Fundamentals of Nursing

 Self-esteem
THEORETICAL FOUNDATIONS OF NURSING  Love and belongingness
Theory – set of concepts to explain a phenomenon
Paradigm – pattern  Safety and Security
o Being free from harm or danger
4 Metaparadigms of Nursing o 2 forms: Physical safety (free from physical harm)
 Person - Most important because knowing the client will and Psychological safety (explaining the
make your nursing care individualized, holistic, ethical, and procedure to the patient)
humane.  Physiologic (priority)
 Health o If all the needs are within the physiologic level
 Environment High Priority needs – (life threatening needs) Airway,
 Nursing Breathing, Circulation
Medium priority needs – (Health threatening needs)
Concepts of Man Elimination, Nutrition, Comfort,
 Man is a bio-psychosocial and spiritual being who is in Low Priority needs – (Person’s developmental needs)
constant contact with the environment.
 Man is an open system in constant interaction with a NURSING THEORISTS
changing environment. Florence Nightingale
 Man is a unified whole composed of parts, which are  Environment Theory
interdependent and interrelated with each other.  May 12, 1830 – August 13, 1910
 Man is composed of parts, which are greater than and  Environmental sanitation
different from the sum of all his parts.
o Simply saying, you cannot remove 1 system from Hildegard Peplau
man.  Psychodynamic Theory of Nursing
 Man is composed of subsystems and suprasystems.  Interpersonal Process
o Subsystem (within) Example: biological,  Phases of Nurse-patient relationship:
psychological, emotional. 1. Orientation (client seeks)
o Suprasystem (outside) Example: Family, 2. Identification (independence, dependence)
community, population 3. Exploitation (accept service of nurse)
4. Resolution
CONCEPTS OF NURSING
Florence Nightingale Virginia Henderson
 Act of utilizing the environment of the patient to assist him  14 Fundamental needs of the person
in his recovery.
Faye Abdellah
Sister Callista Roy  Typology of 21 Nursing problems
 Theoretical system of knowledge that prescribes a process  Patient-centered approach
of analysis and action related to the care of the ill person. o The client’s needs are the basis of the nursing
problems
Martha Rogers Lydia Hall
 Nursing is a humanistic science dedicated to the  3 C’s:
compassionate concern with maintaining and promoting 1. Core (therapeutic use of self) – Patient
health and preventing illness and caring for and 2. Care (nursing function) – Nurse
rehabilitating the sick and disabled. 3. Cure (medical) – Doctor
o Levels of prevention
 Primary – Health promotion and disease Jean Watson
prevention  Human Caring Theory
 Secondary – Treatment, curative  Caring is an innate characteristic of every nurse.
 Tertiary – Rehabilitation  10 Carative factors

Ida Jean Orlando-Pelletier

Dorothea Orem (Self-care and Self-care deficit theory)
 Dynamic Nurse-Patient Relationship Model
 Helping or assisting service to persons who are wholly or
 Nursing Process Theory
partly dependent, when they, their parents and guardians,
o Nursing as a process involved in interacting with
or other adults responsible for their care are no longer able
an ill individual to meet an immediate need.
to give or supervise their care.
 Four Practices Basic to Nursing
o I.e. – completely assisted, partially assisted, and
o Observation, reporting, recording, and actions
self-assisted.
Madeleine Leininger
ANA (American Nurses Association)
 Transcultural Theory of Nursing
 Nursing is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury,
Myra Levine
alleviation of suffering through the diagnosis and
 4 Principles of Conservation
advocacy in the care of individuals, families, communities,
1. Conservation of energy
and populations (2003).
2. Conservation of structural integrity of the body
3. Conservation of personal integrity
Abraham Maslow’s Hierarchy of needs
4. Conservation of social integrity
 Self-actualization

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing

Sister Callista Roy

 Adaptation Model FILIPINO NURSING THEORISTS
 Individuals cope through biophysical social adaptation
 4 mode of adaptation Carmencita Abaquin
o Role function, interdependence, physiological,  Chairman of Board of Nursing
self-concept  PREPARE ME intervention
 P – presence which in
Dorothea Orem  RE – reminisce therapy
 Self-care and Self-care Deficit Theory  P - prayer
 Universal self-care requirement (nutrition, oxygenation),  Re - relaxation
developmental self-care requirement (developmental  ME – medication
tasks), health care deviation self-care requirement
 3 Nursing systems: wholly compensatory ,partially Sr. Caroline Agravante
compensatory, supportive-educative compensatory  The CASAGRA Transformative Leadership model
 5 C’s for Transformational leadership: creative, caring,
Dorothy Johnson critical, contemplative, collegial
 Behavioral Systems Theory
 Man is composed of subsystems and these systems exist in Carmelita Divinagracia
dynamic stability.  COMPOSURE Behavior for wellness
 COMpetence
Martha Rogers  Presence of Prayer, Open mindedness, Stimulation,
 Science of Unitary Human Being Understanding, Respect, Relaxation, Empathy
 Unitary man is an energy field in constant interaction with
the environment. Mila Delia Llanes
 Conceptual model on Core Competency Development
Imogene King
 Goal Attainment Theory Ma. Irma Bustamante
 Interacting systems framework - The effects of the Nursing Self-Esteem Enhancement
 Nurses purposefully interact with the patient and mutually (NurSe) Program to the Self-Esteem of Filipino Abused
set the goal, explore, and agree to means to achieve the Women
goals.
Sr. Letty Kuan
Betty Neuman - Retirement and Role Discontinuity
 Total Person Model
 3 types of stressors: intra-personal, extra personal, St. Elizabeth of Hungary - Patroness of nurses
interpersonal St. Catherine of Siena – The 1st lady with the lamp
 Primary, secondary, tertiary levels of prevention Clara Barton – Founder of American Red Cross
 The goal of nursing is to assist individual families and groups Fabiola – Wealthy Matron who donated her wealth to build a
in attaining and maintaining a maximal level of total hospital the Christian world
wellness by purposeful interventions. T. Fliedner – Founder of the first organized school of nursing
Rose Nicolet – Helped establish the first school of nursing in the
Parse Philippines
 Theory of Human Becoming Lilian Wald – Founder of Public Health Nursing
 emphasizes how individual chose and bear responsibility
for patterns of personal health
HISTORICAL DEVELOPMENT OF NURSING
Patricia Benner
 Novice – Expert Theory Intuitive
Stage 1: Novice - Practiced during the prehistoric, nursing was untaught,
Stage 2: Advance beginner rendered by the mothers (by intuition, it is the woman who
Stage 3: Competent (2-3 years) is more caring).
Stage 4: Proficient (3-5 years) - Out of love, sickness caused by black spirits, based on
Stage 5: Expert instinct
 Skills acquisition - Shamans, spells, rituals

Joyce Travelbee *Trephining – boring a hole into a skull without anesthesia to release
 Human to Human Relationship evil spirits
*Egyptians – art of embalming, anatomy and physiology
Ernestein Weidenbach *Moses – Father of Sanitation, asepsis, art of circumcision
 Clinical Nursing: A Helping Art *China – material medica – book of pharmacology
*Babylonians – Bill of Rights, Code of Hammurabi (made by King
Nola Pender Hammurabi which include freedom to refuse treatment), medical
 Health Promotion Model fee
*India – Shushurutu – list of function of the nurse – combination of
masseur, caregiver

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 Fundamentals of Nursing
*Romans – Fabiola – a rich matron who contributed her home to
serve as first hospital
Apprentice
- Known as the “on the job training” period, under the
supervision of a more experienced person, but yet there is
no formal education.
- Experienced (through trial and error) nurse teaches new
volunteer nurses who usually came from religious orders
- Nursing the sick and wounded from the wars
- Charles Dickens – novel “Martin Chuzzlewit” about Sairy
Gump and Betsy Prag (exemplification of nurses in the Dark
Period of Nursing)
- Pastor Theodore Fliedner (Protestant) – first training school
for Nursing, “Deaconess School of Nursing”, 6 months
program at Kaiserswerth,Germany
- 
Educated
Florence Nightingale School of Nursing
- First theory author, first nurse-researcher
- Lady with a Lamp/ Mother of Modern Nursing
- 3 months of study from Kaiserswerth
- Developed her own training “Nightingales System of
Nursing Education” which is implemented in St. Thomas
Hospital in London
- Correlate theory and practice, updates, continuing
education, research, self-supporting nursing school
(separate from hospital)
- Changed image of nursing, revolutionized practice
- Professionalized as a nursing
- Notes of Nursing: What it is, What it is not, Notes on
Hospitals
Nursing as a profession is not as old as mankind but nursing as an act
itself is.
Contemporary
- Modern nursing practice
Anastacia Giron-Tupas
- Grand lady of Philipine Nursing
- Founded PNA
Hilaria Aguinaldo – Development of Red Cross
Loreto Tupas – Florence Nightingale of Iloilo
Melchora Aquino – Tandang Sora
HISTORY OF NURSING IN THE PHILIPPINES
 First hospital – Hospital de Real de Manila (1577)
 1578 – San Lazaro Hospital, Intramuros – leprosy and mental
illness
 Hospital de San Gabriel – Chinese General Hospital
 Aliping sagigilid and aliping namamahay – first volunteer
nurses who served as apprentice in the first hospitals
 1878 – Escuela de Practicantes (UST)
– First school for Nursing (short-lived)
 1906 – Iloilo Mission Hospital School for Nursing
– 6 months training, no board exam (NON-EXISTENT)
 Mission Hospital (1901) – still existent
 1907 – PGH Hospital, St. Lukes Hospital, St. Paul Hospital
 Normal Hall in PNU is used as training ground – Same
instruction (central school idea) for 6 months then go back
to hospital
 Act 2493 (1915) – Medical act which included Sec.7 & 8
about nursing practice which mandated registration and
examination
 Act 2808 (1919)
University of Santo Tomas – College of Nursing / JSV
- First true nursing law
- Board of Examiner for Nurses (BEN)
- 1 Doctor and 2 Nurses
- 1920 – First board examination
- Anna Dulgent – first board exam topnotcher
 GN Program (Graduate Nurse) – 1 year
 After World War II, BSN degree for four years was given by
UST (1946). Managerial, teaching and supervision position.
Equal to Master’s degree.
 RA 877 – BEN is composed of BSN
 1966 – Master’s degree needed
 RA 6136 – can administer intravenous meds as long as
physician, violaion of professional autonomy; did not
materialize but instead nurse prepared medication and
doctor administered until 1992 but it had conflict with the
drug administration principle of “administer what you
prepare”
1960s – 5-year curriculum
 1976 – 4-year curriculum; GN program was phased out,
practicing GNs must go back to 4th year to earn a BSN
degree but they won’t take board exam anymore since
they are already licensed
 1980 – overlapping of 4 and 5 year curriculum graduates
 RA 7164 (1992) – IV training for nurses by ANSAP, signed by
Cory Aquino, valid only after 2 months
 RA 9173 (2002) – New Nurse Practice Act
HEALTH, DISEASE, AND ILLNESS
Health – Defined as the merely the absence or presence of disease
or infirmity. WHO defined health is a state of complete physical,
mental, and social well-being and not just merely the absence of
disease or infirmity.
Disease – Malfunctioning of the body system.
Illness – It is a state wherein the person’s physical, emotional, and
social well-being is thought to be diminishing. Felt by the patient. It is
highly subjective.
 2 types
o Acute – Sudden onset, short duration, may or
may not require immediate intervention.
o Chronic – Gradual/slow onset, long duration,
lessen complications or debilitating effects of the
condition for the client to be able to function
given the limitations of the condition.
Models of Health
Judith Smith
Clinical Model
- Absence of the signs and symptoms of a disease.
- Narrowest
Role Performance Model
- Able to perform job
Adaptive Model
- Capable of adjusting
- Although there is infirmity, he is able to find ways to cope.
Eudemonistic Model
- Individual is able to achieve the apex of Maslow’s
Hierarchy of needs (self-actualization).
- Maximization of potential and mission in life
- Fulfillment of his purpose in life
Levell and Clark
Ecologic Model of Health
- Epidemiological triad –agent, host, environment
 Fundamentals of Nursing
- Any of these triad must be manipulated or enhanced to Distress – harmful to health
maintain health Body adapts to the changes in the environment which leads to
Homeostasis (Walter B. Cannon)
Cloud Bernard – called homeostasis as “therapeutic milieu”
Multiple Causation Theory of Disease
- health is affected by different factors in the environment Adaptation - change to maintain integrity of the environment
Rosenstoch – Becker’s Health Belief Model
- Individual perception affect modifying factors which may Models of Adaptation
influence likelihood of action Biological/Physiological – GAS and LAS; compensatory physical
changes
Travis’ Illness-Wellness Continuum Emotional/Psychological – involves a change in attitudes or
- Health is in a spectrum which moves into polarity of behavior
directions Socio-cultural – changes in the person’s behavior in accordance
- Premature of death  Disability/Disease  Symptoms  with norms, conventions and beliefs of various groups.
Signs  Awareness  Education  Growth  High level Technological – involves the use of modern technology
wellness
Principles of Homeostatic Mechanisms
Dunn’s High Level Wellness Grid - Automatic, self-regulatory
- Health-illness Continuum - Compensatory
- health axis “Favorable/Unfavorable environment” - Negative feedback except for uterine contraction during
Quadrants: labor
1. High level wellness in a favorable environment - Has limits
2. Emergent high levels in Level Wellness in an One physiologic error is corrected by several homeostatic
unfavorable environment mechanisms
3. Poor Health in an Unfavorable Environment
4. Poor health in a favorable environment STRESS RESPONSE
Lazarus’ Stress Response Theory
Schumann’s Stages of Illness Behaviors General Adaptation Syndrome (GAS) – a physiological response is a
1. Symptom experience systemic response
2. Assumption of sick role Local Adaptation Syndrome (LAS) - Only a part of the body
3. Medical care contact
4. Dependent client role General Adaptation Syndrome Stages
5. Convalescence/ Rehabilitation  Alarm
- Awareness of stressor
Opposite of health is illness, not disease - Increase in vital signs
- Mobilization of defense
STRESS - Decreased body resistance
 Organisms reacts as a unified whole - Increased hormone level
 Fabric of life  Resistance
- Repel of stressor; overcome
Models of Stress - Adaptation
Response Based Model (Selye) - Normalization of hormone levels and vital signs
– Non-specific response of the body to any demand made upon it - Increase in body resistance
- Going back to pre-stress state
Transaction-based Model  Exhaustion
– Individual perceptual response rooted in psychological and - Unable to overcome stressor
cognitive process - Decreased energy level
- Breakdown in feedback mechanism
Stimulus Based Model - Organ/tissue damage; decreased physiological
– Disturbing or disruptive characteristics within the environment function
- Exaggeration of
Adaptation Model
– Anxiety provoking stimulus General Adaptation Response
– People experience anxiety and increased stress when they are Sympathoadreno-medullary Response (SAMR)
unprepared to cope with stressful situations - activation of sympathetic system which stimulated adrenal
medulla
CRISIS - Release of epinephrine and norepinephrine ---- > inc.
- disequilibrium, not merely psychological but physiologic as physiological activities
well (shock) - Sympathetic stimulation (inc. HR, RR, BP, visual perception,
- spontaneous resolution is 6 weeks metabolism – glycogenolysis in liver, dec. GI, GU)
- grieving process: 4 years - Propanolol (Inderal) – bronchoconstriction
Stressor
- Internal/ intrinsic Adrenocortical Response
- External / extrinsic Anterior pituitary gland Adreno corticotropic hormone  adrenal
- Developmental/ Maturational cortex
- Situational (1) release of aldosterone  kidneys  increase Na
reabsorption
Eustress – helpful stress (2) release of cortisol  fats & CHON catabolism  glucose

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 Fundamentals of Nursing
Tertiary Intention – “Delated primary intention”, suturing or closing of
Neurohypophyseal Response the wound is delayed i.e. due to poor circulation in the area
Posterior pituitary gland release
(1) Antidiuretic hormone  kidneys  inc. Na, H2O NURSING PROCESS
reabsorption  dec. urine output, inc. blood volume, inc. A – Assessment
BP D - Diagnosis
(2) Inc. oxytocin (aids in ejaculation/sperm motility)  uterine P – Planning
contraction I - Implementation
E – Evaluation
Methods to decrease stress: An overlapping of process can be noted since it is cyclic
- Progressive relaxation – muscle tension
- Benzon relaxation method – dimming the light, music ASSESSMENT
- Yoga, meditation
- Ventilation of feelings Types
- Initial assessment
Local Adaptation Syndrome - Problem focused assessment
Inflammatory Response - Emergency assessment
All infections cause an inflammatory response - Time-lapsed assessment
Not all tissue damage results to inflammation
Inflammation can heal spontaneously as long as the body can Data Collection – first step in assessment
manage  Primary/ Secondary
 Object (over)/ Subjective (covert)
I. Vascular Stage
(1) Vasoconstriction which limits injury and contain damage Methods of Gathering Data
(transient) Interview
(2) Release of chemical mediators – kinins  Therapeutic and non-communication
a. Bradykinin – most potent vasodilator/ universal  Health history
pain stimulus, inc. chemical activity  warmth o Medical history – disease focused (physiological)
(calor), redness (rubor) o Nursing history – needs, psychosocial dimension,
b. Prostaglandin spiritual aspects
(3) Capillary permeability  swelling (tumor), pain (dulor),  Personal space
temporary loss of function (function laesa) o Intimate Space – 1 ½ foot
o Personal Space – 1 ½ - 4 feet
II. Cellular Stage o Social Space – 4 –12 feet
(1) Neutrophils – bands and segmenters in differential count; o Public Space – 12–15 feet
first one to arrive. If elevated, it suggests acute infection
(2) Lymphocytes, Monocytes, or Macrophages – suggests Observation
chronic infection.  Use of senses to gather data
(3) Eosinophils – allergy  Clinical eye – comes with practice and experience
(4) Basophils – healing Examination
 Inspection, Palpation, Percussion, Auscultation (general)
III. Exudating  Inspection, Auscultation, Percussion, Palpation
Types of Exudate (abdominal)
 Serous – plasma (watery)
 Sanguinous/hemorrages – blood Steps in assessment
 Serosaguinous – pink 1. Collection of data
 Pus – purulent/ suppurative 2. Validation of data
 Catarrhal – mucin 3. Organization of data
 Fibrin fibers – fibrinous 4. Categorizing or identifying patterns of data
5. Making influences or impressions of data
IV. Reparative
Phagocytosis – ingestion of foreign substances After data collection, synthesis, analysis and validation are
Macrophages  Monocytes performed
Chemotaxis – movement of substances to a chemical signal
Healing methods: DIAGNOSIS
 Cold compress for first hours then warm compress after Problem + etiology +defining symptoms
 Nutrition and fluid intake *Guided by the NANDA
Knowledge deficit – kulang sa kaisipan
Types of wound healing Knowledge deficiency – kulang sa kaalaman (preferred)
Primary Intention – Wound edges are well approximated (closed), Self-care deficit – acceptable
minimal tissue damage i.e. surgically created wound; this can be
done with stitches, staples, etc. Types of Nursing Diagnosis
 Actual
Secondary Intention – Wound edges are not well approximated,  Risk for/ Potential for
moderate to extensive tissue damage and edges can’t be brought  Wellness - readiness and enhancement/ achieve higher
together i.e. Decubitus ulcer level of functioning
 Syndrome – “syndrome”

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
 Possible – vague/ unclear – possible/probable 5. Charting by Exception (CBE) – only significant change is
Prioritization of Nursing Diagnosis documented
 Airway, breathing, circulation
Case Management done with a Critical Pathway Variance
– Comprehensive and make sure that it won’t legally be implicated
PLANNING
 Short Range PHYSICAL EXAM (Plan Order)
 Long Range - Cephalo-caudal
*Must be SMART (Specific, Measurable, Attainable, Realistic, Time o Inspect, palpation percussion, auscultation
bound) o Inspection, auscultation, percussion, and
Classify as dependent, interdependent, and collaborative palpation sequence on abdomen to prevent
stimulation of peristalsis and for the patient to
IMPLEMENTATION follow a more comfortable to least comfortable
 Reassess if the patient still needs intervention examination
 Determine if you need assistance
 Carry out intervention, ensure that we have background Focused Assessment – on specific part/symptom
 Document
Process of implementing Bruit – normal if with AV fistula, abnormal in other since it may signify
- Reassess client arterial occlusion
- Determine nurses’ needs for assistance
- Implementing nursing interventions Auscultate the scrotum in inguinal hernia since it may have bowel
- Supervising the delegated care sounds
- Documenting nursing activities
Compare each body part to the other
EVALUATION
POSITIONING
Purposes of evaluation
 Sitting
Determine the:  High Fowlers (90%)
- Client’s progress or lack of progress  Orthopneic position (leaning on a table, hands extended)
- Overall quality of care provided  Supine, Back Lying, Dorsal, Horizontal Recumbent
- Promote nursing accountability  Flat on Bed – no pillow
Guidelines for evaluation  Dorsal Recumbent – legs flexed to relax abdominal
- Systemic process muscles, abdominal palpation/ exam – followed by
- On-going basis diagonal draping
 Standing/Errect – curvature of the spine
- Revision of the plan of care when needed
 Prone/ Face – lying position
- Involve the client, significant others, and other  Sim’s Position, Left lateral, Side-lying
members of the health team – Rectal exam, suppository insertion, enema administration
- Must be documented  Knee Chest position/ Geno-pectoral position/ Jack Knife
Process - nurse position
Structure - system – Rectal exam, dysmenorrhea
Outcome – patient  Kraaske – inverted V
 Lithototomy – stirrups
DOCUMENTATION or CHARTING  Trendelenburg – foot up; head down
 STAT – now  Reverse trendelenburg – head up, foot down
 Ad lib – as desired  Modified trendelenburg – only 1 leg up for shock: L
 PRN – as required
 OD – right eye/ once a day MCNAP – training to perform internal examination
 OS – left eye
 OU – both Chest
 AD – right ear - Pectus excavatum – funnel chest (congenital);
 AS – left ear compression of heart and breathing
 AU – both ears - Pectus carinatum – pigeon chest – deformity for rickets (Vit
 Ss – half D deficiency); AP diameter decreased
ERROR: draw a straight line, signature, initials Posture
- Kyphosis
Types of Documentation - Lordosis
1. Source Oriented Recording – narrative account by nurse; - Scoliosis – lateral
all the sheets in the patient’s chart (Standing Order, Skin
Physician’s Order etc.) - Capillary refill test = 1-2 seconds
2. Problem Oriented Recording (POR) – problems ranked - Icteric sclera
according to priority by the health care team, date - Cyanosis – late sign of oxygen deprivation
dissolved, progress notes, problem list - Vitiligo
a. FDAR – Focus, Data, Action, Response (patient) - Erythema
b. SOAPIER – subjective, objective, assessment, - Pallor
planning, implementation, evaluation, revision
3. Computer Assisted Recording – problem with privacy Nail Beds
4. Flow Chart - Clubbing - Beyond 180 degree due to dec. oxygen

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 Fundamentals of Nursing
- Koilonychia -Spoon shaped nail due to iron deficiency Gurgles (rhonchi) – Continuous, low-pitched, course, gurgling, harsh
anemia sounds with moaning / snoring quality
- Onycholysis/Oncolysis – separation of nail - rubbing hair in wide airway
- Paronychia – severe inflammation of nail Friction rub – Superficial grating or creaking sounds
- Unguis incartatus - ingrown toenail Vocal (tactile) fremitus – Faintly perceptible vibration felt through
the chest wall when the client speaks
PALPATION Stridor – noisy breathing
- Light (indentation half an inch) Stertor – laryngeal spasm
o Fontanels, buldges, pulses, lymph nodes, thyroids, Cardiac Sounds
symmetry, neck veins, edema - 5th ICL MCL at the PMI
- Deep - Llllleft – Pulmonic valve
- Rrrrrr- Aortic valve
NPH – Ntrmediate
IE is a form of palpation Humulin R- rapid
Chest expansion must be symmetrical Glargular – rapid
Tactile fremitus - sound that is palpable Bowel Sounds
- Increase in consolidation, pneumonia - Normoactive: 5-30 bowel sounds per minute
- Decrease in pneumothorax - Wait 3-5 mins before concluding that bowel sounds are
Thrill – palpable murmur absent
Edema – on dependent area and may occur in legs - Hyperactive – Borborygmus
- Pitting/Non-Pitting - Paralytic ileus – paralysis after surgery
Anasarca – generalized edema
Peri-orbital edema – about the eye Voice Transmitted Sounds
- Egophony – say “E” but hears “A”
PERCUSSION - Whispered Pertoriloquy – whisper but we hear it loudly,
- Touch and healing secondary to consolidation
- Vocal fremitus
Tuning Fork Shifting dullness to check for ascites
- Weber’s test/ Lateralization test – conduction hearing
- Rhinne’s Test – bone-air conduction LABORATORY EXAMS
- Properly collect the specimen
Indirect Palpation - Give instructions correctly
- Flexor – Hiitting
- Pleximeter – Receiving Urinalysis
Sounds - Color: Amber, tea-colored (biliary d/o), urobilinogen
- Dull – organ - Odor: Aromatic/ Ammoniacal (decomposed urine)
- Flat – bones, muscles - pH: Acidic – does not favor bacterial growth
- Tympany – abdoment - Specific gravity: 1.050-1.025, if elevated urine is
- Resonant – lungs concentrated, suspect dehydration
- Hyperresonance – abnormal (emphysema) - Phosphates/Urates: Normal
- Glycosuria – Diabetes (BS is more than 200mg)
Typanism – “kabag” - Hematuria – Stones, BPH, renal diseases, UTI
DTR - +2: NORMAL, above it hyper resonant, below it is hyporesonant - Albuminemia – protein in urine, eccampsia
- Pyuria – UTI
Parts of the Stethoscope - Cyllinduria – cast in urine (stones)
Diaphragm – high pitched; lung sounds - First voided urine, mid-stream to clean the urethra first
Bell – low pitched; heart sounds - Sterile specimen
- Indwelling catheter – wait in the end of the catheter for 30
Adventitious breath sounds – no abnormal sounds mins
- Indwelling catheter – aspirate from 10ml syringe
Respiratory Sounds - Wee bag (*)
Normal Breath Sounds
Vesicular – Soft intensity, low pitched Urine Culture & Sensistivity Test
- T5 onward - Exact microbe
- Peripheral lung, base of the lung - Result is final only after 5-7 days
Bronchovesicular – Moderate intensity, moderate pitch - Same collection process but less amount
- T3-T5 - Ideal is catheterized cath
- Between scapulae lateral to the sternum
Bronchial – High pitch, loud harsh sounds Chemical Tests for Urine
- T1-T3 - Clinitest – way to determine sugar in urine (glycosuria)
- Anteriorly over the trachea - Benedict’s test – used Benedict’s solution then heat to
check for potency: must remain blue; if not blue, discard
Adventitious Breath Sounds - NO BOILING
Wheeze – Continuous, high-pitched, squeaky musical sounds o Then add 3-10 drops of urine then heat
- narrowed airway; asthma, bronchitis o Negative results
Crackles (rales) – Fine, short, interrupted crackling sounds o Negative: Blue
- rubbing hair in small airways; retained secretions; o +1 - Green
o +2 - Yellow

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
o +3 – Orange - prick at the side since low blood vessels
o +4 - Red
o Collected before meals Thoracentesis
- Heat and Acetic Acid Test – test of albuminuria; divide into - aspiration of pleural fluid through a needle
3 parts then add 2/3 urine, then 1/3 acetic acid - orthopneic position
- informed consent
- Fluid - 7-8 or 8-9 in intercostal posterior axillary line
o Turbid/Cloudy – positive - Air - 2-3, 3-4 in intercostals
o Not reliable since no microscopic instruments - Needs chest x-ray
were used - Positioned lying on unaffected side
o Done mostly in the community, NO BOILING
Thoracostomy
Quantitative Urine Exam - to return to negative pressure
- 24-hour Urine Collection – HCG, urinary amylase, urinary
catecholamines, urinary creatinine, urine albumin, Abdominal Paracentesis
corticosteroids - Aspiration of peritoneal fluid in ascites
o 6pm order, discard urine on 6pm, start on 6:01pm - Semi-sitting/sitting position
o Whole amount of urine, need not be midstream - Void before procedure
o Preserve in ice – cold storage - May be therapeutic or diagnostic
o Leeway of 15-30mins; get urine after deadline as - Watch out for hypovolemia
long as not too far
- Fractional Urine Collection – shorter span; time determined Lumbar Puncture/ Tap
by doctor - L3, L4, L5, subarachnoid space
- Paralysis risk low
Fecalysis - Fetal position – widens the angle of the lumbar spine
- Color of stool is influenced by stercobilin - 50-200mm – normal CSF pressure
- Clay colored = acholic stool = biliary track obstruction - Prepare 4 test tubes since every test requires a different
- Hematochezia = red = lower GI bleeding test tube
- Melena = blood = upper GI bleeding - Label test tubes and seal with appropriate cover; not with
- Steatorrhea = fat = gall bladder rpoblem cotton
- Foul smelling – indole and skatole - Xanthochromic – hemolyzed blood; yellowish discoloration
- Soft/formed - Flat on bed after procedure (6-8 hours) to prevent spinal
- Dead bacteria, fibers, amorphous phosphates – normal headache
- Live bacteria – abnormal
- After 1 hour, the stool cannot be used for fecalysis Diagnostic Exams
- Collect abnormal looking feces, not the one which is well - Visualization procedures
formed - Endoscopy
o direct visualization; lighted instrument
Stool Culture and Sensitivity - X-Ray – graphy
- Determining exact microorganism o Contraindicated in pregnant women due to
- Result also final after 5-7 days terratogenic effect
- Sterile container - Transformed
o Ultrasound/ Sonogram
Guiac Test
- Occult blood test Electroencephalography (EEG)
- No meat, highly colored food, iron preparation, Vit. C in - Shampoo hair before and after procedure
diet - Sedative must be withheld
- 3 days occult blood sample - Determining seizure disorders
-
Sputum Exam Electrocardiography (ECG)
- Done in early morning since secretions already pooled
- Sputum C &S – may give oral hygiene to remove mouth Electromyogram (EMG)
bacteria - Invasive
- Acid Fast Bacilli – 3 consecutive days - Phase 2 – insertion of needle into muscle
- Sputum Cytology – cancer cells
- Eosinophil determination – to determine allergic reaction CBC needs a heparinized syringe
- If unconscious, suction may be done: mucus trap
Magnetic Resonance Imaging
Blood Examinations - CI: steel implant and pace maker
- FASTING - Some ortho implants/prosthesis are allowed
o Triglyceride (1-12 hours), BUN (6-8 hours), HDL, - Assess for claustrophobia
LDL, FBS, Total Protein, Albumin Globulin ration, - Needs consent since it’s expensive
uric acid - With contrast in special procedures
- NON FASTING - NPO – to avoid aspiration in case of untoward reaction
o Crea, Na, K, Ca, CBG (but pre meals)
Computed Tomography Scan
CBG - Lesion must be bigger
- before meals - Dye and NPO

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 Fundamentals of Nursing
- Enema to evacuate barium to prevent fecal impaction
Positron Emission Tomography
- Radioactive glucose (Fluorine) Lower GI Series
- Cancer cells have strong affinity for glucose; detect - Barium enema
cancer sites of metastasis - Outline of colon
- Laxative and cleansing enema until it is clean
- Pink phosposoda (oral cleansing enema)
Nuclear Medicine Thyroid Scan - Evacuate barium through enema to prevent fecal
- Nodule/tumor on thyroid impaction
For abdominal scans laxative, (castor oil/ Dulcolax) and NPO may
be necessary Excretory Urography
- Intravenous Pyelography
Opthalmoscopy o Hypaque- - made from iodine substance; check
- Opthalmoscope for allergy for seafoods
- Used in determining cataract o Laxative + NPO
- Dim the light and focus light of opthalmoscope in the eye o Given through IV port and the xray series is made
- Fundoscopy may be determined o Assesses kidney’s ability to filter
o Assesses presence of stones
Otoscopy o If reverse, retrograde pyelography
- Otoscope - Oral Cholecystography
- A cannula is inserted in the external auditory canal o Iapanoic acid (Telepaque) – taken every 5-10
- No need for written consent minute interval; 6 tablets
- 3 y/o above – up & back o Low fat meal the day before the exam
- 3 y/o below – down & back o Laxative + NPO

Rhinoscopy Ultrasound/ Sonogram

- Rhinoscope - US Brain
- Hyperextend the neck - US Heart (2D ECHO, Echocardiography)
o Regurgitation
Endoscope o Stenosis
- Can be used for surgery, biopsy - US Lungs
- Pharyngoscopy - US Breast/ Sonomamogram
- Bronchoscopy o Needs tranducer
- Langyngoscopy - US Abdomen
- Esophagogastroduedenoscopy o Colon – laxative, NPO
- Anoscopy o Kidney – KUB
- Proctoscopy – rectum o Pelvic ultrasound – drink 6-8 glasses to have a full
- Sigmoidoscopy bladder; do not allow to void
- Coloscopy – anus to ileum o Gallbladder ultrasound
o Cleansing enema until clear - Transvaginal Ultrasound
- Remove dentures o Will outline fallopian tube, uterus and ovaries
- Remove gag reflex by local anesthetic agent and check o consent
gag reflex - Transrectal Ultrasound
- Resume food only when gag reflex is present o Consent
- Consent and NPO o Empty the bladder for comfort and good
- Urethroscopy visualization
- Cystoscopy – bladder, written consent, cystoclysis set up o Visualization of uterus/ prostate
(continuous flow of sterile water which also exits)
- Colposcopy – vaginal examination, needs vaginal ADMITTING A CLIENT
speculum Types of Bed
o Shirodkar – tying the cervix so that miscarriage is - Closed – in anticipation for an admission
avoided; incompetent cervix - Open
- Post-Op/ Surgical/ Anesthetic/ Heater bed
Roentgenography - Occupied
- Electromagnetic radation photography
- Xray but without contrast medium Principle of Bed-making
- Chest X-Ray - Body Mechanics: Bed from knees, wide base of support
o Not definitve of TB - Obtain help
- Mammography - Asepsis, do not let linen touch uniform
o Examination of breast - Do not let the linen fall into ground
- Scout Film of Abdomen - Finish one side of bed first
- KUB - Remove wrinkles to have aesthetic value
o Top sheet – excess linen in foot part
Upper GI Series o Bottom sheet – excess linen in head part
- Esophagus, stomach, duodenum CHANGING GOWN
- Barium swallow (dye) – outline the GI system, flavored, has - Remove with free arm first in changing gown
constipating effect – inc. fluid - If both with contraption, any arms
- Uses laxative, NPO ORIENTING THE CLIENT

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 Fundamentals of Nursing
ASSESSMENT  Course / Plateau phase: absence of chills, feels warm, up
HISTORY TAKING HR, RR, thirtst
PHYSICAL EXAM  Abatement phase: flushed skin, sweating, reduced
VITAL SIGNS shivering
DOCUMENT
- chief complaint only found on admission sheet Average: 36˚ - 38˚ degrees
DISCHARGE OF PATIENT Hypothermia: 36˚ degrees below
- may be against medical advice (DAMA) but it needs Death: 34˚ degrees
doctor’s order
- health instruction Types of Fever
- Illegal detention (false imprisonment) Intermittent – fluctuates from febrile to afebrile
Remittent – febrile, temperature fluctuation is minimal
VITAL SIGNS Relapsing – fluctuates in days
Children – Respiratory Rate, Pulse Rate, Temperature Constant / Continuous – febrile, temperature fluctuation is wide (+2)
* Blood Pressure can also be obtained in children
Heat Stroke – depletion of fluid, hypothalamus does not regulate
Hypothermia – induced (surgery), extreme temperature

Nursing interventions
Feels chilled – provide extra blankets
TEMPERATURE Feels warm – remove excess blankets; loosen clothing
Types of Temperature Adequate nutrition and fluids
Core temp. – more important; can’t be affected by environment Reduce physical activity
Surface temp. – more important in children since hypothalamus not Oral hygiene
yet developed Tepid Sponge Bath – increase heat loss (conduction, convection,
evaporation)
Poikilothermia – temp is same with environment; newborn
Homeothermia – different with the environment Unexpected Situation and Associated Interventions
During rectal temperature assessment, the patient reports feeling
Factors that affect Body Temperature lightheaded or passes out  Remove the thermometer
1. Age immediately. Quickly assess the patient’s BP and HR. Notify
2. Ovulation – temp is higher; progesterone physician. Do not attempt to take another rectal temperature on
3. Activity – inc. BMR this patient.
4. Environment
Temperature conversion PULSE
C-F multiply 1.8 + 32 - Temporal
F-C subtract 32/ 1.8 - Carotid – cardiac arrest
- Apical
Methods of taking body temperature - Brachial
- Oral – contraindicated in brain damage, mental illness, - Radial – thumb site
retarded, problem with nose and mouth, tooth extraction, - Femoral
contraption in nose and mouth, altered LOC, dyspnea, - Popliteal
seizures, 7 y/o below
o 2 mins under the tongue Affected by the following:
- Rectal – contraindicated in imperforate anus, rectal 1. Age – the younger, the faster
polyps, hirschprung’s disease, diarrhea, increase ICP, 2. Activity
cardiac disease (may cause vagal stimulation) 3. Stres
o Not safe since it can cause rectal trauma 4. Drugs
o 1 min  Increase – anticholinergic, sympathomimetic
- Axillary – 3mins  Decrease – cardiac glycoside
- Tympanic – external ear. contraindicated in otitis, ear
surgery; most Palpation
accurate Pattern of Beat (Rhythm)
- Temporal Scanner - done in temporal; most convenient - Regular (60 – 100 bmp)
- Irregular (arrhythmia)
Temperature can be checked every 30 mins since hypothalamus o Bigeminal pulse – 1, 2, disappear
can only fluctuate the temperature every 30 mins o Trigeminal pulse – 1, 2, 3, disappear

Spot Vital Signs – HR, RR, BP Pulse Strength = pulse volume

Thermopacifier – for crying babies +1 – collapsible. thready
Plastic strip Thermometer – Amitemp +2 – normal
+3 – full
Alterations in body temperature +4 – full, bounding
Hyperpyrexia: 41˚ degrees +
Pyrexia: 37.5˚ - 38˚ degrees + Corrigan pulse/ Waterhammer pulse – thready and with full
 Onset / Chill phase: up HR, up RR, shivering, cold skin, expansion followed
cessation of sweating by sudden collapse.

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 Fundamentals of Nursing
Auscultation
Apical (PMI) Kinds
 3rd – 4th ICS MCL (below 7 years old) - Direct – venous pressue, CVP, invasive, cutdown (5-
 4th - 5th ICS MCL (7 years old and aboe) 12mmHg)
Unexpected Situations and Associated Interventions - Indirect
The pulse is irregular  Monitor the pulse for a full minute. If the pulse o Palpatory
is difficult to assess, validate pulse measurement by taking the o Ausultatory
apical pulse for 1 minute. If this is a change for the patient, notify the
physician. Pulse pressure – 40 mmHg
Pulse deficit (systolic - diastolic)
You cannot palpate a pulse  Use a portable ultrasound Doppler to Mean Arterial Pressure ([2D+S]/D)
assess the pulse. If this is a change in assessment or if you cannot
find the pulse sing an ultrasound Doppler, notify the physician. Classification SBP DBP Lifestyle
mmHg mmHg Modification

RESPIRATION Normal: 16-20 bpm Optimal <120 And <80 Encouraged

Pre- 120-139 Or 80-89 YES
Three processes
hypertension
Ventilation – the breathing in and breathing out
Stage 1 HPN 140-159 Or 90-99 YES
 Intact CNS
 Clear airway Stage 2 HPN >160 Or > 100 YES
 Intact thoracic cavity Stage 3 HPN > 180 Or > 110 YES
 Compliance and recoil
Diffusion – movement of gases from higher to lower concentration Choose the higher BP
 Adequate concentration of gases Sources of error is BP Assessment
 Normal lung tissue High BP reading
Perfusion – circulation of the oxygenated blood to the different  Bladder cuff too narrow
tissues of the body  Arms unsupported
 Insufficient rest before the assessment
Inhalation / Inspiration – 1 to 1.5 seconds  Repeating reassessment too quickly
Exhalation / Expiration – 2 to 3 seconds  Deflating cuff too slowly
 Assessing immediately after a meal or while client smokes
Alterations in Breathing Patterns or has pain
Rate Low BP reading
Tachypnea – fast breathing  Bladder cuff too wide
Bradypnea – slowed breathing  Deflating cuff too quickly
Apnea – absence of breathing  Arm above the level of the heart
Eupnea – normal breathing  Failure to identify auscultatory gap

Rhythm
Biot’s – shallow breathing with periods of apnea OXYGENATION
Cheyne-Strokes – deep breathing with apnea
Kussmaul’s – deep, rapid breathing (If with respiratory acidosis – to Respiratory Modalities
blow off excess carbon dioxides) Abdominal (diaphragmatic) and purse-lip breathing
Volume  Semi / high fowlers position
Hyperventilation – leads to respiratory alkalosis  Slow deep breath, hold for a count of 3 then slowly exhale
Hypoventilation – leads to respiratory acidosis through mouth and pursed lip
 5 – 10 slow deep breaths every 2 hours on waking hours
Ease of effort
Dyspnea – difficulty of breathing Coughing exercise
Orthopnea – difficulty of breathing within supine position  Upright position
(best position for this is orthopneic position)  Contraindicated: post brain, spinal or eye surgery
Katupnea - Difficulty of breathing while in sitting position  Take two slow deep breaths; on the third breath, hold for
Trepopnea - ease when in side-lying position dew seconds, cough twice without inhaling in between
Hyperpnea – inc. rate and depth of respiration  May splint surgical incisions
 Every 2 hours while awake
BLOOD PRESSURE
Factor’s Affecting Blood pressure Incentive spirometry
- Age, Gender  A breathing device that provides visual feedback that
- Activity, exercise, stress encourages patient to sustain deep voluntary breathing
- Time of the day and maximum inspiration.
 10 times every 1 to 2 hours
Korotkoff sounds
Phase 1 – sharp tapping (systolic) Chest Physiotherapy
Phase 2 – swishing or wooshing sound  Postural drainage
Phase 3 – thump softer than the tapping in phase 1  Percussion
Phase 4 – softer blowing muffled sound that fades (end = diastolic)  Vibration
Phase 5 – silence

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 Fundamentals of Nursing
 Positioning > percussion > vibration > removal of secretions  Safety precuations: “NO SMOKNG” and “O2 IN USE” signs
by coughing or suction at the door
o Contraindications:
 ICP more than 20mmHg, head and neck injury, Nasal Cannula (approx. 20-40% of oxygen)
active hemorrhage, recent spinal surgery, active  1L/min = 24%
hemoptysis, pulmonary edema, confused or  2L/min = 28%
anxious patients, rib fracture  3L/min = 32%
 4L/min = 36%
Postural Drainage  5L/min = 40%
 When = morning, at bedtime, 30 minutes – 1 hour before or  6L/min = 40%
1-2 hours after meal Priority nursing interventions:
 Each position = assumed for 10 – 15 minutes o Check frequently that both prongs are in the patient’s
 Entire treatment should last only for 30 minutes nares.
o Encourage the patient to breathe through the nose,
Percussion with mouth closed.
 Rhythmical force provided by clapping the nurse’s o May be limited to no more than 2-3L/min to patient
cupped hands against the client’s thorax with chronic lung disease.
 Over affected segment for 1-2 minutes Face mask
Simple face mask (approx. 40-60%)
Vibration  5-6L/min = 40%
 Perform by contracting all the muscles in the nurse’s upper  7-8L/min = 50%
extremities to cause vibration while applying pressure to  10L/min = 60%
the client’s chest wall Priority nursing interventions:
 One hand over the other o Monitor patient frequently to check the placement of the
mask.
Suctioning o Support patient if claustrophobia is a concern.
Purposes o Secure physician’s order to replace mask with nasal
 Maintain patent airway cannula during meal time
 Promote adequate exchange of O2 and CO2
 Substitute for effective coughing Partial rebreather mask (approx. 60-80%)
Size  6-10L/min = up to 80%
 Adult: Fr 12-18 Priority nursing interventions:
 Child: Fr 8-10 o Set flow rate so that mask remains two-thirds full during
 Infant: Fr 5-8 inspiration
Length o Keep reservoir bag free of twists or kinks.
 From tip of nose to earlobe (5 in.)
 Nasopharyngeal = 5-6 inches Nonrebeather mask
 Oropharyngeal = 3-4 inches  10L/min = 80-100%
 Nasotracheal = 8-9 inches Priority nursing interventions:
 ET = lenth of ET + 1 inch o Maintain flow rate so reservoir bag collapses only slightly
 Tracheostomy = length of trachea + 1 cm during inspiration.
Suctioning o Check that valved and rubber flaps are functioning
 Duration of suction: 5-10 seconds properly (open during expiration and closed during
 Intermittent suctioning upon withdrawal using rotating inhalation)
motion o Monitor SaO2 with pulse oximeter.
 If to repeat: 1-2 mins interval
 Limit suctioning in a total of 5 minutes Venturi mask (most accurate and precise oxygen concentration
delivery)
Unexpected Situations and Associated Interventions  4L/min = 24%
Patient vomits during suctioning  If patient gags or becomes  4L/mins = 28%
nauseated, remove the catheter; it has probably entered the  6L/min = 31%
esophagus inadvertently. If the patient needs to be suctioned  8L/min = 35%
again, suction catheter because it is probably contaminated.  8L/min = 40%
 10L/min = 50%
Secretion appear to be stomach content  Ask the patient to
extend the neck slightly. This helps to prevent the tube from passing Oxygen Tent
into the esophagus. Unexpected Situations and Associated Interventions
Child refuses to stay in the tent  Parent may play games in the tent
Epistaxis noted with continued suctioning  Notify the physician and with child. Alternative methods of O2 delivery may need to be
anticipate the need for a nasal trumpet. considered if child still refuses to stay in tent.

It is difficult to maintain an O2 level above 40% in the tent  Ensure

Oxygen Therapy that the flap is closed and edges of tent are tucked under blanket.
Special consideration: Check O2 delivery unit to ensure that rate has not been changed.
 Given with a doctor’s order
 Careful and continuous assessment to evaluate the need Patient was confined on O2 delivered by nasal canula but now is
for and its effect on the patient cyanotic, and the pulse oximeter reading is less than 05%  Check
to see that O2 tubing is still connected to the flow meter.

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
When dozing, patient begins to breathe through the mouth 
Temporarily place the nasal cannula near the mouth. If this does not
raise the pulse oximetry reading, you may need to obtain an order
to switch the patient to a mask while sleeping.
Inhalation Therapy
Moist inhalation – Steam inhalation = 12- 18 inches; 15 – 20 mins.
Dry inhalation – Metered dose inhaler = use of spacer; hold breath
for 10 seconds with 5 minutes interval
**Water
Child – has 70- 90 percent water
Adult – has 50-70 percent water
Males have more water than females since they have more adipose
tissue
Artificial Airways
Oropharyngeal airway
 Prevents tongue from falling back against the posterior
pharynx
 Measurement: from opening of the mouth to the ear (back
angle of the jaw)
 Check for loose teeth, food and dentures
Unexpected Situations and Associated Interventions
o The patient awakens  Remove the oral airway
o The tongue is sliding back into the posterior pharynx,
causing respiratory difficulties  Put on disposable gloves
and remove airway. Make sure airway is the most
appropriate size for the patient.
o Patient vomits as oropharyngeal airway is inserted 
Quickly position patient onto his side to prevent aspiration
Nasopharyngeal Airway / Nasal Trumpets
 Indications Clenched teeth, enlarged tongue, need for
frequent nasal suctioning
 Measurement: from the tragus of the ear to the nostrils plus
one inch
 Proper lubrication for easy insertion
Endotracheal
 Indications: route for mechanical ventilation, easy access
for secretion removal, artificial airway to relieve
mechanical airway obstruction.
 Care for patients with ET:
o Repositioned at least every 24-48 hours
o Depth and length during insertion should be
maintained
o Level of tube: gumline / biteline
o Maintain cuff pressure of 20-25 mmHg
o Check lips for cracks and irritation
Unexpected Situations and Associated Interventions
o Patient is accidentally extubated during
suctioning  Remain with the patient. Instruct
assistant to notify physician. Assess patient’s vital
signs, ability to breathe without assistance and O2
saturation. Be ready to administer assisted breaths
with a bag-valve mask or administer O2.
Anticipate need for reintubation.
o Oxygen saturation decreases after suctioning 
Hyperoxygenate patient.
o Patient develops signs of intolerance to
suctioning; O2 saturation level decreases and
remains low after hyperoxygenating, patient
University of Santo Tomas – College of Nursing / JSV
becomes cyanotic or patient becomes
bradycardic  Stop suctioning. Auscultate lung
sounds. Consider hyperventilating patient with
manual resuscitation device. Remain with
patient.
o Patient is accidentally extubated during tape
change.  Remain with the patient. Instruct
assistant to notify physician. Assess patient’s vital
signs, ability to breathe without assistance and O2
saturation. Be ready to administer assisted breaths
with a bag-valve mask or administer O2.
Anticipate need for reintubation.
o Patient is biting on ET  Obtain a bite block. With
the help of an assistant, place the bite block
around the ET or in patient’s mouth.
o Lung sounds are greater on one side  Check
the depth of the ET. If the tube has been
advanced, the lung sounds will appear greater
on one side on which the tube is further down.
Remove the tape and move tube so that it is
placed properly.
Tracheostomy
 To maintain patent airway and prevent infection of
respiratory tract.
 Care of patient with tracheostomy:
o Sterile technique: acute phase
o Clean technique: home care
o 1st 24 hours: tracheostomy care every 4 hours
o Prevent aspiration
Unexpected Situations and Associated Interventions
o Patient coughs hard enough to dislodge
tracheostomy  Keep a spare tracheostomy and
obturator at the bedside. Insert obturator into
tracheostomy tube and insert tracheostomy into
stoma. Remove obturator. Secure ties and
auscultate lung sounds.
Pulse Oxymetry
 Purpose: measure arterial blood O2 by external sensor
(non-invasive)
 Placement
o Adult: usually on the finger
o Pedia: usually on the big toe
o Other sites: earlobes, nose, hand and feet
NUTRITION
Principles in the Promotion of Good Nutrition
 The body requires food to:
o Provide energy for organ function, movement,
and work.
o Provide raw materials for enzyme function,
growth, replacement of cells and repair.
 The process of digestion, absorption, and metabolism work
together to provide all body cells with energy and
nutrients.
 Man’s energy requirement vary and is influenced by many
factors: Age, body size, activity, occupation, climate,
sleep, physiological stress, pathological disorders, lifestyle,
and gender.
 Fundamentals of Nursing
Foods are described according to the density of their nutrients.
Nutrient density – the proportion of essential nutrients to the number **Kaesselbach’s plexus – prone to epistaxis
of kilocalories.
Macronutrients – Give off calories for energy B Vitamins – Metabolism since these have enzymatic activity
 Fat soluble viramins: Vit. A, D, E, and K Vit B1 (Thiamin)
Micronutrients – No calories, vitamins and nutrients - Deficiency: Beri-beri; Wernicke-Korsakoff Syndrome
 Water soluble vitamins: Vit. C, B1, B2, B3, B6, B9, and B12 - Edema in wet Beri-beri
Calorie (kcal) – unit of energy measurement; amount of heat
required to raise the temperature of 1kg of water to 1°C Vit B2 (Riboflavin)
- Deficiencies: Ariboflavinosis, cheilosis
Sources: o Angular stomatitis - mouth fissures
CHO – 4 calories/gm; first to be burned
FATS – 9 colories/gm; stored as adipose tissue Vit B3 (Niacin)
CHON – 4 calories/gm; meat - Deficiency: Pellagra – butterfly sign, cassel’s collar
Alcohol – 7 calories/gm
Vit B5 (Pantothenic Acid)
Vitamins - Keeps integrity of hair
- Fat soluble - ADEK - Deficiency: alopecia
- Water soluble – B complex , C
Macrominerals – 100 mg or more Vit B6 (Pyridoxin)
Microminerals – Less than 100 mg; Zinc, iron, iodine - Deficiency: Neuritis

**Potato – highest in potassium Vit B12 (Cyanocobalamin)

**The tip of the banana has the highest amount of potassium - Definition: pernicious anemia, neuritis

Iodine – prevent cretinism Vit C (Ascorbic)

Zinc – to improve appetite - Inc. absorbtion of iron
Iron - correct anemia - Deficiency : scurvy – easy bruising, gums, perifollicular
Hypervitaminosis – increase in vitamins intake; occurs commonly in lesion, hemorrhage
fat soluble Types of Diet
Regular
No hypervitaminosis in water soluble since it is easily eliminated in – Has all essentials, no restrictions
urine – No special diet needed
Clear liquid
Overweight – increase in macronutrients; may progress to obese – “see-through foods” like broth, tea, strained juices, gelatin
Marasmus – Recovery from surgery or very ill
- calorie malnutrition Full liquid
- Old man facie, intercostals and subcostal retractions – Clear liquids plus milk products, eggs
Kwashiorkor – Transition from clear to regular diet
- moon face, Globular abdomen, edema Soft diet
- protein malnutrition – Soft consistency and mild spice
– Difficulty swallowing
VITAMIN DEFICIENCIES Mechanically soft
Vit A (Retinol) – Regular diet but chopped or ground
- Healthy eyes, skin, and gums – Difficulty chewing
- Deficiency: Xeropthalmia (night blindedness) – Bitot’s spot Bland
- Severe: Keratomalacia (irreversible) – Chemically and mechanically non stimulating, no spicy
Vit D (Calciferol) food
- Not coming from the sun; but sunlight activates it – Ulcers or colitis
- Enhances calcium and phosphorus absorption Low residue
- Deficiency: Ricketts – No bulky foods, apples or nuts, fiber, foods having skins and
- Severe: Osteomalacia seeds
o Bow legged – genu varum – Rectal disease
o Knock knee – genu valgum High calorie
o Pectus carinatum (Harrison’s groove) – High protein, vitamin and fat
o Spinal deformity – Malnourished
o Stunted growth Low calorie
You can store calcium up to 31 years – Decreased fat, no whole milk, cream, eggs, complex CHO
– Obese
Vit E (Tocopherol) Diabetic
- Antioxidant: remove free radicals – Balance of protein, CHO and fat
- Amount should not go 400 units because if it exceeds. It – Insulin-food imbalance
becomes prooxidant High protein
- En hances RBC maturation – Meat, fish, milk, cheese, poultry, eggs
- Deficiency: anemia – Tissue repair and underweight
Vit K (Menadione) Low fat
- Anti-hemorragic – Little butter, cream, whole milk or eggs
- Deficiency: hemorrhagic, bleeding – Gallbladder, liver or heart disease

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 Fundamentals of Nursing
Low cholesterol pressure to remove the clog; Never use a stylet to unclog
– Little meat or cheese the tubes; Tube may have to be replaced.
– Need to decrease fat intake
Low sodium Gastrostomy / Jejunostomy Feeding
– No salt added during cooking  Long term nutritional support, more than 6 – 8 weeks
– Heart or renal disease  Place in high fowler’s position
Nutritional Problems  Check the patency of the tube: Pour 15-30 cc of water
1. Antropometric Measurement  Check the patency of the tube: Pour 15-30 cc of water
a. BMI – kg/m2  Check for residual feeding
i. Underweight – below 18  Hold asepto-syringe 3-6 inches above ostomy feeding
ii. Normal – 18-24  Frequently assess for skin breakdown
iii. Overweight – 24 above
2. Biochemical Assay – laboratory exams Unexpected Situations and Associated Interventions
3. Clinical signs – sx/s o Gastrostomy tube is leaking large amount of drainage 
4. Dietary History Check tension of the tube; Apply gentle pressure to tube
a. Food habits while pressing the external bumper closer to the skin; If
tube has an internal balloon holding it in place, check to
Anorexia – no eating make sure that the balloon is inflated properly.
Bulimia – binge-purge syndrome o Skin irritation around the insertion site  Stop the leakage,
as prescribed previously and apply a skin barrier.
Management: o Site appears erythematous and patient complains of pain
- Hygiene at the site  Notify physician, patient could be developing
- Small frequent feeding cellulitis at the site.
- Serve attractively French is directly proportional to size
Gauge is inversely proportional to size
Enteral and Parenteral Nutrition
Parenteral Nutrition **Intravenous Hyperalimentation/ TPN
 Nonfunctional GIT - Kabiven
 Extended bowel rest - Watch out for gylcosuria and blood sugar
 Preoperative TPN - May necessitate insulin
Enteral Nutrition - Large needle since it is central route
 Cancer - Monitor for complications
 Neurological and Muscular disorder ELIMINATION
 Gastrointestinal disorder
 Respiratory failure with prolonged intubation URINE ELIMINATION
1200 – 1500cc/day
Nasogastric Tube Feeding/ Levine’s Tube Normal output: 30ml/hour
 Position: sitting Urge to urinate: 300-500ml
 Head: hyperextend and slightly flexed
 Insertion: NEX (Tip of the nose – Earlobe – Xyphoid Process) Poliacuria – frequent, scanty urine
 pH gastric content: 4 – 6 Urgency – urge but unproductive of urinate
 Confirmation: By X-ray Retention – stimulate urination, running water, warm water over
perineum, warm compress, and straight catheterization
Gavage
 Position: sitting Catheterization
 Gastric aspirate: >1000mL – withhold feeding; put back the Indication:
residue  Decompression
 If with medication and is not gastric irritant: 20-30cc  Instillation
flushing > meds > feeding > 20-30cc flushing  Irrigation
 Specimen collection
Lavage  Urine measurement: Residual urine; Hourly urine output
 To irrigate the stomach in case of gastric bleeding, food  Promotion of healing of GUT
poisoning or ingestion; if corrosive substance: do not Catheter size
irrigate  Children: Fr 8-10
 Position: sitting  Female adult: Fr 14-16; Fr 12 for young girls
 Gastric aspirate: discard  Male adult: Fr 16-18
 Amount of irrigating solution: 750mL – 1L Position
 Female: dorsal recumbent
Unexpected Situations and Associated Interventions  Male: supine with thighs slightly abducted
o Tube found not to be in the stomach or intestine  Replace Length of insertion
the tube  Female: 2-3 inches (5 – 7.5 cm)
o Patient complains of nausea after tube feeding  Ensure  Male: 7-9 inches (17 – 22.5 cm)
that the head of the bed remains elevated and that Anchor
suction equipment is at bedside; Check medication record  Female: inner thigh
to see if any antiemetics is ordered.  Male: Top of thigh or lower abdomen
o When attempting to aspirate contents, the nurse notes that Unexpected Situations and Associated Interventions
tube is clogged  Try using warm water and gentle

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
o No urine flow is obtained and you note that catheter is in Stimulant / Irritant – Irritates / stimulates (Dulcolax, Senokot, Castor
vaginal office  Leave catheter in place as a marker; Oil)
Obtain new sterile gloves and catheter set; Once new Lubricant – Lubricates (Mineral Oil)
catheter is correctly in place, remove the catheter in Saline / Osmotic – Draws water into intestine (Epsom salts, Milk of
vaginal orifice. Magnesia)
o Patient complains of extreme pain when you are inflating Enema
the balloon  Stop inflation of balloon; Withdraw solution Types
from the balloon. Cleansing Enema
 Prior to diagnostic test, surgery
Bladder Irrigation  In cases of constipation and impaction
Open system (intermittent)  Either be: High enema (12-18 in.) or Low enema (12 in.)
– For installation of medications or irrigation of catheter Carminative Enema
Closed system (Intermittent or Continuous)  To expel flatus
– For those who had genitourinary surgery  60 – 80 mL of fluid
– For instillation of medications, promoting homeostasis, Retention Enema
flushing of  Solution retained for 1-3 hours
clots or debris  Oil enema, antibiotic enema, anti-helminthic enema,
nutritive enema
**NEVER INFLATE THE BALLOON UNLESS URINE FLOWS Return-flow Enema
**If inserted in vagina, keep in place but insert another one  To expel flatus
 Alternating flow of 100-200 mL of fluid in and out of the
Catheter can be placed in one month as long as no signs of rectum
infection
Condom Catheter – must be secured through a belt Enema Administration
Fides’ Maneuver – application of pressure in the bladder to stimulate Appropriate Size
urine  Adult: Fr 22-30
 Child: Fr 12-18
Correct Volume
BOWEL ELIMINATION  Adult: 750 – 1,000 mL
 Adolescent: 500 – 750 mL
Assessment  School-aged: 300 – 500 mL
 Inspection – Auscultation – Percussion – Palpation  Toddler: 250 – 350 mL
approach  Infant: 150 – 250 mL
 Bowel sound (4 quadrants) Length of Insertion
o Active – every 5-20 seconds  Adult: 3-4 inches
o Hypoactive – 1 per minute  Child: 2-3 inches
o Hyperactive – every 3 seconds  Infant: 1 – 1 ½ inches
o Absent – None heard in 3-5 minutes
 Fecalysis – an inch of formed stool, 15-30 mL of liquid stool Commonly Used Enema Solutions
 Fecal occult blood testing / Guiac test Hypertonic – Draws water into colon (Sodium phosphate solution)
Hypotonic – Distends colon, stimulates, softens (Tap water)
Fecal Elimination Problems Isotonic – Distends colon, stimulates, softens (Normal saline)
Diarrhea – watery stools; ORESOL; banana rice apple Soap suds – Irritates mucosa, distends colon (3-5 mL soap to 1L of
Constipation – hard stools; laxative; Psilium (bulk-formers), Castor oil water)
(GI irritant) Oil – Lubricates feces (Mineral, olive, cottonseed)
Tenesmus – urge to but unproductive of stool

Fecal impaction Unexpected Situations and Associated Interventions

- constipation and seepage of watery stools
- No enema
- Digital/Manual extraction with doctor’s order
- Monitor for vagal stimulation; stop if signs are noted
Eructation/ Belching
- Expulsion of gases through mouth
Flatulence/Typanism
- Avoid gas forming foods: cauliflower, cola
- Carminative enema – expel flatus
- Rectal tube insertion – inserted in anus then placed in
water for 20 mins; if need to be repeated wait for 2-3 mins.
to prevent anal sphincter damage
Types of Laxatives
Bulk forming – Increases fluid, gaseous or solid bulk (Metamucil,
Citrucel)
Emolient / Stool Softener – Softens and delays drying of feces
(Colace)
o Solution does not flow into the rectum  Reposition
rectal tube, if solution will still not flow, remove tube
and check for any fecal contents.
o Patient cannot retain enema solution for adequate
amount of time  Patient needs to be placed on
bedpan in the supine position
o Patient cannot tolerate large amounts of enema
solution  Amount and length of administration may
have to be modified if the patient begins to complain
of pain
o Patient complains of severe cramping with
introduction of enema solution  Lower solution
container and check temperature and flow rate; If
the solution is too cold, or too fast, severe cramping
may occur.
Colostomy
 Size of stoma will be stabilized within 6-8 weeks
 Effluent; Foul-smelling and irritating to the skin = ileostomy
Guidelines for Ostomy Care

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
 Keep patients as free of odors as possible. Empty ostomy  Decrease inflammation
appliance frequently.  Local anesthetic effect
 Inspect stoma frequently
 Normal color of stoma, pinkish-red, moist. Pale or bluish Inflammation – first 24 hours = cold; then heat
indicates cyanosis or decreased circulation in the tissue Pain – cold; to block nerve
 Note the side of the stoma
 Keep skin around the peristomal area clean and dry Dry heat
 Intake and output - Hot water bags temperature: 110-125 degrees F
- Disposable hot packs
Unexpected Situations and Associated Interventions - Floor lamp / gooseneck lamp / heat cradle
o Peristomal skin is excoriated or irritated  Make sure o Bulb = 25 watts
appliance is not cut too large; Assess for presence of o Distance = 12-24 inches
fungal skin infection; Thoroughly cleanse skin and Dry cold application
apply skin barrier; Allow to dry completely; Reapply - Ice cap
pouch - Compress
o Patient continues to notice odor  Check system for - After 15 mins
any leaks or poor adhesion; Thoroughly empty pouch
Tepid Sponge Bath
MEDICATIONS - Do anterior first
Parenteral - Use 1 washcloths
Intradermal
- Gauge 25 -25 Sitz Bath
- Insert only the bevel; zero to 15 degree angle - immersion of 110-115 degrees Fahrenheit
- Epidermal - do not remove rectal pack, remove rectal dressing
- Sensitivity test - may have cerebral hypoxia – put ice cap on forehead
Subcutaneous
- Stretch if fat, pinch if thin
- Adipose layer of the buttocks, arms WOUND MANAGEMENT
- Best site is abdomen, below the umbilicus! No gauze cause it can stick to skin
- Gauge 23-25, 5/8 inch inserted Center to outer when cleaning
- If long needle, insert 5/8; if short 90 degree
Intramuscular Jackson Pratt
- Must be strictly 90 percent - keep in negative pressure; remove drainage
- 1-1.5 inch - in head injury, can have JP but not on negative pressure
- Gauge 22-23 since it can interfere with ICP

Z-track technique
- Deep IM HYGIENIC MEASURES
- Prevent leakage of solution to tissue
Perineal care
**NO INSERTION IN GLUTEUS MAXIMUS, BUT ON MINIMUS AND MEDIUS - Female: Dorsal recumbent; front to back
- Male: Supine; circular
Intravenous - one stroke, one direction
IV Push – check backflow, if none do not insert Oral Care
- Brushing – sulcular technique
IV infusion pump – for more accurate drip - Lemon-glycerine swab, mineral oil
Soluset – chamber up to 100cc; microset calibration Oral hygiene for unconscious
- supine, head turned to one side
Opthalmic solution – lower conjunctival site; 1-2 drops at maximum - antiseptic solution
Bed Bath
Rectal Suppository – go beyond the anal sphincter - Water temperature: 43-46C or 110-115F
Inhaler – may use spacer - Arms: Long, firm strokes, distal to proximal
- Breasts: Female – circular; Male – Longitudinal
DO NOT USE INHALER IN STEROIDS TO PREVENT MOUTH SORES!

HEAT AND COLD APPLICATION EXERCISE AND ACTIVITY

 Do not prolong more than 20 mins. because of rebound Active-assitive – one side help the affected side
Isotonic – jogging; change in length
Heat Isometric – mucle tension no change in length
 Vasodilation Isokinetic – weights
 Increase capillary permeability
 Increase cellular metabolism Aerobic – exceed oxygen needs
 Increase inflammation Anerobic – does not exceed oxygen needs
 Sedative effect
Cold Massages
 Vasoconstriction Effleurage – smooth, long gliding stroke
 Decrease capillary permeability Petrissage – large pinch of skin; “kneading”
 Decrease cellular metabolism Tapotement – side of each hand, sharp hacking movement

University of Santo Tomas – College of Nursing / JSV

 Fundamentals of Nursing
PAIN
Immobility - Subjective
- Thrombus formation - May have psychogenic pain as well
- Edema - Acute – less than 6 months
- Constipation - Chronic – more than 6 months
- Urinary stasis – stones- calculi - Intractable – not relieved
- Atrophy
- Disuse syndrome Wong and Baker Scale – 1-10 rating
- Trochanter roll to prevent external rotation of femur Phantom pain – pain from amputated limb

Pressure Ulcer Gate Theory of Pain - Substantia gelatinosa

- Decubitus ulcer/ bed sore
- Prone in bony surfaces Pain threshold
- 1 – non blanchable erythema - May be psychological/ physiological
- 2 – open lesion o Heat and cold
- 3- with fat exposed o Imagery and distraction
- 4 – exposed mucles and bones
DEATH
Dressing Thanantology – study of death
- Transparent barrier
- Gauze not used Stages of Grieving by Kubler Rosss
- To absorb exudates
- Hydrocolloid Post-mortem care
- Must be pronounced dead by physician

SLEEP Rigor Mortis - stiffening

Rest – State of calmness; relaxation without emotional stress or Algor Mortis – change in temperature
freedom from anxiety. Livor Mortis – color change
Sleep – State of consciousness in which the individual’s perception
and reaction to the environment are decreased.

Physiology of Sleep
Reticular Activating System (RAS) – responsible in keeping you
awake and alert
Bulbar Synchronizing Region (BSR) – causes sleep

Types of Sleep

NREM (Non-Rapid Eye Movement/ deep, restful sleep / slow-wave

sleep)
Stage I: very light; drowsy; relaxed, eyes roll from side-to-side; lasting
a few mins.
Stage II: light sleep; body processes slow further (decrease PR/RR),
eyes are still; lasts about 10-20 mins.
Stage III: domination of the PNS; difficult to arouse; not disturbed by
sensory stimuli; snoring; muscles totally relaxed.
Stage IV: delta sleep; deep slow-wave sleep

REM (Rapid Eye Movement)

 Where most dreams take place.
 Brain is highly active, hence, paradoxical sleep

Common Sleep Disorders

Insomnia – warm bath, massage, milk (tryptophan), medication
Parasomnia – periods of waking up while asleep
Somabulism – sleep walking; lock the door
Soliloquy – sleep talk
Notcurnal enuresis (night)/Diurnal enuresis (morning) – Bed wet,
place diaper
Bruxism – anxiety; grinding of teeth
Hypersomnia – excessive sleep; may have hypothyroid, DKA
Narcolepsy – uncontrolled desire to sleep; ampethamine - taken
after breakfast, anorexiant

University of Santo Tomas – College of Nursing / JSV