A1 Passers Review Center

FUNDAMENTALS OF NURSING
Carielle Joy V. Rio, R.N., M.A.N.
HISTORY OF NURSING
Period of Intuitive Nursing
- Nursing is untaught & instinctive
- Performed out of compassion & wish to help others
Period of Apprentice Nursing
- Began during the crusades (11th century 1836)
- Period of on the job training
Dark Period of Nursing
Period of Educated Nursing
- Florence Nightingale School of Nursing (June 15, 1860) at St.Thomas
Hospital in London.
Florence Nightingale
- Mother of Modern Nursing
- Lady with the Lamp
- Born May 12, 1820 in Florence , Italy
- Noted the need for preventive medicine and good nursing
- Upgraded the practice of nursing to an honorable profession
- 2 published books Notes on Nursing & Notes on Hospital.
Earliest

hospitals established in the Philippines:

Hospital Real de Manila (1577)
San Lazaro Hospital (1578)
Hospital de Indio (1586)
Hospital de Aguas Santas (1590)
San Juan de Dios Hospital (1596)

Earliest

Hospitals & School of Nursing:

Iloilo Mission Hospital School of Nursing (1906)
St. Pauls Hospital School of Nursing (1907)
Philippine General Hospital School of Nursing (1907)
St Lukes Hospital School of Nursing (1907)

NURSING AS A PROFESSION
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 peaceful death
that he would perform unaided if he had the necessary strength, will or knowledge.
And to do in such a way to help him gain independence as rapidly as possible.
(Virginia Henderson)

Nursing Theories
Concept- the building blocks of theory which are abstract ideas or mental images of
phenomena

Four Main Concepts:

Person/Client
Environment
Health/Illness
Nursing
Environmental Theory (Florence Nightingale)
- signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the
proper selection and administration of diet
14 Basic Needs (Virginia Henderson)
breathing
eating & drinking
elimination
movement
rest & sleep
suitable clothing
body temperature
clean body & protected integument
safe environment
communication
worship
work
play
learning
Nursing as Energy Field (Martha Rogers)
-Human and environment are integrated, inter-related energy fields
Self-care Theory (Dorothea Orem)
- Delineation of the need for nursing care that comes from a client self-care
deficit focuses on the role of the nurse in helping clients meet their needs
Universal Self-Care Requisites:
1. sufficient intake of air, water, and food
2. provision of care associated with elimination
3. balance between activity and rest
4. balance between solitude and social interaction
5. prevention of hazards to human life, functioning, and well-being
6. promotion of human functioning and development within social groups

Behavioral System Model (Dorothy Johnson)

-a person is a behavioral system with patterned, repetitive and purposeful ways
of behaving that links the person with the environment
7 sub-systems:
Ingestive
Eliminative
Sexual & role identity
Affiliative
Aggressive
DependenceAchievement
Adaptation Model (Sister Callista Roy)

health is not the freedom from the inevitability of death, disease,

unhappiness or stress, but the ability to cope with them in a competent way.

4 adaptation modes:
Physiologic needs
Self-concept
Role function
Interdependence
Goal Attainment Theory (Imogene King)
- decision-making process and outcomes of mutual goal attainment are
specified for nurse-client interaction.
Psychodynamic Nursing Theory (Hildegard Peplau)
- nurse assume several roles: stranger, teacher, resource, surrogate, leader
and counselor.
- health is the forward movement of personality in the direction of creative,
constructive, and productive personal and community living.
Transcultural Care Theory (Madeleine Leininger)
- culture care universality and specificity
21 Nursing Problems (Faye Abdellah)
1. maintain good hygiene & physical comfort
2. promote optimal activity
3. promote safety
4. maintain good body mechanics
5. maintain supply of oxygen
6. maintain nutrition
7. maintain elimination
8. maintain fluid & electrolyte balance
9. recognize body responses to diseases
10.
maintain regulatory mechanism & function
11.
maintain sensory function
12.
identify & accept +/- expressions, feelings & reactions
13.
identify & accept the interrelatedness of emotions & organic illness
14.
maintain effective verbal and non-verbal communication
15.
development of productive interpersonal relationship
16.
achievement of personal spiritual goal
17.
create &/or maintain therapeutic environment
18.
awareness of self as an individual
19.
accept optimum possible goals in the light of limitation, physical &
emotional
20.
use of community resources
21.
understand the role of social problems as influencing in the case of illness
3 Cs Nursing Model (Lydia Hall)
Care (body)
Core (person)
Cure (disease)
Stages of Nursing Expertise (Patricia Benner)
Novice
Advance beginner
Competent
Proficient
Expert
HEALTH AND ILLNESS
Models of Health

Clinical Model
- views people as a physiologic system with related functions.
Role Performance Model (Smith)
- describes health in terms of the individuals ability to fulfill societal roles.
Adaptive Model (Dubos)
- views disease as a failure in adaptation.
Eudaemonistic Model
- views health as a condition of actualization or realization of ones
potentials
Leavell and Clarks Agent-Host-Environment Model (Ecologic Model)
- Three elements: host, agent & environment.
Health-Illness Continuum (Dunn)
- High level wellness: maximizing ones potentialities within the limitations
of the environment
- Health-Illness Continuum Scale:
1. High level wellness in a favorable environment
2. Emergent high level wellness in an unfavorable environment
3. Protected poor health in a favorable environment
4. Poor health in an unfavorable environment
Health Belief Model (Becker/Rosenstock)
- describes relationship between persons belief and behavior.
Perceived susceptibility
Perceived seriousness
Perceived threat
Illness a personal state in which the person feels unhealthy
Disease an alteration in body functions resulting in reduction of capacities or a
shortening of
the normal life span.
Illness behavior- is any activity undertaken by a person who feels ill, to define the
state of his health and to discover a suitable remedy.
Classification of Diseases
According to Etiologic Factors:
Hereditary
Congenital
Metabolic
Deficiency
Traumatic

Neoplastic
Idiopathic
Degenerative
Iatrogenic
Allergic

According to Duration or onset

Acute illness
Chronic illness
Remission disease is controlled and symptoms not obvious
Exacerbation disease becomes more active again with pronounce
symptoms
Other descriptions:
Organic
Functional
Occupational

Endemic
Pandemic
Sporadic

Familial
Venereal

Epidemic

NURSING PROCESS
Methods of Data Collection:
Observation
Interview
Physical Examinations
Laboratory and diagnostic data
Data to be collected:
Demographic information
Health history
Developmental level
Psychosocial history
Socio-cultural history
Activities of daily living

Data Collection:
Sources of data
Primary
Secondary
Types of data
Objective
Subjective
Nursing Diagnosis - a clinical judgment about an individual, family, or community that
is derived though a deliberate, systematic process of data collection
and analysis.

Types of Nursing Diagnosis

Actual problems- indicates that the problem exist

Risk/Potential Nursing diagnosis- indicates that the problem does not yet exist

Wellness condition- indicates the clients expression of a desire

to attain higher level of wellness in some area of function

13 domains under which NANDA approved nursing diagnosis are placed:

Health promotion
Nutrition
Elimination/exchange
Activity/rest
Perception/cognition
Self-perception
Role relationship
Sexuality
Coping/stress tolerance
Life principles
Safety/protection
Comfort
Growth & development
Components of a Nursing Diagnosis:

Problem statement- describes the health problem

NANDA labels (qualifiers): altered, impaired, decrease, ineffective, acute,
chronic
Related Factors and Risk Factors- gives direction to the required nursing therapy
- enables the nurse to individualize patient care
Defining characteristics- signs and symptoms
Planning- the nurse establishes goals for resolution of the clients problems, nursing
intervention aimed at achieving these goals, and the outcome
criteria by which the nurse can evaluate whether or not the goals are met.
Components of an appropriately written goal:
Subject
Task statement
Criteria
- a time limit
- amount of activity
- characteristic of accurate performance
- description of the performance to be followed
Conditions
- the experiences the client is expected to have
Time frame

Implementation activities
Ongoing assessment
Establishment of priorities
Allocations of resources
Initiation of nursing interventions
Documentation of interventions & client responses
Evaluation- to judge or to appraise
Types of evaluation:
ongoing
intermittent
terminal
Components of the evaluation process:
- identifying the expected outcomes
- collecting data related to the expected outcome
- comparing data with the expected outcome
- relating nursing actions to client outcome
- drawing conclusions about the problem status
- reviewing and modifying the clients care plan
ADMISSION AND DISCHARGE
Types of admission:

Routine
Emergency

Pre-admission:

Authorization for admission

Day of admission:

Patient orientation
Initial nursing assessment

Discharge:

To an extended care facility

To Home
Against medical advice

INFECTION CONTROL
Types of infection:

Exogenous infection
Endogenous infection
Modes of transmission:

Contact
o Direct
o Indirect
Droplet
Airborne
Vehicle
Vector

Stages of infectious process:

Incubation
Prodromal period
Illness stage
Convalescence

Types of immunity:

Active
o Natural
o Artificial

Passive
o Natural
o Artificial

Specific vs. Non-specific defenses:

Specific defenses:
o Antibody mediated
o Cell mediated

Non-specific defense:
o Skin
o Gastric acid
o Inflammatory response

Standard Precautions - designed for all clients in the hospital

- assumes that every person is potentially infected
- utilize gloves when there is a potential contact with blood, all body fluids,
secretions, & excretions except ______, non-intact skin; and mucus membranes and use
mask, eye protection, clean gown

Transmission Based Precautions:

1. Airborne precaution
- private room with negative pressure
- N 95 respirator
- limit movements outside the room to essential purposes
2. Droplet Precaution
- private room
- mask w/ in 3 feet
- limit movements outside the room to essential purposes
3. Contact precaution

Donning and removal of PPE:

Donning
1. Gown
2. Face mask
3. Eyewear
4. Gloves

Removal
1. Gloves
2. Eyewear
3. Gown
4. Mask

VITAL SIGNS
Body temperature:
Core temperature
Surface temperature
Variation in body temperature by age:
Newborn
36.1-37.7
1 year
37.7
2 years
37.2
5 years
37.0
Adult
36.4 (axillary)/
37.8 (rectal)
Duration of measurement:
Oral (2-3 minutes)
Axillary (5-9 minutes)
Rectal (2 minutes)
Conversion:
C = 5/9 x (F-32)
F = 9/5 x C + 32
Alterations in body temperature:

Hyperthermia/ Pyrexia
- intermittent
- remittent
- relapsing
- constant
Hypothermia
Pulse
Sites:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Assessing the pulses:
Pulse rate
Newborn- 1 month
1 year
2 years
6 years
Adult

80 180
80 140
80 130
75 120
60 100

Pulse rhythm
Pulse volume
0 - Absent
1 - Thready
2 - Normal
3 - Bounding
Respiration:
Rate
Variations in respiratory rate by age:
Newborn
1 year
2 years
8 years
Adult
Depth
Deep
Shallow
Volume
Hyperventilation
Hypoventilation

Rhythm
Ease
Quality

30 80
20 40
20 30
15 25
12 20

Blood pressure:
Variations in blood pressure by age:
Newborn
1 year
6 years
10 years
14 years
Adult

73/ 55
90/ 55
95/ 57
102/ 62
120/ 80
120/ 80

When not to use an arm?

Injury in the arms, shoulders or hand
Cast or bulky bandage
Breast or axilla surgery
IV infusion or BT running
AV Fistula
Errors in blood pressure reading:
Too high:
Narrow cuff
Unsupported arms
Immediately after meal
Insufficient rest
Repeating immediately
Unevenly wrapped
Too low:
Wide cuff
Arm above the heart
PHYSICAL ASSESSMENT
Components of nursing assessment:
1. Health history
2. Physical assessment
- complete assessment
- assessment of body system
- assessment of body parts
Health History:
- biographic data
- chief complaint
- history of present illness
- past history
- family history of illness
- review of systems
- lifestyle
- social data
- psychologic data
Physical Assessment:
Positions during assessment:
- sitting
- lithotomy
- knee chest
- Sims
- prone

Methods of Examining:
Inspection
Palpation

- deep
- light
Percussion
- direct
- indirect
Auscultation
Skin

color, edema, lesions, moisture, temperature, turgor

- hyperhydrosis
- anhydrosis
- cyanosis
- erythema
- lesions
Types of skin lesions:
- macule
- papule
- nodule
- vesicles
- pustule
- telangiectacia

- bromhidrosis
- pallor
- jaundice
- hyperpigmentation

- patch
- plaque
- tumor
- bulla
- wheal
- petechiae

Hair

distribution, thickness, texture, infection, infestation, body hair

color, curve, grooves, blanch test

neck muscles, head movement, muscle strength, lymph nodes, trachea,

shape, symmetry, spinal alignment, thoracic expansion, fremitus, breath sounds

inspect skull for size, shape and symmetry

palpate skull for nodules, masses or depressions
inspect the facial features
inspect eyes for edema and hollowness
note symmetry of facial movements

inspect the external eye structures

inspect the eyelids for surface characteristics, ability to blink and frequency of blinking
inspect the conjunctiva
palpate the nasolacrimal duct, lacrimal sac and gland
perform cornea sensitivity test
assess for PERRLA
assess the extraocular muscles
assess visual acuity

inspect the auricles for color, symmetry, and position

inspect the inner ear
palpate the auricles for texture, elasticity, and tenderness
assess gross hearing acuity
Webers test
Rinne test

Nails

Neck
thyroid gland

Chest
Head

Eyes

Ears

Nose and Sinuses

inspect the external nose for shape, size, or color, flaring or discharges
lightly palpate the external nose to determine any areas of tenderness, masses, and displacement
of bones
inspect the nasal cavity
palpate the frontal and maxillary sinuses
transilluminate the frontal sinus
transilluminate the maxillary sinus
Lips and Buccal Mucosa
inspect lips for symmetry of contour, color, and texture
inspect and palpate the inner lips and buccal mucosa for color, moisture, texture, and lesions
Teeth and Gums
inspect the teeth and gums while examining the buccal mucosa
inspect the dentures
Tongue and Floor of Mouth
inspect the surface for position, color, texture
inspect tongue movement
inspect the tongue, mouth floor, and frenulum
palpate the tongue and floor of mouth for any nodules, lumps, or excoriated areas
Palates and Uvula
inspect the hard and soft palate for color, shape, texture, and the presence of bony prominence
inspect the uvula for position and mobility
Oropharynx and Tonsils
inspect the oropharynx for color and texture
inspect the tonsils for color, discharges, and size
elicit a gag reflex
Grading System for Tonsil Size:
1
Normal
2
Between the pillars and the uvula
3
Touches the uvula
4
One or both tonsils extend to the midline
Neurologic System
Mental status exam:
Language (sensory, motor & mixed)
Orientation (time, place, person)
Memory (immediate recall, recent, remote)
Attention span and calculation
Level of Consciousness:
Glasgow Coma Scale
Eyes

Spontaneously
To speech
To pain
No response

4
3
2
1

Verbal response

Oriented
Confused
Inappropriate words
Incomprehensible sounds
No response

5
4
3
2
1

Obeys command
Localizes pain
Withdraws from pain
Flexion
Extension
Flaccid

6
5
4
3
2
1

Motor response

Level of Consciousness:
Conscious
Lethargic
Stuporous
Semi-comatose
Comatose

Reflexes
biceps (C- 5 & 6)
triceps (C- 7 & 8)
brachioradialis (C- 3 & 6)
patellar (L- 2, 3 & 4)
Achilles (S- 1 & 2)
plantar

Grading reflex response:

0
no reflex

1
minimal activity

2
normal

3
more than normal

4
hyperactive

Motor Functions
gross motor balance
standing in one foot with eyes closed
heel-to-toe walking
toe or heel walking
finger-to-nose test
alternating supination and pronation of hands on knees
finger to nose- to nurses finger
fingers-to-fingers
fingers to thumb
heel down opposite shin

Sensory Function
light touch sensation
pain sensation
temperature sensation
position or kinesthetic sensation
tactile discrimination
stereognosis (coin, key, writing)

Musculoskeletal System:
bones- structure, deformities, edema, tenderness
muscle- muscle size, contractures, abnormal movements, muscle tone,
muscle strength
joints- swelling, movement, crepitations, nodules, ROM

Cardiovascular System

Heart- inspect and palpate the precordium, auscultate

Right 2nd intercostal space- aortic area
Left 2nd intercostal space- pulmonic area
Left 5th intercostal space- tricuspid or right ventricular area
Left 5th intercostal space (midclavicular line)- mitral area

Peripheral Vascular System:

palpate the peripheral pulses
palpate and auscultate the carotid arteries
inspect the jugular vein
inspect the peripheral veins

smoothness of movement,

assess peripheral perfusion

Breast and Axilla:

inspect size, symmetry, contour and shape
inspect skin color, retractions, dimpling, swelling or edema
accentuate any retractions
inspect areola for size, shape, symmetry, color, any masses or lesions
inspect the nipples for size, shape, position, color, discharges, lesions
palpate the axillary, subclavicular, supraclavicular lymph nodes
palpate the breast and nipples

Abdomen:
inspect for skin integrity, contour, and symmetry
observe abdominal movements
auscultate for bowel sounds, vascular sounds, peritoneal friction rub
palpate the four quadrants
palpate the liver
palpate the bladder

Female Genitalia:
inspect the distribution, amount, and characteristic of pubic hair
inspect the skin of the pubic hair for parasites, swelling and lesions
inspect the clitoris and vaginal orifice
inspect the cervical os and vagina
palpate the Skenes grand and Bartholins gland
assess the pelvic musculature

Male Genitalia
inspect the distribution, amount and characteristics of the pubic hair
inspect the penile shaft and the glans penis for lesions, nodules, and inflammation
inspect the urethral meatus for swelling, inflammation and discharges
inspect the scrotum for appearance, general size and symmetry
palpate the penis for tenderness, thickening and nodules
palpate the scrotum
palpate the inguinal area for bulges
palpate the hernia

Rectum and Anus

inspect the anus and surrounding tissue for color, integrity, and skin lesions
palpate the rectum for anal sphincter tonicity, nodules, masses and tenderness
observe the color of feces when withdrawing the fingers
palpate the prostate gland
palpate the cervix

MEDICATION ADMINISTRATION

Pharmakokinetics:
Absorption
Distribution
Metabolism
Excretion

Types of medication action:

Therapeutic effect
Side effect

Adverse effect
Toxic effect
Idiosyncratic effect
Allergic reaction
Iatrogenic effect

Types of medication order:

Stat order
Single order
Standing order
Prn order

Types of drug preparation:

Aqueous solution
Aqueous suspension
Capsule
Elixir
Extract
Liniments
Tablet
Syrup
Suppository
Cream

10 Rights
1. Medication
2. Dose
3. Time
4. Route
5. Client
6. Client education
7. Right documentation
8. Right to refuse
9. Right assessment
10. Right evaluation
11.
12. Systems of Measurement:
13. Metric
Apocthecaries
Household
14.1ml
15 minims
15 gtts
15.4-5 ml
1 fluid dram
1 teaspoon
16.15 ml
4 fluid drams
1 tablespoon
17.30 ml
1 fluid ounce
18.60 mg
1 grain
19.
20. Routes for medication administration:
Oral
21.
Parenteral
o Subcutaneous
o Intramuscular
Z-track
o Intravenous
Bolus
Piggyback
o Intradermal
22.
Topical
o Transdermal
o Inhalation
o Ophthalmic
o Otic
o Nasal
23.

24.
25. Intravenous Therapy
26.
27. Common intravenous solutions:
28.0.45% saline (1/2 NS)
- hypotonic
29.
0.9% saline (NS)
- isotonic
30.
5% dextrose in water
- isotonic
31.
5% dextrose in 0.225% saline
- isotonic
32.
Lactated ringers
- isotonic
33.
5% dextrose in LR soln
- hypertonic
34.
5% dextrose in 0.45% saline
- hypertonic
35.
5% dextrose in 0.9% saline
- hypertonic
36.
10% dextrose in water
- hypertonic
37.
38. Types of infusion:
Peripheral
Central
Continuous
Intermittent
39. Complications of IV therapy:
Infection
Air embolism
Hypersensitivity reaction
Circulatory overload
Infiltration
Phlebitis
40.
41.
42. Blood Transfusion:
43.
44. Types of blood components:
Whole blood
Packed RBC
Fresh frozen plasma
Clotting factors
45.
46. DOs when administering blood products:
Check patients baseline data.
Check the blood product:
Blood product
Blood type and Rh
Unit number
Expiration date and time
Use only PNSS with any blood product.
Use blood transfusion set.
Administer blood slowly during the first 15 min.
Monitor patient for transfusion reactions.
Administration of each unit should not exceed 4 hours.
47.
48. Transfusion reactions:
Hemolytic
Febrile
Allergic
Hypervolemia
Sepsis
49.
50.
51. HEAT AND COLD THERAPY
52.
53.
Heat application:
54.
Indication:
55.
Contraindication:
56.
Duration:
57.
58.
Cold application:
59.
Indication:
60.
Contraindication:

61.
Duration:
62.
63.
64. OXYGENATION
65. Respiration
66.
- is the process of gaseous exchange between the individual and the environment.
67.
68. Three parts of the respiration process:
69.
1. Pulmonary ventilation
70.
2. Diffusion of gases
71.
3. Transport of gases
72.
73. Four factors that affects ventilation:
74.
1. Adequate atmospheric oxygen
75.
2. Clear air passages
76.
3. Adequate pulmonary compliance & recoil
77.
4. Regulation of respiration
78.
79. Alterations in breathing pattern:
Tachypnea
Bradypnea
Hyperventilation
Hypoventilation
Orthopnea
Cheyne stokes breathing
Kussmauls beathing
80.
81. Types of oxygen delivery:
82.
83. Cannula
24-45%
84.
O2 (L/min) 1 24%
85.
2
28%
86.
3
32%
87.
4
36%
88.
5-6
40%
89. Simple face mask
40-60%
90.
O2 (L/min)
5-6
40%
91.
7-8
50%
92.
10
60%
93. Partial re-breather mask
94.
6-10 60-90%
95. Non-rebreather mask
96.
10
95-100%
97. Venturi mask
4
24% (blue)
6.8
35% (green)
98.
99. Artificial airways:
Orotracheal tube
Nasotracheal tube
100.
101.
Materials:
102.
1.
103.
2.
104.
3.
105.
4.
106.
5.
107.
108.
Care of patients with endotracheal tubes:
x-ray after initial placement
auscultate __________________
auscultate __________________
monitor skin and mucus membrane. Move to the opposite side of the mouth daily.
keep resuscitation bag at bed side
109.
110.
111.
Tracheostomy
112.
- surgical incision in the trachea
113.

114.
Care of patients with tracheostomy:
assess respiration
monitor ABG
suction secretions
assess stoma for blood and mucus
keep ambubag, tracheostomy set, clamps at bedside
115.
116.
Complications of tracheostomy:
Tracheomalacia
Tracheal stenosis
Tracheoesophageal fistula
Tracheal innominate artery fistula
117.
118.
Chest tube drainage system:
returns negative pressure to the intra-pleural space
removes abnormal accumulation of air and fluids from the pleural space
119.
120.
121.
122.
123.
124.
125.
126.
127.
Care of patients with chest tube drainage:
monitor fluctuation level
note for gentle bubbling
x-ray before and after initial placement
do not strip or milk
keep occlusive dressing and extra bottle at bedside
128.
129.
130.
If the bottle cracks or breaks:
insert the tube into a bottle with sterile water
131.
132.
If the tube is accidentally pulled out:
pinch the skin opening
instruct patient to bear down
apply occlusive sterile dressing
133.
134.
135.
COMFORT AND HYGIENE
136.
137.
Types of hygienic care:
Early morning care
Morning care
Afternoon care
HS care
prn
138.
139.
Types of therapeutic bath:
Saline
Oatmeal
Cornstarch
Sodium Bicarbonate
Potassium permanganate
140.
141.
Types of massage:
Effleurage
Petrissage
Tapotement
142.
143.
Types of sleep:
NREM
o Stage I
o Stage II

o
o
REM

Stage III
Stage IV

144.
145.
Common sleep disorders:
Insomnia
Hypersomnia
Narcolepsy
Sleep apnea
146.
147.
Parasomnias:
Somnambulism
Sleeptalking
Nocturnal enuresis
Nocturnal emission
Bruxism
148.
149.
150.
151.
152.
153.
154.
155.
156.
157.
158.
159.
NUTRITION AND METABOLISM
160.
161.
Caloric value
162. - amount of energy that a nutrient or food supplies to the body.
163.
164.
Carbohydrates
- 4 kcal/gram
165.
Protein
- 4 kcal/gram
166.
Fat
- 9 kcal/gram
167.
168.
169.
170.
Food pyramid:
171.
172.
173.
174.
176.
177.
178.
179.
180.
181.
182.
183.
184.
185.
Serving sizes:
186.
187.
Carbohydrates
188.
1 serving = 1 slice of bread
189.
= cup of rice or noodles
190.
191.
Vegetable
192.
1 serving = 1 cup raw leafy
193.
= cup other veggies
194.
= cup frozen or cup dried veggies
195.
196.
Fruits
197. 1 serving = 1 medium apple, banana,
198.
= 1 medium orange
199.
= cup canned fruits,

200.
= cup fruit juice
201.
202.
Meat and poultry
203. 1 serving = 1 egg
204.
= cup cooked legumes
205.
= 2-3 oz of lean meat
206.
207.
Milk products
208.
1 serving = 8 oz milk
209.
= 2/3 cup ice cream
210.
211.
212.
Body Mass Index
213.
214.
Formula:
215.
216.
217.
BMI Classification:
218.
Underweight
<18.5
219.
Normal
18.5 - 24.9
220.
Overweight
25 - 29.9
221.
Obese
30 - 34.9 (I)
222.
35 - 39.9 (II)
223.
Extreme obese
40 and above (III)
224.
225.
226.
227.
228.
229.
Therapeutic diets:
230.
231.
Clear liquid
post-operative, initial feeding after complete bowel rest
consist of foods which are relatively transparent and stays liquid at body temperature
water, clear broth, gelatin, hard candy, popsicles and carbonated beverages
dairy products are not allowed
client should not stay on clear liquid diet for more than a day or two
232.
233.
Full liquid diet
second diet after clear liquid following surgery, or if the client is unable to chew
includes clear and opaque liquid foods and those that liquefy at body temperature
includes items like ice cream, breakfast drinks, milk, custard, strained soups, strained vegetable juices
234.
Bland diet
usually prescribed for patients with gastritis, ulcers, reflux esophagitis and other GI disorders
bland foods are less like to form gas and are less irritating to the gastric mucosa
foods to be avoided include alcohol, caffeine-containing beverages, pepper and spicy foods
235.
236.
Low residue diet
this diet supplies foods that are least likely to form an obstruction when the intestinal tract is narrowed by
inflammation or scarring
foods to be avoided are raw fruits, except banana, vegetables, seeds, plant fibers, and whole grains
237.
238.
239.
Nasogastric tube insertion:
240.
241.
Purposes:
gavage
lavage
GI decompression
medication administration
242.
243.
Materials:
244.
1.
245.
2.
246.
3.
247.
4.
248.
5.
249.

250.
Nursing care during insertion:
high fowlers position
measure from the tip of nose to earlobe to xyphoid process
instruct the client to slightly bend the head forward
give the client sips of water
do not force if there is resistance
if the client experiences any respiratory distress during insertion, pull back on the tube and wait until the
distress subsides
radiography (after initial placement)
251.
252.
Administration of NGT feeding:
253.
1. Elevate patients head of bed.
254.
2. Verify tube placement & measure residual
255.
3. Flush with 30 mL of water
256.
4. Initiate feeding.
257.
5. Flush with 30 mL of water
258.
6. Clamp NGT.
259.
260.
Common complications:
Intolerance of feeding
Aspiration.
Diarrhea (> 3x/24 hrs)
Hyperglycemia
Fluid imbalance
261.
262.
263.
264.
265.
266.
267.
268.
Total Parenteral Nutrition (TPN)
supplies nutrients via the vein
indicated for clients whose GI tract is severely dysfunctional or clients with multiple gastrointestinal
surgeries
CPN (4 wks or more)
PPN (5-7 days)
269.
270.
Complications:
air embolism
fluid overload
hyperglycemia or hypoglycemia
infection
271.
272.
Weight reduction and gain:
Realistic goal is 1 lb/week
o 1 lb = 3500 cal
Decrease or increase intake by 500 cal/day to meet the goal.
Weight loss is more rapid if calorie reduction is combined with exercise (30 min. 3x/week)
273.
274.
Fecal Elimination:
275.
276.
Common fecal elimination problems:
Constipation
Fecal impaction
Diarrhea
Fecal incontinence
Flatulence
Helminths
277.
278.
Diagnostic studies:
Visualization studies:
o anoscopy
o proctosigmoidoscopy
o colonoscopy
279.

Fecalysis
Occult blood test
280.
281.
282.
Enema
283.
284.
Types of enema:
Cleansing enema
High
Low
Carminative enema
Retention enema
Return flow enema
285.
286.
Types of enema solution:
Tap water enema
Soapsuds enema
Saline enema
Oil retention enema
Commercial enema
287.
288.
Comfort and Safety measures for giving enemas:
Ensure that there is a readily available bathroom or bedpan.
Observe standard precautions.
Solution temp for adults:
40.5 C
289.
children:
37 C
Left Sims position
Height: 12 inches above the anus
Lubricated enema tubing is inserted only 6 inches into the adults rectum.
Give the solution slowly: 10-15 minutes/ 750-1000 mL
290.
291.
292.
293.
294.
295.
Tube size:
Infants: F 10-12
Toddlers: F 14-16
School age: F 16-18
Adults: F 22-30
296.
297.
Volume of solution:
Infants: 50-250 mL
Toddlers: 200-300 mL
School age: 300-500 mL
Adolescents: 500-1000 mL
Adults: 500- 1000 mL
298.
299.
Bowel diversions:
Gastrostomy
Jejunostomy
Ileostomy
Colostomy
300.
301.
Assessing the stoma for:
Color
Size and shape
Bleeding
Skin integrity
Amount and type of feces
Comfort
302.
303.
Symptoms to monitor in a patient with bowel diversions:
Fever of 101 F or greater
Redness of the stoma
A severe change in pain

Abdominal bloating
Nausea or vomiting
Severe diarrhea
Lack of passing gas or moving bowels
Difficulty with stoma appliance placement
304.
305.
306.
URINARY ELIMINATION
307.
308.
Characteristics of normal urine:
1200 to1500 mL/ 24 hrs
clear, straw or amber
faint aromatic
no microorganisms present
pH 4.5-8
1.010 to 1.030 specific gravity
no glucose
no ketones
no blood
no albumin

Women
Men

Diagnostics:
Urinalysis
Culture and sensitivity tests
24-hour urine collection
Radiographic tests
o KUB
o IVP
o RP
Blood vessel exam
o Renal angiography

Urinary catheterization:
Materials:
1.
2.
3.
4.
5.
Sizes:
Fr 8-10 for children
Fr 14-16 for women
Fr 16-18 for men
Position:

Length of insertion:
Children = 2.5 cm ( 1 inch)
Female = 5 cm (2 inches)
Male = 18-20 cm. (8 inches)
Proper anchoring:
thigh, right angle = female

thigh/abdomen = male

Types of urinary diversion:

Cutaneous ureterostomy
Ileal conduit
Continent vesicostomy (Koch pouch)
Uterosigmoidostomy

MOBILITY AND EXERCISE

Guidelines for body movement:

Adjust working area to waist level and keep your body close to the area.
Implications: elevate adjustable beds and overbed tables, and lower the side rails to prevent stretching
and reaching.
Face in the direction of the task. If a change of direction is required, turn the body and extremities as a
single unit pivoting.
Use the palmar grip when grasping and lifting objects. Finger alone have little power. The strength of the
entire hand should be used.
When picking up heavy objects. Squat rather than stoop.
Lift objects by flexing the hips and knees, placing one foot forward and keeping the shoulders in the
same plane as the pelvis.
Implication: bending forward at the waist produces unnatural body alignment and causes back strain.
Lift items with a bent elbow for added involvement of the muscles of the upper chest, shoulders and
upper arms.
Friction can be reduced by application of an intermediate surface.
Make your body movements smooth and rhythmic. Sudden jerky movements expend more energy than
controlled smooth motions and put more strain on the muscles.
Whenever the clients health permits, ask him or her to assist with the movement. This also helps
maintain some degree of independence on the part of the client.

Range of motion exercise

Types:
Active
Passive
Active-assistive
Resistive

Mechanical aids for walking:

Canes
When maximum support is needed:

1. Hold the cane with the hand on the stronger side of the body.

2. Move the cane forward about 1 foot.

3. Move the affected leg towards the cane.

4. Move the unaffected leg ahead of the cane and the affected leg.

When less support is required:

1. Move the cane and the affected leg forward at the same time
2. Move the stronger leg forward

Walkers:
When maximum support is required:
1. move the walker ahead about 6 inches
2. move the right foot up to the walker
3. move the left foot up tot the right foot

If one leg is weaker than the other:

1. move the walker and affected leg all together

2. move the stronger leg ahead

1.
2.
3.
4.

1.

1.
2.

1.
2.

1.
2.

Crutches:
Measuring clients for crutches:
The client lies supine and the nurse measures from the anterior fold of the axilla to the heel of
the foot and adds 1 inch.
Angle of elbow flexion should be about 30.

Four point gait:

Move the right crutch ahead
Move the left foot forward
Move the left crutch forward
Move the right foot forward

Three point gait:

Move both crutches and weaker leg forward
2. Move the stronger leg forward

Two point gait:

Move the left crutch and right foot forward together
Move the right crutch and left foot ahead together

Swing to gait:
Move both crutches ahead together
Lift the body weight by the arms and swing to the crutch

Swing through gait:

Move both crutches ahead together
Lift the body weight by the arms and swing through and beyond the crutch

WOUND CARE

Types of wound:
Incision
Contusion
Abrasion
Puncture
Laceration
Penetrating wound

Types of wound drainage:

Serous
Purulent
Sanguineous
Types of healing:
Primary intention
o tissue surfaces have been closed
o minimal or no tissue loss
o minimal scarring
Secondary intention
o considerable tissue loss
o repair time is longer
o scarring is greater
o increased susceptibility to infection
Tertiary intention
o indicated when there is a reason to delay the closure

Complications of wound healing

Hemorrhage
Infection
Dehiscence
Evisceration

Types of dressing:
gauze
synthetic dressing

Modes of applying gauze dressing:

Dry-to-dry
Wet-to-dry
Wet-to-damp
Wet-to-wet

Pressure ulcers:

Common sites of pressure ulcers:

back of head, sacrum elbows, scapula, heels
side of head, ears, shoulders, ilium, greater trochanter, knee, malleolus
cheek and ear, acromial process, knee, genitalia, toes

Stages of pressure ulcers:

Stage 1
Stage 2
Stage 3
Stage 4

Key elements in treating/ preventing pressure ulcers:

Reposition every 2 hours
Reduce friction on intact skin by applying a small amount of cornstarch to the bed sheet
Encourage ambulation, unless contraindicated
ROM
Clean and dress the ulcer using surgical asepsis. Do not use alcohol.
Use pressure relieving devices
If the pressure ulcer is infected, obtain sample of drainage

POSITIONING PATIENTS
Positioning clients in bed:

Dorsal Recumbent Position

Problem to be Prevented

Unsupported
Position
Head is flat on bed
surface

Hyperextension of neck in
thick-cheated person

Pillow of suitable thickness under head

and shoulders if necessary for alignment

Lumbar curvature
of spine is apparent

Posterior flexion of lumbar

curvature

Roll on small pillow under lumbar

curvature.

Legs may be
externally rotated

External rotation of legs

Roll or sandbag placed laterally to be

trochanter of the femur

Hyperextensions of knees

Small pillow under the thigh to flex the

knee slightly

Plantar flexion (foor drop)

Footboard or rolled pillow to support feet

in dorsal flexion

Legs are extended

Feet assume
plantar flexion

Prone Position

Problem to be Prevented

Corrective Measures

Unsupported
Position
Head is turned to
side and neck is
slightly flexed

Corrective Measures

Flexion or hyperextension
of neck

Small pillow under the head unless

contraindicated because of promotion of
mucous drainage from the mouth

Body lies flat on

abdomen
accentuating
lumbar curvature

Small pillow or roll under the abdomen,

just below the diaphragm

Toes rest on bed

surface; feet are in
plantar flexion

Hyperextension of lumbar
curvature; difficulty
breathing; pressure on
breast (women); pressure
on the genitals (men)
Plantar flexion of feet (foot
drop)

Allow feet to fall naturally over the end of

the mattress, or support the lower legs
on a pillow so that the toes do not touch
the bed

Lateral Position

Problem to be Prevented

Unsupported
Position
Body is turned to
the side, both
arms in the front of
the body, weight
resting primarily on
the lateral aspects
of the scapula and
the ilium

Lateral flexion and fatigue or

sternocleidomastoid muscles

Corrective Measures

Pillow under head and neck to

provide good alignment

Upper arm and

shoulder are
rotated internally
and adducted
Upper thigh and
leg are rotated
internally and
adducted

Internal rotation and adduction of

shoulder and subsequent limited
function; impaired chest
expansion
Internal rotation and adduction of
the femur; twisting of the spine

Pillow under upper arm to place it

in good alignment; lower arm
should be flexed comfortably
Pillow under leg and thigh to place
them in good alignment; shoulders
and hips should be aligned

Sims (Semi-Prone) Position

Problem to be prevented

Unsupported
Position
Head rests on bed
surface; weight in
borne by lateral
aspects of cranial
and facial bones
Upper shoulder
and arm are
internally rotated

Upper leg and

thigh are adducted
and internally
rotated
Feet assume
plantar flexion

Corrective Measures

Lateral flexion of the neck

Pillow supports head, maintaining

it in good alignment unless
drainage from the mouth is
required

Internal rotation of shoulder and

arm; pressure on chest,
restricting expansion during
breathing
Internal rotation and adduction
of hip and leg

Pillow under upper arm to prevent

internal rotation

Pillow under upper leg to support it

in alignment

Foot drop

Sandbags to support feet in dorsal

flexion

Pillow at lower back to support

lumbar region

Fowlers Position

Posterior flexion of lumbar

curvature

Bed-sitting position
with upper part of
the body elevated
30-90C
commencing at
hips
Head rests on bed
surface

Hyperextension of the neck

Pillows to support head, neck and

upper back

Arms fall at sides

Pillows under forearms to

eliminate pull on shoulder and
assist venous blood flow from the
hands and lower arms.

Legs lie flat and

straight on the
lower bed surface
Heels rest on bed
surface
Feet are in plantar
flexion

Shoulder muscle strain, possible

dislocation of shoulders, edema
of hands and arms with flaccid
paralysis, flexion contracture of
the wrist
Hyperextension of the knees

Small pillow under the thighs to

flex knees

Pressure on heels

Pillow under lower legs

Plantar flexion of feet (foot drop)

Footboard to provide support for

dorsal flexion