She defined caring as a nurturing way or responding to a valued client
towards whom the nurse feels a personal sense of commitment and
responsibility. It is only demonstrated interpersonally that results in the
satisfaction of certain human needs. Caring accepts the person as what
he/she may become in a caring environment
Carative Factors:
1. The formation of a humanistic-altruistic system of values
2. Instillation of faith-hope
3. The cultivation of sensitivity to ones self and others
4. The development of a helping- trust relationship
5. The promotion and acceptance of the expression of positive and
negative feelings.
6. The systemic use of the scientific problem-solving method for
decision making
7. The promotion of interpersonal teaching-learning
8. The provision for supportive, protective and corrective mental,
physical, socio-cultural and spiritual environment
9. Assistance with the gratification of human needs
10. The allowance for existential phenomenological forces

A valued being to be cared for, respected, nurtured, understood, and
assisted, a fully functional, integrated self
Social environment, caring and the culture of caring affect health
Physical, mental, and social wellness
A human science of people and human health; illness experiences that are
mediated by professional, personal, scientific, aesthetic, and ethical human
care transactions.

Joyce Travelbee
(1966, 1971)
Interpersonal Aspects of Nursing

Interpersonal Aspects of Nursing
She postulated the Interpersonal Aspects of Nursing Model. She advocated
that the goal of nursing individual or family in preventing or coping with
illness, regaining health finding meaning in illness, or maintaining maximal
degree of health.
She further viewed that interpersonal process is a human-to-human
relationship formed during illness and experience of suffering
She believed that a person is a unique, irreplaceable individual who is in a
continuous process of becoming, evolving and changing.

A unique, irreplaceable individual who is in a continuous process of
becoming, evolving, and changing.
Not defined
Heath includes the individuals perceptions of health and the absence of
An interpersonal process whereby the professional nurse practitioner
assists an individual, family, or community to prevent or cope with the
experience of illness and suffering, and if necessary, to find meaning in
these experiences.

Lydia Hall
Core, Care and Cure Model

Core, Care and Cure Model
The client is composed of the ff. overlapping parts: person (core),
pathologic state and treatment (cure) and body (care).
Introduced the model of Nursing: What Is It? Focusing 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 physicians orders. Core and cure are shared with
the other health care providers.
The major purpose of care is to achieve an interpersonal relationship with
the individual that will facilitate the development of the core.

Client is composed of body, pathology, and person. People set their own
goals and are capable of learning and growing.
Should facilitate achievement of the clients personal goals.
Development of a mature self-identity that assists in the conscious
selection of actions that facilitate growth.
Caring is the nurses primary function. Professional nursing is most
important during the recuperative period.

Madeleine Leininger
(1978, 1984)
Transcultural Care Theory and Ethnonursing

Transcultural Care Theory and Ethnonursing
Developed the Transcultural Nursing Model. She advocated that nursing is
a humanistic and scientific mode of helping a client through specific
cultural caring processes (cultural values, beliefs and practices) to improve
or maintain a health condition.
Nursing is a learned humanistic and scientific profession and discipline
which is focused on human care phenomena and activities in order to
assist, support, facilitate, or enable individuals or groups to maintain or
regain their well being (or health) in culturally meaningful and beneficial
ways, or to help people face handicaps or death.
Transcultural nursing as a learned subfield or branch of nursing which
focuses upon the comparative study and analysis of cultures with respect
to nursing and health-illness caring practices, beliefs and values with the
goal to provide meaningful and efficacious nursing care services to people
according to their cultural values and health-illness context.
Focuses on the fact that different cultures have different caring behaviors
and different health and illness values, beliefs, and patterns of behaviors.
Awareness of the differences allows the nurse to design culture-specific
nursing interventions.

Martha Rogers
Science of Unitary Man

Science of Unitary Man
Nursing is an art and science that is humanistic and humanitarian. It is
directed toward the unitary human and is concerned with the nature and
direction of human development. The goal of nurses is to participate in the
process of
Nursing interventions seek to promote harmonious interaction between
persons and their environment, strengthen the wholeness of the Individual
and redirect human and environmental patterns or organization to achieve
maximum health.
5 basic assumptions:
1. The human being is a unified whole, possessing individual
integrity and manifesting characteristics that are more than and
different from the sum of parts.
2. The individual and the environment are continuously exchanging
matter and energy with each other
3. The life processes of human beings evolve irreversibly and
unidirectionally along a space-time continuum
4. Patterns identify human being and reflect their innovative
5. The individual is characterized by the capacity for abstraction and
imagery, language and thought, sensation and emotion

Unitary man, a four-dimensional energy field.
Encompasses all that is outside any given human field. Person exchanging
matter and energy.
Not specifically addressed, but emerges out of interaction between human
and environment, moves forward, and maximizes human potential.
A learned profession that is both science and art. The professional practice
of nursing is creative and imaginative and exists to serve people.

Myra Estrin Levine
Conservation Model

Conservation Model
Believes nursing intervention is a conservation activity, with conservation
of energy as a primary concern, four conservation principles of nursing:
conservation of client energy, conservation of structured integrity,
conservation of personal integrity, conservation of social integrity.
Described the Four Conversation Principles. She advocated that nursing is
a human interaction and proposed four conservation principles of nursing
which are concerned with the unity and integrity of the individual. The four
conservation principles are as follows:
1. Conservation of energy. The human body functions by utilizing
energy. The human body needs energy producing input (food,
oxygen, fluids) to allow energy utilization output.
2. Conservation of Structural Integrity. The human body has
physical boundaries (skin and mucous membrane) that must be
maintained to facilitate health and prevent harmful agents from
entering the body.
3. Conservation of Personal Integrity. The nursing interventions are
based on the conservation of the individual clients personality.
Every individual has sense of identity, self worth and self esteem,
which must be preserved and enhanced by nurses.
4. Conservation of Social integrity. The social integrity of the client
reflects the family and the community in which the client
functions. Health care institutions may separate individuals from
their family. It is important for nurses to consider the individual in
the context of the family.

A holistic being
Broadly, includes all the individuals experiences
The maintenance of the clients unity and integrity
A discipline rooted in the organic dependency of the individual human
being on his or her relationship with others

Rosemarie Rizzo Parse
Theory of Human Becoming

Theory of Human Becoming
Nursing is a scientific discipline, the practice of which is a performing art
Three assumption about Human Becoming
1. Human becoming is freely choosing personal meaning in situation
in the intersubjective process of relating value priorities
2. Human becoming is co-creating rhythmic patterns or relating in
mutual process in the universe
3. Human becoming is co-transcending multidimensionality with
emerging possibilities.

A major reason for nursing existence
Man and environment interchange energy to create what is in the world,
and man chooses the meaning given to the situations he creates
A lived experience that is a process of being and becoming
Nursing Practice is directed toward illuminating and mobilizing family
interrelationships in light of the meaning assigned to health and its
possibilities as language in the co created patterns of relating.

Sister Callista Roy
Adaptation Model

Adaptation Model
Viewed humans as Biopsychosocial beings constantly interacting with a
changing environment and who cope with their environment through
Biopsychosocial adaptation mechanisms.
Presented the Adaptation Model. She viewed each person as a unified
biopsychosocial system in constant interaction with a changing
environment. She contented that the person as an adaptive system,
functions as a whole through interdependence of its part. The system
consists of input, control processes, output feedback.
Focuses on the ability of Individuals, families, groups, communities, or
societies to adapt to change.
The degree of internal or external environmental change and the persons
ability to cope with that change is likely to determine the persons health
Nursing interventions are aimed at promoting physiologic, psychologic,
and social functioning or adaptation.
To identify the types and demands placed on a client and clients
adaptation to the demands.

Biopsychological being and the recipient of nursing care.
All conditions, circumstances, and influences surrounding and affecting the
development of an organism or groups of organisms
The person encounters adaptation problems in changing the environment.
A theoretical system of knowledge that prescribes a process of analysis
and action related to the care of the ill or potentially ill persons

Virginia Henderson
The Nature of Nursing Model

The Nature of Nursing Model
Introduced The Nature of Nursing Model. She identified fourteen basic
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.
She further believed that nursing involves assisting the client in gaining
independence as rapidly as possible, or assisting him achieves peaceful
death if recovery is no longer possible.
Defined Nursing: Assisting the individual, sick or well, in the performance
of those activities contributing to health or its recovery (or to peaceful
death) that an individual would perform unaided if he had the necessary
strength, will or knowledge.
Identified 14 basic needs :
1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body wastes
4. Moving and maintaining desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature within normal range
8. Keeping the body clean and well-groomed
9. Avoiding dangers in the environment
10. Communicating with others
11. Worshipping according to ones faith
12. Working in such a way that one feels a sense of accomplishment
13. Playing/participating in various forms of recreation
14. Learning, discovering or satisfying the curiosity that leads to normal
development and health and using available health facilities.

Individual requiring assistance to achieve health and independence or a
peaceful death. Mind and body are inseparable.
All external conditions and influences that affect life and development
Equated with independence, viewed in terms of the clients ability to
perform 14 components of nursing care unaided: breathing, eating,
drinking, maintaining comfort, sleeping, resting clothing, maintaining body
temperature, ensuring safety, communicating, worshiping, working,
recreation, and continuing development.
Assists and supports the individual in life activities and the attainment of

Principles of Nutrition
1. Digestion process by which food substances are changed into forms that
can be absorbed through cell membranes
2. Absorption the taking in of substance by cells or membranes
3. Metabolism sum of all physical and chemical processes by which a living
organism is formed and maintained and by which energy is made available
4. Storage some nutrients are stored when not used to provide energy; e.g.
carbohydrates are stored either as glycogen or as fat
5. Elimination process of discarding unnecessary substances through
evaporation, excretion


1. Carbohydrates the primary sources are plant foods

Types of Carbohydrates

a. Simple (sugars) such as glucose, galactose, and fructose
b. Complex such as starches (which are polysaccharides) and fibers (supplies
bulk or roughage to the diet)

2. Proteins organic substances made up of amino acids

3. Lipids organic substances that are insoluble in water but soluble in alcohol
and ether.
o Fatty acids the basic structural units of all lipids and are either
saturated (all the carbon atoms are filled with hydrogen) or
unsaturated (could accommodate more hydrogen than it
presently contains)
o Food sources of lipids are animal products (milk, egg yolks and
meat) and plants and plant products (seeds, nuts,oils)

4. Vitamins organic compounds not manufactured in the body and needed in
small quantities to catalyze metabolic processes.

a. Water-soluble vitamins include C and B-complex vitamins
b. Fat-soluble vitamins include A, D, E, and K and these can be stored in limited
amounts in the body

5. Minerals compounds that work with other nutrients in maintaining structure
and function of the body

a. Macronutrients calcium, phosphate, sodium, potassium, chloride,
magnesium and sulfur
b. Micronutrients (trace elements) iron, iodine, copper, zinc, manganese and
fluoride The best sources are vegetables, legumes, milk and some meats

6. Water the bodys most basic nutrient need; it serves as a medium for
metabolic reactions within cells and a transporter fro nutrients, waste products and
other substances

According to the International Association for the Study of Pain, pain is an
unpleasant, subjective sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage.

Pain Theories

Specific Theory
1. Proposes that bodys neurons & pathways for pain transmission are
specific, similar to other senses like taste
2. Free nerve endings in the skin act as pain receptors, accept input &
transmit impulses along highly specific nerve fibers
3. Does not account for differences in pain perception or psychologic
variables among individuals.
Pattern Theory
1. Identifies 2 major types of pain fibers; rapidly & slowly conducting
2. Stimulation of these fibers forms a pattern; impulses ascend to the brain to
be interpreted as painful
3. Does not account for differences in pain perception or psychologic
variables among individuals.
Gate Control Theory
1. Pain impulses can be modulated by a transmission blocking action within
the CNS.
2. Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or
scratching an area) and may inhibit smaller diameter fibers to prevent
transmission of the impulse (close the gate).
Current Developments in Pain Theory

Indicate that pain mechanisms & responses are far more complex than believed to
be in the past.
1. Pain may modulate at different points in the nervous system.
o First-order neurons at the tissue level
o Second-order neurons in the spinal cord that process nociceptor
o Third-order tracts & pathways in the spinal cord & brain that
relay/process this information
2. The role of the pain experience in the development of new nociceptors
and/or reducing the threshold of current nociceptor is also being

Types of Pain

Acute Pain
1. Usually temporary, sudden in onset, localized, lasts for 6 months; results
from tissue injury associated with trauma, surgery, or inflammation.
Types of Acute Pain
Somatic: arises from nerve receptors in the skin or close to bodys surface;
may be sharp & well-localized or dull & diffuse; often accompanied by
nausea & vomiting
Visceral: arises from bodys organs; dull & poorly localized because of
minimal noriceptors; accompanied by nausea & vomiting, hypotension &
Referred pain: pain that is perceived in an area distant from the site of
stimuli (e.g. pain in a shoulder following abdominal laparoscopic
2. Acute pain initiates the fight-or-flight response of the Autonomic Nervous
System and is characterized by the following symptoms:
Rapid, shallow respirations
Increased BP
Dilated pupils
Fear & Anxiety
Chronic Pain
1. Prolonged, lasting longer than 6 months, often not attributed to a definite
cause, often unresponsive to medical treatment.
Types of Chronic Pain
Neuropathic: painful condition that results from damage to peripheral
nerves caused by infection or disease; post-therapeutic neuralgia (shingles)
is an example
Phantom: pain syndrome that occurs following surgical or traumatic
amputation of a limb.
o The client is aware that the body part is missing
o Pain may result of stimulation of severed nerves at the site of
o Sensation may be experienced as an itching, pressure, or as
stabbing or burning in nature
o It can be triggered by stressors (fatigue, illness, emotions,
o This experience is limited for most clients because the brain
adapts to amputated limb; however, some clients experience
abnormal sensation or pain over longer periods
o This type of pain requires treatment just as any other type of pain
Psychogenic: pain that is experienced in the absence of a diagnosed
physiologic cause or event; the clients emotional needs may prompt pain
2. Depression is a common associated symptom for the client experiencing
chronic pain; feelings of despair & hopelessness along with fatigue are
expected findings.

Pain Assessment

Tools/Instruments Used
1. A Verbal Report using an intensity scale is a fast, easy & reliable method
allowing the client to state pain intensity & in turn, promotes consisted
communication among the nurse, client & other healthcare professionals
about the clients pain status; the 2 most common scales used are 0 to 5
or 0 to 10. With 0 specifying no pain & the highest number specifying the
worst pain
2. A Visual Analog Scale is a horizontal pain-intensity scale with word
modifiers at both ends of the scale, such as no pain at one end and
worst pain at the other, clients are asked to point or mark along the line
to convey the degree of pain being experienced
3. A Graphic Rating Scale is similar to the visual analog scale but adds a
numerical scale with the word modifiers, usually the numbers 0 to 10 are
added to the scale.
4. Faces Pain Scale children, clients who do not speak English & clients with
communication impairments may have difficulty using a numerical pain
intensity scale; the FACES pain scale may be used for children as young as 3
years old; this scale provides facial expressions (happy face reflects no
pain, crying face represents worst pain)
5. Physiologic Indicators of Pain may be the only means a nurse can use to
assess pain for a non-communicating client, facial & vocal expression may
be the initial manifestations of pain; expressions may include rapid eye
blinking, biting of the lip, moaning, crying, screaming, either closed or
clenched eyes, or stiff unmoving body position
A B C D E method of pain assessment
1. This acronym was developed for cancer pain; however, it is very
appropriate for clients with any type of pain, regardless of the underlying
2. A = Ask about pain
3. B = Believe the client & family reports pain
4. C = Choose pain control options appropriate for the client
5. D = Deliver interventions in a timely, logical &coordinated fashion
6. E = Empower clients & families
P Q R S T assessment for pain reception
1. This method is especially helpful when approaching a new pain problem
2. P = What precipitated the pain?
3. Q = What are the quality & quantity of the pain?
4. R = What is the region of the pain?
5. S = What is the severity of the pain?
6. T = What is the timing of the pain?
Pain History
1. Location when clients report pain all over, this generally refers to total
pain or existential distress (unless there is an underlying physiologic reason
for pain all over the body, such as myalgias); assess the clients emotional
state for depression, fear, anxiety or hopelessness.
2. Intensity It is important to quantify pain using a standard pain intensity
scale. When clients cannot conceptualize pain using a number, simple
word categorizes can be useful (e.g. no pain, mild, moderate, severe).
3. Quality- Nociceptive pain are usually related to damage to bones, soft
tissues, or internal organs; nociceptive pain includes somatic & visceral
o Somatic pain is aching, throbbing pain; example arthritis
o Visceral pain is squeezing, cramping pain; example: pain
associated with ulcerative colitis
4. Pattern pain may be always present for a client; this is often termed
baseline pain. Additional pain may occur intermittently that is of rapid
onset & greater intensity than the baseline pain; known as breakthrough
pain. People at end-of-life often have both types of pain. Cultural beliefs
regarding the meaning of pain should be examined
Physical Examination


The nurse uses physical assessment for the following reasons:
To gather baseline data about the clients health
To supplement, confirm or refute data obtained in the nursing history
To confirm and identify nursing diagnoses
To make clinical judgments about a clients changing health status and

Preparation of Examination
Environment A physical examination requires privacy. An examination
room that is well equipped for all necessary procedures is preferable
Equipment Hand washing is done before equipment preparation and the
examination. Hand washing reduces the transmission of microorganisms
1. Psychological Preparation clients are easily embarrassed when
forced to answer sensitive questions about bodily functions or
when body parts are exposed and examined. The possibility that
the examination will find something abnormal also creates anxiety
so reduction of this anxiety may be the nurses highest priority
before the examination
2. Physical Preparation the clients physical comfort is vital to the
success of the examination. Before starting, the nurse asks if the
client needs to use the toilet.
3. Positioning during the examination, the nurse asks the clients to
assume proper positions so that body parts are accessible and
clients stay comfortable. Clients abilities to assume positions will
depend on their physical strength and degree of wellness.

Order of Examination
1. General Survey includes observation of general appearance and
behavior, vital signs, height and weight measurement
2. Review of systems
3. Head to toe examination

Skills in Physical Examination
1. Inspection to detect normal characteristics or significant physical signs.
To inspect body parts accurately the nurse observes the following
o Make sure good lighting is available
o Position and expose body parts so that all surface can be viewed
o Inspect each areas fro size, shape, color, symmetry, position and
o If possible, compare each area inspected with the same area of
the opposite side of the body
o Use additional light (for example, a penlight) to inspect body
2. Palpation the hands can make delicate and sensitive measurements of
specific physical signs, so palpation is used to examine all accessible parts
of the body. The nurse uses different parts of the hand to detect
characteristics such as texture, temperature and the perception of
3. Percussion examination by striking the bodys surface with a finger,
vibration and sound are produced. This vibration is transmitted through
the body tissues and the character of the sound depends on the density of
the underlying tissue
4. Auscultation is listening to sound created in body organs to detect
variations from normal. Some sounds can be heard with the unassisted
ear, although most sounds can be heard only through a stethoscope.
o Bowel sounds
o Breath sounds:
Examples of Adventitious Breath Sounds
1. Crackles (previously called rales)
2. Rhonchi
3. Wheeze
4. Friction rub
Preparing the Skin for a Surgical Operation

I. Purpose:
To make the skin as clean as possible with a minimum irritation to prevent infection

II. Preparation of the Patient and the Environment:
1. Explain the procedure to the patient.
2. Close the window if necessary
3. Draw the curtains

III. Equipments:
Tray containing:
Safety razor with new blade
A bowl for soap solution
A bowl for warm water
Bottle of green soap
Several O.S
Cotton applicators
Kidney basin
Flashlight p.r.n
Bath towel
Bed protector
Bed screen p.r.n

IV. Procedure:
1. Read the order book to verify the patients name and the area to be
2. Wash your hands and bring the equipment to the bedside.
3. Screen the bed, and replace top sheet with bath blanket. Fanfold to sheet
at foot of bed. Place bed protector under area to be shaved. Impose area.
Place light in a convenient location to provide the best light for shaving.
4. Inspect the area for any signs of eruptions or break in the skin.
5. Report to the headnurse if any skin abrasions are noted.
6. If the hair is long. It is clipped with scissors first.
7. With an O.S. and soap solution, lather the area thoroughly being careful
not to irritate the skin by rubbing too vigorously.
8. Hold the skin taut and shave the area following the shaft of the hair.
9. Rinse razor as necessary in the small bowl of water.
10. Use the cotton applicator to cleanse the umbilicus if it is an abdominal
11. If the area to be prepared includes the pubic or perineal area, shave the
pubic region last. Drape the patient with the blanket for the perineal
preparation. Pace the bed protector under the buttocks. Remove excess
hair from the razor with toilet tissue and place in kidney basin or paper
12. When the entire area is shaved, the skin is cleansed well with soap and
13. Inspect the entire area with the flashlight. Remove any remaining hair.
14. Replace top sheet, make patient comfortable and carry equipment to the
utility room.

V. After Care of Equipment:
1. Discard blade. Cleanse safety razor and sterilize.
2. Cleanse other equipment well with soap and water and keep in proper

Important Note:
1. The area varies with the type of operation and may vary with different but
an extensive area is always prepared. This allows extension of the
operative field when necessary.
2. Preparation of local skin area is usually done in the evening before the
scheduled time for surgery except in emergency cases.
3. For operation in the head or face or orthopedic cases, shaving is frequently
done in the morning of operation.
Private Duty Nursing: Roles and Responsibilities
Nursing has a vast scope on healthcare and services. Large bulk is composed of
nurse practitioners in healthcare institutions and hospitals. However, it is observed
that the ratio of nurses to patients has become inadequate, nursing demands
increase to home-bound patients and in long-term facilities posing some
discrepancies to health delivery services. Thus, patients sort to hiring private duty
Private Duty Nurses (PDN) are eligible professionals who work as freelancers or
through hospital and nursing agencies, delivering healthcare services to a patient or
two. They tend to be patients in hospitals, supplementing the care given by staff
nurses or work independently at home or in a long-term facility. They provide
primary and focused nursing care and implements care plans that are specialized to
individual medical needs.
How to become a Private Duty Nurse?
Possessing only a bachelors degree in nursing is rather premature to venture PDN.
It is necessary for one to undergo clinical experience, trainings and seminars to
equip oneself to actual patient care. PDN should have at least the following
At least one year of clinical experience
Basic life support training
First aid training
Intravenous therapy course
Attended several nursing seminars and forums
Delivering Patient Care
Since PDN is a one-to-one interaction, nursing care encompasses almost all aspects.
The nurse is therefore responsible for the following:
1. Adequate medical assessment and history is taken in collaboration with
other members of the healthcare providers such as the dietician or the
2. Day-to-day patient interaction
3. Vital signs checking (changes and alterations documented)
4. Administration of medications and treatments (as pre ordered by
5. Changes dressings, bandages and contraptions as prescribed
6. Diet supervision and monitoring (with considerations to dietician advise
and medical condition)
7. Providing or assisting patient in self-care
o Dental care needs
o Bathing needs
o Elimination
o Other self-care needs (may involve hair and nail care)
8. Providing range of motion exercises (may be passive or active depending
on the condition)
9. If bed-ridden, an assertive plan to prevent bed sores, contractures and
muscle wasting is to be provided
10. When alterations are observed, treatments and remedies are to be
performed accordingly
11. Documentation of patients condition and pointing out significant changes,
to be reported to the physician and to the families
12. In case of emergency situations, application of independent emergency
procedures is recommended
13. Maintains optimum health and well-being of the patient
Private duty nursing also involves the family in the care plan. They should be
informed and updated of the current status of the patient and is encouraged to
assist and participate in the delivery of care.
Professional Adjustment or Negligence

Refers to the commission or omission of an act, pursuant to a duty, that a
reasonably person in the same or similar circumstance would or would not
do, and acting or the non-acting of which is the proximate cause of injury
to another person or his property

Elements of Professional Negligence
Existence of a duty on the part of the person charged to use due care
under circumstances
Failure to meet the standard of due care
The foreseeability of harm resulting from failure to meet standard
The fact that the breach of this standard resulted in an injury to the

Specific Examples of Negligence
1. Failure to report observations to attending physicians.
2. Failure to exercise the degree of diligence which the circumstances of the
particular case demands.
3. Mistaken identity.
4. Wrong medicine, wrong concentration, wrong route, and wrong dose.
5. Defects in equipments that may result in injuring the patients.
6. Errors due to family assistance.
7. Administration of medicine without a doctor prescription.

The Doctrine of Res Ipsa Loquitor
1. The thing speaks for itself.
2. It means that the nature of the wrongful act or injury is suggestive of
3. Three conditions are required to establish a defendants negligence
without proving specific conduct.
o That the injury was of such nature that it would not normally
occur unless there was a negligent act on the part of someone.
o That the injury was caused by an agency within the control of the
o That the plaintiff himself did not engage in any manner that
would tend to bring about the injury.

you do things beyond your scope of practice
Also denotes stepping beyond ones authority with serious consequences.

Doctrine of Force Majeure
It means an irresistible force, one that is unforeseen or inevitable.
you cannot stop it from happening
circumstances such as floods, fire, earthquakes and accidents fall under
this doctrine

Doctrine of Respondeat Superior
let the master answer for the acts of the subordinate
the liability is expanded to include the master as well as the employee and
not a shift of liability from the subordinate to the master
this doctrine applies only to those actions performed by the employee
within the scope of his employment

Is the lack of ability, legal qualifications or fitness to discharge the required
Although a nurse is registered, if in the performance of her duty she
manifests incompetency, there is ground for revocation or suspension of
her certificates of registration.

Liability of Nurses for the Work of Nursing Aides
Nursing aides perform selected nursing activities under the direct
supervision of nurses.
Nurses should not delegate their functions to nursing aides since the
Philippine Nursing Act specifies the scope of nursing practice of
professional nurses.
If a nurse delegates, he is responsible.

Liability for the Work of Nursing Students
Under the Philippine Nursing Act of 2002, nursing students do not perform
professional nursing duties.
They are to be supervised by their Clinical Instructors.

Assumption of Risk
A nurse cannot bring suit against the patient if she gets hurt or contacts
the disease since upon accepting the case, the nurse agreed to assume the
risk of harm or infection.

Is defined as a free and rational act that presupposes knowledge of the
thing which consent is being given by a person who is legally capable to
give consent.
It is the NURSE who actually secures the consent of the patient upon
1. Informed Consent
it is established principle of law that every human being of adult years
and sound mind has the right to determine what shall be done with his on
Essential elements of Informed Consent
o Diagnosis and explanation of the condition
o A fair explanation of the procedures to be done and used and the
o A description of alternative treatment or procedures
o A description of benefits to be expected
o Material rights if any
o The prognosis, if the recommended care, procedure, is refused.
2. Proof of Consent
A written consent should be signed to show that the procedure is the one
consented to and that the person understands the nature of procedure
A signed special consent is necessary before any medical or surgical
treatment is done such as X-rays etc.
3. Who Must Consent
Normally the patient himself is the one who gives the consent,
If he is incompetent (minors or mentally ill) or physically unable, consent
must be taken from another who is authorized to give it in his behalf.
4. Consent of Minors
Parents, or someone standing in their behalf
If emancipated minor consent is signed by them.
5. Consent of Mentally Ill
They cannot legally give consent. Parents or guardians.
6. Emergency Situation
When an emergency situation exists, no consent is necessary because
inaction at such time may cause greater injury.
7. Refusal to Consent
Patients other than those who are incompetent to give consent can refuse
If refuses to sign, this should be noted in his chart
8. Consent for Sterilization
Is the termination of the ability to produce offspring.
The husband and wife must consent to the procedure if the operation is
primarily to accomplish sterilization.
If its medically necessary or an incidental result, the patient alone is

Medical Records
As a record of illness and treatment, it saves duplication in future cases
and aids in prompt treatment
It serves as a legal protection for the hospital, doctor, and nurse by
reflecting the disease or condition of patient and its management.
If it was not charted, it was not observed or done.
Nurses have the responsibility of keeping the patients right to
Permission has to be taken from the Medical Records Division of the

Intentional Wrongs
nurse may be held liable for intentional wrongs

Is a legal wrong, committed against a person or property, independent of a
contract which renders the person who commits it liable for damages in a
civil action.
The person who has been wronged seeks compensation for injury or
wrong he has suffered
Examples of Torts are:
1. Assault and Battery
o Assault is the imminent threat of harmful or offensive bodily
contact; banta
o Battery is an intentional, unconsented touching of another
2. False Imprisonment or Illegal Detention
o Unjustifiable detention of a person without legal warrant within
the boundaries fixed by the defendant by an act or violation of
duty intended to result in such confinement
3. Invasion of Right to Privacy and Breach of Confidentiality.
o The right to privacy is the right to be left alone, the right to be
free from unwarranted publicity and exposure to public view
4. Defamation
o Character assassination, be in written or spoken
o Slander is oral defamation of a person by speaking unprivileged or
false words by which his reputation is damaged.
o Libel is defamation by written words, cartoons or such
representations that cause a person to be avoided, ridiculed or
held in contempt or tend to injure him in his work.
Roles and Function of a Nurse

1. Caregiver
The caregiver role has traditionally included those activities that assist the
client physically and psychologically while preserving the clients dignity.
Caregiving encompasses the physical, psychosocial, developmental,
cultural and spiritual levels.
2. Communicator
Communication is an integral to all nursing roles. Nurses communicate
with the client, support persons, other health professionals, and people in
the community. In the role of communicator, nurses identify client
problems and then communicate these verbally or in writing to other
members of the health team. The quality of a nurses communication is an
important factor in nursing care.
3. Teacher
As a teacher, the nurse helps clients learn about their health and the
health care procedures they need to perform to restore or maintain their
health. The nurse assesses the clients learning needs and readiness to
learn, sets specific learning goals in conjunction with the client, enacts
teaching strategies and measures learning.
4. Client advocate
Client advocate acts to protect the client. In this role the nurse may
represent the clients needs and wishes to other health professionals, such
as relaying the clients wishes for information to the physician. They also
assist clients in exercising their rights and help them speak up for
5. Counselor
Counseling is a process of helping a client to recognize and cope with
stressful psychologic or social problems, to developed improved
interpersonal relationships, and to promote personal growth. It involves
providing emotional, intellectual, and psychologic support.
6. Change agent
The nurse acts as a change agent when assisting others, that is, clients, to
make modifications in their own behavior. Nurses also often act to make
changes in a system such as clinical care, if it is not helping a client return
to health.
7. Leader
A leader influences others to work together to accomplish a specific goal.
The leader role can be employed at different levels; individual client,
family, groups of clients, colleagues, or the community. Effective
leadership is a learned process requiring an understanding of the needs
and goals that motivate people, the knowledge to apply the leadership
skills, and the interpersonal skills to influence others.
8. Manager
The nurse manages the nursing care of individuals, families, and
communities. The nurse-manager also delegates nursing activities to
ancillary workers and other nurses, and supervises and evaluates their
9. Case manager
Nurse case managers work with the multidisciplinary health care team to
measure the effectiveness of the case management plan and to monitor
10. Research consumer nurses often use research to improve client care. In a
clinical area nurses need to:
Have some awareness of the process and language of research
Be sensitive to issues related to protecting the rights of human subjects
Participate in identification of significant researchable problems
Be a discriminating consumer of research findings

Expanded role of the nurse

1. Clinical Specialists
Is a nurse who has completed a masters degree in specialty and has
considerable clinical expertise in that specialty. She provides expert care to
individuals, participates in educating health care professionals and
ancillary, acts as a clinical consultant and participates in research.
2. Nurse Practitioner
Is a nurse who has completed either as certificate program or a masters
degree in a specialty and is also certified by the appropriate specialty
organization. She is skilled at making nursing assessments, performing P.
E., counseling, teaching and treating minor and self- limiting illness.
3. Nurse-midwife
A nurse who has completed a program in midwifery; provides prenatal and
postnatal care and delivers babies to woman with uncomplicated
4. Nurse anesthetist
A nurse who completed the course of study in an anesthesia school and
carries out pre-operative status of clients.
5. Nurse Educator
A nurse usually with advanced degree, who beaches in clinical or
educational settings, teaches theoretical knowledge, clinical skills and
conduct research.
6. Nurse Entrepreneur
A nurse who has an advanced degree, and manages health-related
7. Nurse administrator
A nurse who functions at various levels of management in health settings;
responsible for the management and administration of resources and
personnel involved in giving patient care.
Sitz Bath
Purpose of Sitz Bath:
1.To aid healing a wound in the area by cleaning on discharges and slough
2.To induce voiding in urinary retention
3.To relieve pain, congestion and inflammation in cases of:
c.After proctoscopic or cycloscopic examination
e.Uterine and renal colic
4.To induce menstruation.

Contraindication: Menstruating or pregnant women

Sitz tub half filled with water 105F
Pitcher of water 130F
Bath thermometer
Ice cap-with cover
Fresh camisa
Bath towel
Bath blanket
Rubber ring p.r.n.

Preparation of Equipment:
1. Take all necessary equipment to bathroom or treatment room.
2. Run water into tub and check temperature105F
3. Place rubber ring at bottom of tub p.r.n. or line bottom with towel.

Sitz Bath Procedure:
1. Help patient undress and drape with bath blanket. Pin at the back.
2. Help patient set in the tub bringing the blanket covering him around the
shoulder and over the edge of the tub.
3. Place ice cap on the head.
4. Place folded towel at the edge of the tub where the patients back rests
and place another towel under the knees where they rest on the interior
edge of the tub.
5. Gradually raise the temperature of the water to 115-F by pouring hot
water at the sides of the tub. Let patient soak for 20-30 minutes.
6. After the Treatment, dry patient thoroughly, and put on fresh gown. Let
patient sit on a chair for a while before taking him back to bed.
NOTE: Use aseptic technique if there is lesion or in the area, disinfect tub.

Stress (Theory by Hans Selye)
Non specific response of the body to nay demand made upon it
Any situation in which a non specific demand requires an individual to
respond or take action
1. Characteristics of Stress

a. Stress is not nervous energy. Emotional reactions are common stressors
b. Stress is not always the result of damage to the body
c. Stress does not always result in feelings of distress (harmful or unpleasant
d. Stress is a necessary part of life and is essential for normal growth and
e. Stress involves the entire body acting as a whole and is an integrated manner
f. Stress response is natural, productive and adaptive

2. Stressors
Factor or agent producing stress, maybe: physiological, psychological,
social, environmental, developmental, spiritual or cultural and represent
an unmet needs
a. Classification of Stressors
Internal Stressors originate from within the body. E.g. fever, pregnancy,
menopause, emotion such as guilt
External Stressors originate outside a person. E.g. change in family or
social role, peer pressure, marked change in environmental temperature
b. Factors influencing response to stressors
Physiological functioning
Behavioral characteristics
Nature of the stressor: integrity, scope, duration, number, and nature of
other stressors
Homeostasis Process of maintaining uniformity, stability and constancy
with in the living organisms. (From Greek word homotos like, and stasis
Adaptation Bodys adjustment to different circumstances and conditions.
Process by the physiological or psychological dimensions change in
response to stress; attempt to maintain optimal functioning

Adaptation to Stress-Physiological Response (Hans Selye)

1. Local Adaptation Syndrome (LAS) Response of a body tissue, organ or part to
the stress of trauma, illness or other physiological change

a. Characteristics
The response is localized, it does not involve entire body systems
The response is adaptive, meaning that a stressor is necessary to stimulate
The response is short term. It does not persist indefinitely
The response is restorative, meaning that the LAS assists in restoring
homeostasis to the body region or part
b. Two Localized Responses
Reflex Pain Response is a localized response of the central Nervous
system to pain. It is an adaptive response and protects tissue from further
damage. The response involves a sensory receptor, a sensory nerve from the
spinal cord, and an effector muscle. An example would be the unconscious,
reflex removal of the hand from a hot surface.
Inflammatory Response is stimulated by trauma or infection. This
response localizes the inflammation, thus revenging its spread and
promotes healing. The inflammatory response may produce localized pain,
swelling, heat, redness and changes in functioning.
c. Three Phases of Inflammatory Response
First Phase Narrowing of blood vessels occurs at the injury to control
bleeding. Then histamine is released at the injury, increasing the number of
white blood cells to combat infection.
Second Phase It is characterized by release of exudates from the wound
Third Phase The last phase is repair of tissue by regeneration or scar
formation. Regeneration replaces damaged cells with identical or similar
2. General Adaptation Syndrome (GAS) or Stress Syndrome characterized by a
chain or pattern of physiologic events.

a. 3 Stages
Alarm Reaction initial reaction of the body which alerts the bodys
defenses. SELYE divided this stage into 2 parts:
Stage of Resistance occurs when the bodys adaptation takes place; the
body attempts to adjust with the stressor and to limit the stressor to the
smallest area of the body that can deal with it.
Stage of Exhaustion the adaptation that the body made during the second
stage cannot be maintained; the ways used to cope with the stressors have
been exhausted

b. Stressors
Stimulate the sympathetic nervous system, which in turn stimulates the
The HYPOTHALAMUS releases corticotrophin releasing hormone (CRH).
During times of stress, the ADRENAL MEDULLA secretes EPINEPHRINE &
NOREPINEPHRINE in response to sympathetic stimulation. Significant body
responses to epinephrine include the following:
o Increased myocardial contractility, which increases cardiac output
& blood flow to active muscles
o Bronchial dilation, which allows increased oxygen intake
o Increased blood clotting
o Increased cellular metabolism
o Increased fat mobilization to make energy available & to synthesize
other compounds needed by the body.

Physiologic Indicators of Stress
1. Pupils dilate to increase visual perception when serious threats to the body
2. Sweat production (diaphoresis) increases to control elevated body heat
due to increased metabolism.
3. The heart rate & cardiac output increase to transport nutrients and by-
products of metabolism more efficiently.
4. Skin is pallid because of constriction of peripheral vessels, an effect of
5. Sodium & water retention increase due to release of mineralocorticoids,
which results in increased blood volume.
6. The rate & depth of respirations increase because of dilation of the
bronchioles, promoting hyperventilation.
7. Urinary output may increase or decreases.
8. The mouth may be dry.
9. Peristalsis of the intestines decreases, resulting in possible constipation
and flatus.
10. For serious threats, mental alertness improves.
11. Muscle tension increases to prepare for rapid motor activity or defense.
12. Blood sugar increases because of release of glucocorticoids &

Psychologic Indicators
Psychologic manifestations of stress include anxiety, fear, anger,
depression & unconscious ego defense mechanisms.
1. Anxiety a common reaction to stress. It is a state of mental
uneasiness, apprehension, dread, or foreboding or a feeling of
helplessness related to an impending or anticipated unidentified
threat to self or significant relationships. It can be experienced,
subcutaneous or unconscious level.
2. Fear an emotion or feeling of apprehension aroused by
impending or seeming danger, or other perceived threat. The
object of fear may or may not be based in reality.
3. Anger an emotional state consisting of a subjective feeling of
animosity or strong displeasure. People may feel guilty when they
feel anger because they have been taught that to feel angry is
4. Depression common reaction to events that seem
overwhelming or negative. It is an extreme feeling of sadness,
despair, dejection, lack of worth or emptiness.
Emotional symptoms can include: Feelings of tiredness, sadness,
emptiness, or numbness
Behavioral signs include: Irritability, inability to concentrate, difficulty
making decisions, loss of sexual desire, crying, sleep disturbance and social
Physical signs include: Loss of appetite, weight loss, constipation,
headache and dizziness

Cognitive Indicators
Are thinking responses that include problem-solving, structuring, self-
control or self-discipline, suppression and fantasy
1. Problem solving involves thinking through the threatening
situation, using a specific steps to arrive at a solution
2. Structuring arrangement or manipulation of a situation so that
threatening events do not occur.
3. Self-Control (discipline) assuming a manner of facial expression
that convey a sense of being in control or in change.
4. Suppression consciously and willfully putting a thought or
feeling out of mind
5. Fantasy (daydreaming) likened to make believe. Unfulfilled
wishes & desires are imagined as fulfilled, or a threatening
experience is reworked or replayed so that it ends differently
from reality.

Coping Strategies (Coping Mechanisms)
Coping dealing with problems & situations or contending with them
Coping Strategy innate or acquired way of responding to a changing
environment or specific problem or situation.
According to Folkman and Lazarus, coping is the cognitive & behavioral
effort to manage specific external and/ or internal demands that are
appraised as taxing or exceeding the resources of the person.

Coping Strategies: 2 Types
1. Problem-focused coping efforts to improve a situation by making changes
or taking some action
2. Emotion-focused coping does not improve the situation, but the person
often feels better.

Coping strategies are also viewed as:
1. Long-term coping strategies can be constructive & realistic
2. Short-term coping strategies can reduce stress to a tolerable limit
temporarily but are in the end of ineffective ways to deal with reality.

Coping can be adaptive or maladaptive:
1. Adaptive Coping helps the person to deal effectively with stressful events
& minimizes distress associated with them.
2. Maladaptive Coping can result in unnecessary distress for the person &
others associated with the person or stressful event.
Effective coping results in adaptation; ineffective coping results in
maladaptation. The effectiveness of an individuals coping is influenced by
a number of factors:
o The number, duration & intensity of the stressors
o Past experiences of the individual
o Support systems available to the individual
o Personal qualities of the person
If the duration of the stressors is extended beyond the coping powers of
the individual, that person becomes exhausted and may develop increased
susceptibility to health problems.
Reaction to long term stress is seen in family members who undertake the
care of a person in the home for a long period. This stress is called
caregiver burden & produces responses such as chronic fatigue, sleeping
difficulties & high BP.
Prolonged stress can also result in mental illness.

Relaxation Techniques
Used to quiet the mind, release tension & counteract the fight or flight
responses of General Adaptation Syndrome (GAS).
1. Breathing Exercises
2. Massage
3. Progressive Relaxation
4. Imagery
5. Biofeedback
6. Yoga
7. Meditation
8. Therapeutic Touch
9. Music Therapy
10. Humor & Laughter

Psychological Response
Exposure to a stressor results in psychological and physiological and
physiological adaptive responses. As people are exposed a stressors, their
ability to meet their basic needs is threatened. This threat whether actual
or perceived, produces frustration, anxiety and tension. Psychological
adaptive behaviors assist the persons ability to cope with stressors. These
behaviors are directed at stress management and are acquired through
learning and experience as a person identifies acceptable and successful
Psychological adaptive behaviors are also related to as COPING
MECHANISMS. It involves:
1. Task Oriented Behaviors Involve using cognitive abilities to reduce
stress, solve problems, resolve conflicts and gratify needs. It enables a
person to cope realistically with the demands of a stressor.
o Three General Types:
Attack Behavior Is acting to remove or overcome a
stressor or to satisfy a need
Withdrawal Behavior Is removing the self physically or
emotionally from the stressor
Compromise Behavior Is changing the usual method of
operating, substituting goals or omitting the satisfaction of
needs to meet other needs or to avoid stress.
2. Defense Mechanisms Unconscious behaviors that offer psychological
protection from a stressful event. They are used by everyone and help
protect against feelings of worthlessness and anxiety. Frequently activated
by short-term stressors and usually do not result in psychiatric disorders.

Surgical Dressing Technique

I. Purpose:
To assist with or to apply a surgical dressing

II. Equipment:
Sterile dressing container with:
o 1 Tissue Forceps
o 1 Round Nose Forceps
o 1 Mayo Scissors
Sterile Towel
Pick-up forceps in solution
Solution (iodine, zephiran, alcohol 70%, Benzene or other, etc.)
Bed Screen p.r.n
Sterile sponge 4 x 4
Sterile cotton balls
Sterile top dressing
Kidney basin
Adhesive tape
Bandage scissors
Bed protector p.r.n
Paper bag

III. Procedure:
1. Explain procedure to patient. Screen the bed and make patient
2. Expose area to be dressed. Protect beddings p.r.n.
3. Remove adhesive and outer dressings and discard in paper bag or kidney
basin lined with paper.
4. Set sterile field, using pick-up forceps to remove sterile articles from the
a. Place towel open to two thickness, on bed near, dressing or on
patients bedside table.
b. Put out enough dressings and cotton balls on sterile towel. (Use
judgment in setting out the supplies.)
c. Place thumb forceps and hemostat so that handles are over the
edge of the towel.
5. Remove inner dressings with forceps.
6. Using the hemostat, cleanse area with prescribed solution.
a. Pick-up sponge with hemostat pour solution over it.
b. Clean incision line first. Discard sponge. Repeat until clean than
clean area around wound.
7. Apply medicine ordered.
8. Apply dressings and secure with tape.
9. Make patient comfortable and take equipment away.
Suture also known as stitches a piece of thread like material use to secure wound
edges or body partstogether after an injury or surgery. A variety of suture exists in
size strength and durability.Stitches placeddeep inside the wound always requires
the use of dissolvable (absorbable) sutures, whereas stitches visible on the skin
(placed superficially) may use dissolvable or non-dissolving (non-absorbable)

Suture Classification

Surgical sutures as defined by the U.S.P. (United States Pharmacopoeia) are divided
into two majorclassifications based on their reactions with body tissues

1.Absorbable sutures
Description: capable of being absorbed by living mammalian tissue, yet may be
treated to modify resistance to absorption source is both natural and synthetic.
Tissue interaction: absorbable sutures are digested by body enzymes by first losing
their strength then gradually disappearing form the tissue.

2.Non Absorbable sutures
Description: material not affected by enzyme activity or absorption in living tissues
and are natural and synthetic sources.
Tissue interaction: non absorbable sutures become encapsulated in fibrous tissue
during the healingprocess and remains embedded in body tissues unless they are
surgically removed.
a.Class 1-silk or synthetic fibers of monofilament, twisted of branded construction.
b.Class 2 -cotton or linen fibers or coated natural or synthetic fibers. The coating
forms a thickness, yet does not contribute to its strength.

3 Monofilament suture is a single strand that is non capillary (Resistant to fluids
soaking into the suture) it is designed by the U.S.P.

4 Multifilament suture on the other hand is multiple strands of suture held
together by a process of twisting,braiding of spinning the material. All multifilament
sutures have certain capacity to absorb body fluid(capillarity),which elicits a higher
degree of tissue reaction and are classified by the U.S.P. as Type A.

Commonly Use Suture Materials

Suture Type Color Raw Material Interaction Frequent Uses
Surgical Gut Plain Yellowish tan
Blue (Dyed)

Collagen derived
from healthy
Absorbed relatively quickyl
by body tissues
Ligate superficial vessels suture
subcutaneous and other tissues that heal
rapidly may be used in presence of
Chromic Brown
Blue (Dyed)

Collagen derived
form healthy
treated to resit
digestion by
body tissues
Absorbed more slowly by
body tissues due to
chemical treatment
Fascia and peritoneum for support,most
versatile of all materials for use in practically
all tissues ,may be used in presence of
Coated VICRYL(Polyglactin

Braided Violet (Undyed) Copolymer of
lactide and
glycolide coated
with polyglactin
and calcium
Absorbed by slow
hydrolysis in tissues
Ligate or suture tissues where an absorbable
suture is desirable except where
approximation under stress is required.
Surgical Silk Braided Black
Natural protein
fiber spun by
Very slowly absorbed;
remains encapsulated in
body tissues
Most body tissues for ligating and suturing.
Ophtalmology and plastic surgery

Surgical Cotton Twisted White,blue,pink Natural cotton
encapsulated in body
Most body tissues for ligating and suturing
Surgical Steel Monofilament
Silver colored An alloy of iron Nonabsorbable;remais
encapsulated in body
General and skin closure;retention;tendon
repair;orthopedic and neurosurgery.
ETHILON Nylon Monofilament Green Polyamide
Non absorbable;remains
encapsulated in body
Skin closure;retention,plastic
NUROLON Nylon Braided Black Polyamide
Non absorbable;remains
encapsulated in body
Most body tissues for ligating and
suturing;general closure;neurosurgery.
MERSILENE Polyester Fiber Braided Green,white Synthetic
material made
from chemicals
Non absorbable;remains
encapsulated in body
Cardiovascular and plastic surgery.
ETHIBOND Polyester Fiber Braided Green,white Polyester fiber
material treated
with polybutilate
Non absorbable;remains
encapsulated in body
Abdominal closure;cardiovascular and
plastic surgery
PROLENE Polypropylene Monofilament

Clear,blue Polymer of
Non absorbable;remains
encapsulated in body
General plastic and cardiovascular surgery

Theoretical Framework of Nursing Practice

As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by
Virginia Henderson: 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 that the client would
perform unaided if he had the necessary strength, will or knowledge.
Help the client gain independence as rapidly as possible.

Conceptual and Theoretical Models of Nursing Practice
Theorist Description
Developed the first theory of nursing.
Focused on changing and manipulating the
environment in order to put the patient in the
best possible conditions for nature to act.
HILDEGARD PEPLAU Introduced the Interpersonal Model.
She 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
FAYE ABDELLAH Defined nursing as having a problem-solving
approach, with key nursing problems related
to health needs of people; developed list 21
nursing problem areas
IDA JEAN ORLANDO Developed the three elements client
behavior, nurse reaction and nurse action
compose the nursing situation. She observed
that the nurse provide direct assistance to
meet an immediate need for help in order to
avoid or to alleviate distress or helplessness.
MYRA LEVINE Described the Four Conservation Principles.
1. conservation of energy
2. conservation of structured integrity
3. conservation of personal integrity
4. conservation of social integrity
DOROTHY JOHNSON Developed the Behavioral System Model.
1. Patients behavior as a system that is
a whole with interacting parts
2. how the client adapts to illness
3. Goal of nursing is to reduce so that
the client can move more easily
through recovery.
MARTHA ROGERS Conceptualized the Science of Unitary Human
Beings. She asserted that human beings are
more than different from the sum of their
parts; the distinctive properties of the whole
are significantly different from those of its
DOROTHEA OREM Emphasizes the clients self care needs;
nursing care becomes necessary when client is
unable to fulfill biological, psychological,
developmental or social needs.
IMOGENE KING Nursing process is defined as dynamic
interpersonal process between nurse, client
and health care system.
BETTY NEUMAN Stress reduction is a goal of system model of
nursing practice. Nursing actions are in
primary, secondary or tertiary level of
SISTER CALLISTA ROY Presented the Adaptation Model. She viewed
each person as a unified bio-psychosocial
system in constant interaction with a changing
environment. 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
LYDIA HALL Introduced the notion that nursing centers
around three components: person (core),
pathologic state and treatment (cure) and

Conceptualized the Human Caring Model. She
emphasized that nursing is the application of
the art and human science through
transpersonal caring transactions to help
persons achieve mind-body-soul harmony,
which generates self-knowledge, self-control,
self-care and self-healing.

Introduced the Theory of Human Becoming.
She emphasized free choice of personal
meaning in relating to value priorities, co-
creating of rhythmical patterns, in exchange
with the environment and contranscending in
many dimensions as possibilities unfold.
Developed the Transcultural Nursing Model.
She advocated that nursing is a humanistic and
scientific mode of helping a client through
specific cultural caring processes (cultural
values, beliefs and practices) to improve or
maintain a health condition

Therapeutic Communication

Establishing a therapeutic provider-client relationship.
Identify clients concerns and problem.
Assess clients perception of the problem.
Recognize clients needs.
Guide client towards a satisfying and socially acceptable solution

The Qualities of a Good Communicator
Respect and empathy for the client.
Good communication skills.
Tolerance of values and beliefs different from ones own.
Unbiased attitudes.
Awareness of gender issues

Attentive Listening
Listening actively, using all the senses, as opposed to listening passively
with just the ear
It involves paying attention to the total message, both verbal and non
verbal, and noting whether these communications are congruent.

Physical Attending
The manner of being present to
5 specific ways to convey physical attending:
1. Face the other person squarely
2. Adopt an open posture
3. Lean toward the person
4. Maintain good eye contact
5. Try to be relatively relaxed

Therapeutic Communication Technique
Using silence Accepting pauses or silences that may
extend for several seconds or minutes
without interjecting any verbal response.
Sitting quietly (or walking with the
client) and waiting attentively until the
client is able to put thoughts and
feelings into words.

Providing general leads Using statements or questions that (a)
encourage the client to verbalize, (b) choose
a topic of conversation, and (c) facilitate
continued verbalization.
Can you tell me how it is for you?
Perhaps you would like to talk
Would it help to discuss your feelings?
Where would you like to begin?
And then what?

Being specific and
Making statements that are specific rather
than general, and tentative rather than
Rate your pain on a scale of 0-10.
(specific statement
Are you in pain? (general statement)
You seem unconcerned about your
diabetes? (tentative statement)
You dont care about your diabetes
and you will never will (absolute

Using open-ended
Asking broad questions that lead or invite
the client to explore (elaborate, clarify,
describe, compare, or illustrate) thoughts
and feelings. Open-ended question specify
only the topic to be discussed and invite
answers that are longer than one or two
Id like to hear more about that.
Tell me about.
How have you been feeling lately?
What brought you to the hospital?
What is you opinion?
You said you were frightened
yesterday. How do you feel now?

Using touch Providing appropriate forms of touch to
reinforce caring feelings. Because tactile
contacts vary considerably among
individuals, families, and cultures, the nurse
must be sensitive to the differences in
attitudes and practices of clients and self.
Putting an arm over the clients
shoulder. Placing your hand over the
clients hand.
Restating or paraphrasing Actively listening for the clients basic
message and then repeating those thoughts
and /or feelings in similar words. This
conveys that the nurse has listened and
understood the clients basic message and
also offers clients a clearer idea of what they
have said.
Client: I couldnt manage to eat any
dinner last night-not even the dessert.
Nurse: You had difficulty eating
Client: Yes, I was very upset after my
family left.
Client: I have trouble talking with the
Nurse:You find it difficult talking to
people you do not know?

Seeking Clarification A method of making the clients broad
overall meaning of the message more
understandable. It is used when
paraphrasing is difficult or when the
communication is rambling or garbled. To
clarify the message, the nurse can restate
the basic message or confess confusion and
ask client to repeat or restate the message.
Nurses can also clarify their own message
with statements.
Im puzzled.
Im not sure I understand that
Would you please say that again?
Would you tell me more?
I meant this rather than that.
Im sorry that wasnt very clear.
Let me try o explain another way.

Perception checking or
seeking consensual
A method similar to clarifying that verifies
the meaning of specific words rather than
the overall meaning of a message.
Client: My husband never gives me any
Nurse:You mean he has never given
you a present for your birthday or
Client: Well not ever. He does get me
something for my birthday and
Christmas, but he never thinks of giving
me anything at any other time.

Offering self Suggesting ones presence, interest, or wish
to understand the client without making any
demands or attaching conditions that the
client must comply with to receive the
nurses attention.
Ill stay with you until your daughter
We can sit here quietly for awhile; we
dont need to talk unless you would like
Ill help you to dress to go home, if you

Giving information Providing in a simple and direct manner,
specific factual information the client may or
may not request. When information is not
known, the nurse states this and indicates
who has it or when the nurse will obtain it.
Your surgery is schedule for 1 am
You will feel a puling sensation when
the tube is removed from your
I do not know the answer to that, but I
will find out from Mrs. King, the nurse in

Acknowledging Giving recognition, in a non judgmental way,
of a change in behavior, an effort the client
has made, or a contribution to a
communication. Acknowledgment may be
with or without understanding, verbal or
non verbal.
You trimmed your beard and mustache
and washed your hair.
I noticed you keep squinting your eyes.
Are you having difficulty seeing?
You walk twice as far today with your

Clarifying time or
Helping the client clarify an event, situation,
or happening in relationship to time.
Client:I vomited this morning.
Nurse:Was that after breakfast?
Client:I feel that I have been asleep for
Nurse:You had your operation
Monday, and today is Tuesday.

Presenting reality Helping the client to differentiate the real
from the unreal.
That telephone ring came from the
program on television.
I see shadows from the window
Your magazine is here in the drawer .It
has not been stolen.

Focusing Helping the client expand on and develop a
topic of importance. It is important for the
nurse to wait until the client finishes stating
the main concerns before attempting to
focus. The focus may be an idea or a feeling;
however, the nurse often emphasizes a
feeling to help the client recognize an
emotion disguised behind words.
Client:My wife says she will look after
me, but I dont think she can, what with
the children to take care of, and theyre
always after her about something---
clothes, homework, whats for dinner
that night.
Nurse: Sounds like you are worried
about how well she can manage.

Reflecting Directing ideas, feelings, questions, or
content back to clients to enable them to
explore their own ideas and feelings about a
Client: What can I do?
Nurse: What do you think would be
Client: Do you think I should tell my
Nurse:You seem unsure about telling
your husband.

Summarizing and planning Stating the main points of a discussion to
clarify the relevant points discussed. This
technique is useful at the end on an
interview or to review a health teaching
session. It often acts as an introduction to
future care planning
During the past hour we have talked
Tomorrow afternoon we may explore
this further.
In a few days Ill review what you have
learned about the actions and effects of
your insulin.
Tomorrow, I will look at your feeling

Barriers of Communication

Offering generalized and oversimplified
beliefs about groups of people that are
based on experiences too limited to be valid.
These responses categorize clients and
negate their uniqueness as individuals.
Two-year-olds are brats.
Women are complainers.
Men dont cry.
Most people dont have any pain after
this type of surgery.

Agreeing and disagreeing Akin to judgmental responses, agreeing and
disagreeing imply that the client is either
right or wrong and that the nurse is in a
position to judge this. These responses deter
clients from thinking through their position
and may cause a client to become defensive.
Client: I dont think Dr. Broad is a very
good doctor. He doesnt seem
interested in his patients.
Nurse: Dr. Broad is head of the
department of surgery and is an
excellent surgeon.

Being defensive Attempting to protect a person or health
care services from negative comments.
These responses prevent the client from
expressing true concerns. The nurse is
saying, You have no right to complain.
Defensive responses protect the nurse from
admitting weaknesses in the health care
services, including personal weaknesses.
Client: Those night nurses must sit
around and talk all night. They didnt
answer my light for over an hour.
Nurse: Ill have you know we literally
run around on nights. Youre not the
only client you know.

Challenging Giving a response that makes clients prove
their statement or point of view. These
responses indicate that the nurse is failing to
Client: I felt nauseated after that red
consider the clients feelings, making the
client feel it necessary to defend a position.
Nurse: Surely you dont think I gave
you the wrong pill?
Client: I feel as if I am dying.
Nurse: How can you feel that way if
your pulse is 60?
Client: I believe my husband doesnt
love me.
Nurse: You cant say that; why, he
visits you every day.

Probing Asking for information chiefly out of
curiosity rather than with the intent to assist
he client. These responses are considered
prying and violate the clients privacy. Asking
why is often probing and places the client
in a defensive position.
Client: I was speeding along the street
and didnt see the stop sign.

Nurse: Why were you speeding?
Client: I didnt ask the doctor when he
was here.

Nurse: Why didnt you?

Testing Asking questions that make the client admit
to something .These responses permit the
client only limited answers and often meet
the nurses need rather than the clients.
Who do you think you are? (forces
people to admit their status is only that
of client)
Do you think I am not busy? (forces
the client to admit that the nurse is
really busy)

Rejecting Refusing to discuss certain topics with the I dont want to discuss that. Lets talk
client. These responses often make clients
feel that the nurse is rejecting not only their
communication but also the client
Lets discuss other areas of interest to
you rather than the two problems you
keep mentioning.
I cant talk now. Im on my way for
coffee break.

Changing topics and
Directing the communication into areas of
self-interest rather than considering the
clients concerns is often a self-protective
response to a topic that causes anxiety.
These responses imply that what the nurse
considers important will be discussed and
that clients should not discuss certain topics.
Client: Im separated from my wife. Do
you think I should have sexual relations
with other woman?
Nurse: I see that your 36 and that you
like gardening. This sunshine is good for
my roses. I have a beautiful rose

Unwarranted reassurance Using clichs or comforting statements of
advice as a means to reassure the client.
These responses block the fears, feelings,
and other thoughts of the client.
Youll feel better soon.
Im sure everything will turn out all
Dont worry.

Passing judgment Giving opinions and approving or
disapproving responses, moralizing, or
implying ones own values. These responses
imply that the client must think as the nurse
thinks, fostering client dependence.
Thats good (bad).
You shouldnt do that.
Thats not good enough.
What you did was wrong (right).

Giving common advice Telling the client what to do. These
responses deny the clients right to be an
equal partner. Note that giving expert advice
rather than common advice is therapeutic.
Client: Should I move from my home to
a nursing home?
Nurse: If I were you, Id go o nursing
home, where youll get your meals
cooked for you.

Therapeutic Diet

Clear- Liquid Diet

Relieve thirst and help maintain fluid balance.
Post-surgically and following acute vomiting or diarrhea.
Foods Allowed:
carbonated beverages; coffee (caffeinated and decaff.); tea; fruit-flavored
drinks; strained fruit juices; clear, flavored gelatins; broth, consomme;
sugar; popsicles; commercially prepared clear liquids; and hard candy.
Foods Avoided:
Milk and milk products, fruit juices with pulp, and fruit.

Full- Liquid Diet

Provide an adequately nutritious diet for patients who cannot chew or who
are too ill to do so.
Acute infection with fever, GI upsets, after surgery as a progression from
clear liquids.
Foods Allowed:
clear liquids, milk drinks, cooked cereals, custards, ice cream, sherbets,
eggnog, all strained fruit juices, creamed vegetable soups, puddings,
mashed potatoes, instant breakfast drinks, yogurt, mild cheese sauce or
pureed meat, and seasoning.
Foods Avoided:
nuts, seeds, coconut, fruit, jam, and marmalade

Soft Diet

Provide adequate nutrition for those who have troubled chewing.
patient with no teeth or ill-fitting dentures; transition from full-liquid to
general diet; and for those who cannot tolerate highly seasoned, fried or
raw foods following acute infections or gastrointestinal disturbances such
as gastric ulcer or cholelithiasis.
Foods Allowed:
very tender minced, ground, baked broiled, roasted, stewed, or creamed
beef, lamb, veal, liver, poultry, or fish; crisp bacon or sweet bread; cooked
vegetables; pasta; all fruit juices; soft raw fruits; soft bread and cereals; all
desserts that are soft; and cheeses.
Foods Avoided:
coarse whole-grain cereals and bread; nuts; raisins; coconut; fruits with
small seeds; fried foods; high fat gravies or sauces; spicy salad dressings;
pickled meat, fish, or poultry; strong cheeses; brown or wild rice; raw
vegetables, as well as lima beans and corn; spices such as horseradish,
mustard, and catsup; and popcorn.

Sodium- Restricted Diet

Reduce sodium content in the tissue and promote excretion of water.
Heart failure, hypertension, renal disease, cirrhosis, toxemia of pregnancy,
and cortisone therapy.
Mildly restrictive 2 g sodium diet to extremely restricted 200 mg sodium
Foods Avoided:
Table salt; all commercial soups, including bouillon; gravy, catsup, mustard,
meat sauces, and soy sauce; buttermilk, ice cream, and sherbet; sodas;
beet greens, carrots, celery, chard, sauerkraut, and spinach; all canned
vegetables; frozen peas;
All baked products containing salt, baking powder, or baking soda; potato
chips and popcorn; fresh or canned shellfish; all cheeses; smoked or
commercially prepared meats; salted butter or margarine; bacon, olives;
and commercially prepared salad dressings.

Renal Diet

Control protein, potassium, sodium, and fluid levels in the body.
Acute and chronic renal failure, hemodialysis.
Foods Allowed:
High-biological proteins such as meat, fowl, fish, cheese, and dairy
products range between 20 and 60 mg/day.
Potassium is usually limited to 1500 mg/day.
Vegetables such as cabbage, cucumber, and peas are lowest in potassium.
Sodium is restricted to 500 mg/day.
Fluid intake is restricted to the daily volume plus 500 mL, which represents
insensible water loss.
Fluid intake measures water in fruit, vegetables, milk and meat.
Foods Avoided:
Cereals, bread, macaroni, noodles, spaghetti, avocados, kidney beans,
potato chips, raw fruit, yams, soybeans, nuts, gingerbread, apricots,
bananas, figs, grapefruit, oranges, percolated coffee, Coca-Cola, orange
crush, sport drinks, and breakfast drinks such as Tang or Awake

High- Protein, High- Carbohydrate Diet

To correct large protein losses and raises the level of blood albumin. May
be modified to include lowfat, low-sodium, and low-cholesterol diets.
Burns, hepatitis, cirrhosis, pregnancy, hyperthyroidism, mononucleosis,
protein deficiency due to poor eating habits, geriatric patient with poor
intake; nephritis, nephrosis, and liver and gall bladder disorder.
Foods Allowed:
General diet with added protein.
Foods Avoided:
Restrictions depend on modifications added to the diet. The modifications
are determined by the patients condition.

Purine- Restricted Diet

Designed to reduce intake of uric acid-producing foods.
High uric acid retention, uric acid renal stones, and gout.
Foods Allowed:
General diet plus 2-3 quarts of liquid daily.
Foods Avoided:
Cheese containing spices or nuts, fried eggs, meat, liver, seafood, lentils,
dried peas and beans, broth, bouillon, gravies, oatmeal and whole wheat,
pasta, noodles, and alcoholic beverages. Limited quantities of meat, fish,
and seafood allowed.

Bland Diet

Provision of a diet low in fiber, roughage, mechanical irritants, and
chemical stimulants.
Gastritis, hyperchlorhydria (excess hydrochloric acid), functional GI
disorders, gastric atony, diarhhea, spastic constipation, biliary indigestion,
and hiatus hernia.
Foods Allowed:
Varied to meet individual needs and food tolerances.
Foods Avoided:
Fried foods, including eggs, meat, fish, and sea food; cheese with added
nuts or spices; commercially prepared luncheon meats; cured meats such
as ham; gravies and sauces; raw vegetables;
potato skins; fruit juices with pulp; figs; raisins; fresh fruits; whole wheats;
rye bread; bran cereals; rich pastries; pies; chocolate; jams with seeds;
nuts; seasoned dressings; caffeinated coffee; strong tea; cocoa; alcoholic
and carbonated beverages; and pepper.

Low-Fat, Cholesterol- Restricted Diet

Reduce hyperlipedimia, provide dietary treatment for malabsorption
syndromes and patients having acute intolerance for fats.
Hyperlipedimia, atherosclerosis, pancreatitis, cystic fibrosis, sprue (disease
of intestinal tract characterized by malabsorption), gastrectomy, massive
resection of small intestine, and cholecystitis.
Foods Allowed:
Nonfat milk; low-carbohydrate, low-fat vegetables; most fruits; breads;
pastas; cornmeal; lean meats; unsaturated fats
Foods Avoided:
Remember to avoid the five Cs of cholesterol- cookies, cream, cake,
coconut, chocolate; whole milk and whole-milk or cream products,
avocados, olives, commercially prepared baked goods such as donuts and
muffins, poultry skin, highly marbled meats
Butter, ordinary margarines, olive oil, lard, pudding made with whole milk,
ice cream, candies with chocolate, cream, sauces, gravies and
commercially fried foods.

Diabetic Diet

Maintain blood glucose as near as normal as possible; prevent or delay
onset of diabetic complications.
Diabetes mellitus
Foods Allowed:
Choose foods with low glycemic index compose of:
1. 45-55% carbohydrates
2. 30-35% fats
3. 10-25% protein
Coffee, tea, broth, spices and flavoring can be used as desired.
Exchange groups include: milk, vegetable, fruits, starch/bread, meat
(divided in lean, medium fat, and high fat), and fat exchanges.
The number of exchanges allowed from each group is dependent on the
total number of calories allowed.
Non-nutritive sweeteners (sorbitol) in moderation with controlled, normal
weight diabetics.
Foods Avoided:
Concentrated sweets or regular soft drinks.

Acid and Alkaline Diet

Furnish a well balance diet in which the total acid ash is greater than the
total alkaline ash each day.
Retard the formation of renal calculi. The type of diet chosen depends on
laboratory analysis of the stone.
Acid and alkaline ash food groups:
1. Acid ash: meat, whole grains, eggs, cheese, cranberries, prunes, plums
2. Alkaline ash: milk, vegetables, fruits (except cranberries, prunes and
3. Neutral: sugar, fats, beverages (coffee, tea)
Foods allowed:
Breads: any, preferably whole grain; crackers; rolls
Cereals: any, preferable whole grains
Desserts: angel food or sunshine cake; cookies made without baking
powder or soda; cornstarch,
Pudding, cranberry desserts, ice cream, sherbet, plum or prune desserts;
rice or tapioca pudding.
Fats: any, such as butter, margarine, salad dressings, Crisco, Spry, lard,
salad oil, olive oil, etc.
Fruits: cranberry, plums, prunes
Meat, eggs, cheese: any meat, fish or fowl, two serving daily; at least one
egg daily
Potato substitutes: corn, hominy, lentils, macaroni, noodles, rice,
spaghetti, vermicelli.
Soup: broth as desired; other soups from food allowed
Sweets: cranberry and plum jelly; plain sugar candy
Miscellaneous: cream sauce, gravy, peanut butter, peanuts, popcorn, salt,
spices, vinegar, walnuts.
Restricted foods:
No more than the amount allowed each day
1. Milk: 1 pint daily (may be used in other ways than as beverage)
2. Cream: 1/3 cup or less daily
3. Fruits: one serving of fruits daily (in addition to the prunes, plums and
4. Vegetable: including potatoes: two servings daily
5. Sweets: Chocolate or candies, syrups.
6. Miscellaneous: other nuts, olives, pickles.

High- Fiber Diet

Soften the stool
Exercise digestive tract muscles
Speed passage of food through digestive tract to prevent exposure to
cancer causing agents in food
Lower blood lipids
Prevent sharp rise in glucose after eating.
diabetes, hyperlipedemia, constipation, diverticulitis, anticarcinogenics
Foods Allowed:
recommended intake about 6 g crude fiber daily
All bran cereal
Watermelon, prunes, dried peaches, apple with skin; parsnip, peas,
Brussels sprout, sunflower seeds.

Low Residue Diet

Reduce stool bulk and slow transit time
Bowel inflammation during acute diverticulitis, or ulcerative colitis,
preparation for bowel surgery, esophageal and intestinal stenosis.
Foods Allowed:
Eggs; ground or well-cooked tender meat, fish, poultry; milk, cheeses;
strained fruit juice (except prune): cooked or canned apples, apricots,
peaches, pears; ripe banana; strained vegetable juice: canned, cooked, or
strained asparagus, beets, green beans, pumpkin, squash, spinach; white
bread; refined cereals (Cream of Wheat)
Triage Principles
Triage Principles
Mettag: RED Priority I Immediate attention. Identifier is a Mettag torn
to the red stripe or Roman numeral I placed on the forehead or back of left
hand. First priority casualties are those that have life-threatening injuries
that are readily correctable. For purposes of priority for dispatch to the
hospital, however, a second sorting or review may be necessary so only
those transportable cases are taken early. Some will require extensive
stabilization at the scene before transport may be safely undertaken. A red
tag may be used as an additional means of identification.
Mettag: YELLOW Priority II Delayed attention. Identifier is the Mettag
torn to the yellow stripe or Roman numeral II placed on the forehead or
back of left hand. Delayed category casualties are all those whose therapy
may be delayed without significant threat of life or limb and those for
whom extensive or highly sophisticated procedures are necessary to
sustain life.
Mettag: GREEN Minor injuries. Casualties with minor injuries will receive
minimum first aid treatment. They will not be transported to hospitals until
all Priority I and II patients have received care. They will be sent from the
triage area to a designated area away from the disaster scene in order to
reduce confusion. If they are capable, they may also be used as litter
bearers or first aid providers.
Mettag: BLACK Dead. Identifier is the Mettag torn up to the black stripe
or an X on the forehead and covered with a sheet, blanket or other opaque
material as soon as possible. Unless absolutely necessary, they should be
left in place until released by the coroner. The temporary morgue should
be an area away from the scene of the triage area.
Persons who are psychologically disturbed, who interfere with casualty
handling, should be isolated from the incident scene as quickly as possible.
Campus Police will be requested to escort individuals to a designated area
away from the disaster scene.

Triage Category Guidelines
For multiple casualty incidents involving up to 80 victims:

1. Asphyxia
2. Respiratory obstruction from mechanical causes
3. Sucking cheat wounds
4. Tension pneumothorax
5. Maxillofacial wounds in which asphyxia exists or is likely to develop
6. Shock caused by major external hemorrhage
7. Major internal hemorrhage
8. Visceral injuries or evisceration
9. Cardio/pericardial injuries
10. Massive muscle damage
11. Severe burns over 25%
12. Dislocations
13. Major fracture
14. Major medical problems readily correctable
15. Closed cerebral injuries with increasing loss of consciousness
Simple Treatment and Rapid Treatment (START): Quick identifiers for Red
Ventilation > 30/min
Perfusion <>
Mental status: unable to follow simple directions
1. Vascular injuries requiring repair
2. Wounds of the genitourinary tract
3. Thoracic wounds without asphyxia
4. Severe burns under 25%
5. Spinal cord injuries requiring decompression
6. Suspected spinal cord injuries without neurological signs
7. Lesser fractures
8. Injuries of the eye
9. Maxillofacial injuries without asphyxia
10. Minor medical problems
11. Victims with little hope of survival under the best of circumstances of
medical care

For multiple casualty incidents with an overwhelming number of survivors or over
80 victims:

1. Asphyxia
2. Respiratory obstruction from mechanical causes
3. Sucking cheat wounds
4. Tension pneumothorax
5. Maxillofacial wounds in which asphyxia exists or is likely to develop
6. Shock caused by major external hemorrhage
7. Dislocations
8. Severe burns under 25%*
9. Lesser fractures*
10. Major medical problems that can be handled readily
1. Major fractures (if able to stabilize)*
2. Visceral injuries or evisceration*
3. Cardio/pericardial injuries*
4. Massive muscle damage*
5. Severe burns over 25%*
6. Vascular injuries requiring repair
7. Wounds of genitourinary tract
8. Thoracic wounds without asphyxia
9. Closed cerebral injuries with increasing loss of consciousness*
10. Spinal cord injuries requiring decompression
11. Suspected spinal cord injuries without neurological signs
12. Injuries of the eye
13. Maxillofacial injuries without asphyxia
14. Complicated major medical problems*
15. Minor medical problems
16. Victims with little hope of survival under the best of circumstances of
medical care
Legend= * Conditions which have changed categories

Tube Feeding
Tube feeding is the introduction of nourishment into the stomach by mechanical
means through the hose and/or mouth.

Points to Remember:
1. Give mouth care frequently at least 4 times daily.
2. Wet lips and mouth frequently.
3. If not contraindicated, let patient chew some solid food but do not allow
him to swallow.

Tray with:
Feeding tube of appropriate size

Lubricant, water may do
OS and kidney basin
Syringe and small funnel
Bed protector and rubber apron
Bath towel
Bowl containing the nourishment

Preparation of Patient:
Same as in lavage

1.The same as in lavage until the tube is inserted.
2.After the tube has been inserted and is sure to be in the stomach, the
nourishment is introduced using any of this methods:
a.Connect funnel to the tubes and pour the nourishment into the funnel slowly.
Hold funnel at a height which will alloy, the solution to enter the stomach.
b.If given by gravity drip method) connect feeding tube with the drip set connected
with the bottle of nourishment.
c.If given by syringe, inject the nourishment thru the tube, climinating as much air
as possible
3.Flush tube with drinking water.
4.Wait a few minutes, then clamp tube close to the mouth or nose and withdraw
gently. If tube is left for subsequent feeding, secure tube in ph-ice adhesive tape
along the side of the face- in front of the ear or along the nose and the forehead.
Clamp the free and of the tube.
5.Make patient comfortable.
6.Clean equipment and keep.

Record time, kind of feeding, person who inserted the tube, amount of food taken
and patients react
Turning or Changing Mattress with the Patient in the Bed
1. To make mattress even.
2. To change a soiled or infected mattress

Linen required
3 pillows

Method I: (If the same mattress is to be used (2-3 nurses) :
1. Replace the top sheet with the blanket, fold and hang if at the heck of the
chair. Remove the pillows.
2. Loosen the bed linen all around.
3. Fold the top sheet neatly over the patient.
4. Roll firmly both sides of the bottom sheet toward the patient.
5. Lift the patient to one side of the mattress (follow procedure for lifting),
which is drawn from the side partly off the springs.
6. Place pillows on the vacated half of the springs and move the patient on to
these pillows.
7. Turn the mattress from the head towards the foot.
8. Lift back the patient on the mattress; remove the pillows and place the
mattress in position. Put the patient on the center.
9. Remake the bed
Method II: (If the mattress is to be changed):
1. Fold the top sheet neatly over the patient with the feet inside the fold.
2. Remove the pillows; loosen the bed linen all around.
3. Roll the sides of the draw and rubber sheet firmly up to the patients sides.
Then bring the sides of the bottom sheet neatly over the patient.
4. Lift the patient to one side of the old mattress, which is partly drawn from
the springs to the sides.
5. Place the new mattress on the vacated held of the springs and lift patient
on to it
6. Remove old mattress and put the new one in position.
Method III:
1. Loosen all bed linen.
2. Replace to sheet with blanket.
3. Move patient to the side of the bed.
4. Transfer patient to stretcher. Strip the bed.
5. Turn the mattress from head to foot part or change with a new mattress.
6. Remake the bed.
7. Return patient to bed.

Important Points to Remember:
1. Nurse should report any changes that indicate that death is near. Inform
family, friends, minister and physician.
2. Keep (use her judgment) those disturb the patient away from him and
those who comfort him nearby. She should try to make herself
inconspicuous and to sense the patients desire to be left alone with his
family, a minister or his physician.
3. Know certain observances in religion that bring comfort to persons of each
particular faith and try to call the minister or the priest and prepare patient
for it.
4. The patient may desire to make a will. This will be legal if signed by the
patient and witnessed by 2 persons. The nurse may be asked to serve in
this capacity.
5. Provide privacy for the patient and his distressed family.
6. When patients ask the nurse questions about their condition, avoid giving
an untruthful answer, you can generally satisfy the patient by asking him
what his doctor has told him.
7. This is a time, above all others, when the wishes of the patient himself and
those of his family should be considered of paramount importance and no
treatment should be Forced upon a dying man.
Urinary Catheterization

Is the introduction of a catheter through the urethra into the bladder for
the purpose of withdrawing urine.

To relieve urinary retention
To obtain a sterile urine specimen from a woman
To measure the amount of residual urine in the bladder
To obtain a urine specimen when a specimen cannot secure satisfactory by
other means
To empty bladder before and during surgery and before certain diagnostic
examinations ***Several BASIC FACTS about the lower
urinary tract system should be borne in mind when considering

Necessary Equipment for Catheterization
Catheters are graded on the French scale according to the size of the
lumen. For the female adult, No. 14 and No. 16 French catheters are
usually used. Small catheters are generally not necessary and the size of
the lumen is also so small that it increases the length of time necessary for
emptying the bladder. Larger catheter distends the urethra and tends to
increase the discomfort of the procedure. For male adult, No.18 and No.
20 French catheters usually used, but if this appears to be too large,
smaller catheter should be used. No. 8 and No. 10 French catheters are
commonly used for children.

Preparation of the Patient
1. Adequate exploration
2. Position dorsal recumbent for the female and supine for the male using a
firm mattress or treatment table, Sims or lateral position can be an
alternate for the female patient
3. Provision for privacy

Retention or Indwelling Catheter (Foley)
A catheter to remain in place for the following purposes:
1. The gradual decompression of an over distended bladder
2. For intermittent bladder drainage
3. For continuous bladder drainage
An indwelling catheter has a balloon which is inflated after the catheter is
inserted into the bladder. Because the inflated balloon is larger than the
opening to the urethra, the catheter is retained in the bladder.

Procedure for Insertion
1. Inflate the balloon with the prefilled syringe before inserting the catheter
to check for balloon patency. Aspirate the fluid back into the syringe when
it is determined that the balloon is patent.
2. Hold the catheter with one hand and inflate the balloon according to the
manufacturers instructions, as soon as the catheter is in the bladder and
urine has begun to drain from the bladder. Usually 5 ml to 10 ml of sterile
water is used
3. If the patient complains of pain after the balloon is inflated, allow it to
empty and replace the catheter with another one. The balloon is probably
located in the urethra and is causing discomfort owing to distention of the
4. Exert slight tension on the catheter after the balloon is inflated to assure
its proper placement in the bladder
5. Connect the catheter to the drainage tubing and drainage bag if not
already connected
6. Tape the catheter along the interior aspect of the thigh fro a female
patient. Be sure there is no tension on the catheter when it is taped to the
7. Hang the drainage bag on the frame of the bed below the level of the

Caring for the Patient with an Indwelling Catheter
1. Be sure to wash hands before and after caring for a patient with an
indwelling catheter
2. Clean the perineal area thoroughly, especially around the meatus, twice a
day and after each bowel movement. This helps prevent organisms for
entering the bladder
3. Use soap or detergent and water to clean the perineal area and rinse the
area well
4. Make sure that the patient maintains a generous fluid intake. This helps
prevent infection and irrigates the catheter naturally by increasing urinary
5. Encourage the patient to be up and about as ordered
6. Record the patients intake and output
7. Note the volume and character of urine and record observations carefully
8. Teach the patient the importance of personal hygiene, especially the
importance of careful cleaning after having bowel movement and
thorough washing of hands frequently
9. Report any signs of infection promptly. These include a burning sensation
and irritation at the meatus, cloudy urine, a strong odor to the urine, an
elevated temperature and chills
10. Plan to change indwelling catheters only as necessary. The usual length of
time between catheter changes varies and can be anywhere from 5 days to
2 weeks. The less often a catheter is changed, the less the likelihood than
an infection will develop

Removing the Indwelling Catheter and Aftercare of the Patient
1. Be sure the balloon is deflated before attempting to remove the catheter.
This may be done by inserting a syringe into the balloon valve or by cutting
the balloon valve
2. Have the patient take several deep breaths to help him relax while gently
removing the catheter. Wrap the catheter in a towel or disposable,
waterproof drape
3. Clean the area at the meatus thoroughly with antiseptic swabs after the
catheter is removed
4. See to it that the patients fluid intake is generous and record the patients
intake and output. Instruct the patient to void into the bedpan or urinal
5. Observe the urine carefully for any signs of abnormality
6. Record and report any usual signs such as discomfort, a burning sensation
when voiding, bleeding and changes in vital signs, especially the patients
temperature. Be alert to any signs of infection and report them promptly
Urinary Elimination
Normal Urinary Function
1. Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr
to ensure continued normal kidney function
2. Urine normally consists of 96% water
3. Solutes found in urine include:
a. Organic solutes: urea, ammonia, uric acid and creatinine
b. Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium &

Common Assessment Findings
1. Urgency strong desire to void my be caused by inflammations or
infections in the bladder or urethra
2. Dysuria painful or difficult voiding
3. Frequency voiding that occurs more than usual when compared with the
persons regular pattern or the generally accepted norm of voiding once
every 3 to 6 hours
4. Hesitancy undue delay and difficulty in initiating voiding
5. Polyuria a large volume of urine or output voided at any given time
6. Oliguria a small volume of urine or output between 100 to 500 mL/24 hr
7. Nocturia excessive urination at night interrupting sleep
8. Hematuria RBCs in the urine

Vaginal Irrigation (Douche)
Injection of Fluid plain or medicated into the vaginal canal under low

1. Mechanical cleansing of the vaginal tract and the cervix as in leukorrhea
2. To help remove any foul odor that may be present
3. To cleanse and irrigate the cervix after cauterization ~and at the same
time to reduce the swelling and promote healing
4. Pre-operative procedure on most patients having the type of gynecologic

Points to Remember:
1. Never give without doctors order
2. Never give during pregnancy or menstruation
3. Conduct of the procedure should be with all regards to the patient.
Provide strict privacy
4. Examine douche nozzle for any chips before using
5. Scrub hands before and after the procedure
6. In giving to gonorrheal patients, wear gown and use gloves and goggles
7. Use smaller nozzles for virgins
8. Test temperature of the solution before using

Sterile douche tray for CSR
Irrigating can with tubing
Bath blanket
Irrigating stand
Solution prescribed
Flushing tray
Bedpan with cover
Bed protector and clamp
2 douche nozzles
Kidney basin

Preparation of Patient:
1. Explain to patient the nature and necessity of the treatment.
2. Let patient void first before giving the douche.

1. Bring all preparations to the bedside.
2. Screen the bed. Replace topsheet with bath blanket.
3. Slip the bed protector under the patients buttocks.
4. Assist patient on to bedpan.
5. Position and drape patient.
6. Flush external genitalia.
7. Hang the irrigating can covered) about 2 feet above bed level.
8. Attach douche nozzle to the end of the tubing. Expel the air. Test
temperature of water by allowing solution to flow at the back of the
9. Insert the nozzle gently downward backward while the solution is flowing.
Gently move the nozzle around during the process.
10. Before all solution runs out clamp and withdraw the nozzle. Disconnect
and place in kidney basin.
11. Let patient stay on bedpan for a while to drain excess solution.
12. Remove bedpan and dry area thoroughly.
13. Fix patient, make her comfortable.
14. Take preparation to lavatory. Examine contents of bedpan before
throwing into hopper. Clean and keep all equipment in their proper

Treatment, time, amount, kind and temperature of solution used and character of
the return flow.

Suture Size

The size of suture material is measured by its width or diameter and is vital to
proper wound closure. As a guide the following are specific areas of their usage:
1-0 and 2-0: Used for high stress areas requiring strong retention, i.e.
fascia repair
3-0: Used in areas requiring good retention, i.e. scalp, torso, and hands
4-0: Used in areas requiring minimal retention, i.e. extremities. Is the
most common size utilized for superficial wound closure.
5-0: Used for areas involving the face, nose, ears, eyebrows, and eyelids.
6-0: Used on areas requiring little or no retention. Primarily used for
cosmetic effects.

Suturing Techniques

When suturing the edges of a wound together, it is important to evert the skin
edges that is, to get the underlying dermis from both sides of the wound to touch.
For the wound to heal, the dermal elements must meet and heal together. If the
edges are inverted (the epidermis turns in and touches the epidermis of the other
side), the wound will not heal as quickly or as well as you would like. The suture
technique that you choose is important to achieve optimal wound healing.