MODULE 1 : NURSING AS  MAINTAINING BELIEF - sustaining

AN ART AND A SCIENCE faith to get through an event

NURSING AS A PROFESSION

 DEFINITIONS MARIE JAHODA

-Profession: an organization of an
 American Nurses Association (ANA, occupational group based on the application of
2003) special knowledge with corresponding rules
-”Nursing is the protection, promotion and and standards
optimization of health and abilities, prevention
of illness and injury, alleviation of suffering - serves all members of the society
through the diagnosis and treatment of human
response, and advocacy in the care of  Nursing is a profession with the following
individual, families, communities and characteristics:
populations” 1. Education
2. Theory
 Florence Nightingale 3. Service
- “Act of utilizing ENVIRONMENT of the 4. Autonomy
patient to assist him in his recovery” 5. Code of Ethics
6. Caring
 Virginia Henderson
-“The unique function of the nurse is to assist ROLES AND FUNCTIONS OF A
the individual, sick or well, in the performance PROFESSIONAL NURSE
of those activities contributing to health, its
recovery, or to a peaceful death. The client will A. Care Provider
perform these activities unaided if he had the B. Communicator/Helper
necessary strength, will or knowledge. Nurses C. Teacher
help the client gain independence as rapidly D. Counselor
as possible.” E. Client Advocate
F. Change Agent
 Patricia Benner G. Leader
-”Caring creates possibility. It is a word of H. Manager
being connected. It enables nurses to help I. Researcher
clients recover in the face of illness, to give J. Case Manager
meaning to that illness and maintain or K. Collaborator
reestablish connection”

FIVE PROCESSES OF CARING NURSING CARE DELIVERY MODELS

 KNOWING - striving to understand an Total Patient - RN is responsible for

event as it has meaning in the life of the Care all aspects of patient
other care
 BEING - being emotionally present to the - shift-based
other - maintains continuity
 DOING FOR - doing for the other as he or of care
she would do for herself if it were at all - client-focused
possible Functional - involves division of
 ENABLING - facilitate coping mechanisms Nursing tasks
through life transitions (e.g birth, death) - nurses become highly
competent

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 - task-focused King - nursing is a helping
- communication is profession that assists
unclear individuals and groups in
Team Nursing - care is rendered by society to attain, maintain, and
staff of various restore health
educational Madeleine Transcultural Nursing Model
preparations (e.g. NA) Leininger -nursing is a humanistic and
- RN as leader scientific mode of helping a
- provides direct care client through specific cultural
to clients caring processes
Primary - responsible for client Myra Levin - Conservation Principles
Nursing care over a period of A. Conservation of energy
time - The human body
- maintains continuity functions by utilizing energy
of care
Case - coordinates and links B. Conservation of Structural
Management health care services Integrity
- case-type-based - body has physical
barriers to prevent occurrence
of diseases
NURSING THEORIES AND
CONCEPTUAL FRAMEWORK C. Conservation of Personal
Integrity
Theorist Theory
- nursing interventions are
Florence -author of Notes on Nursing: highly individualized
NightingalWhat it is, What it is not - e.g: sense of identity,
e - Environmental theory self worth and self esteem
-believed that in the nurturing
environment, the body could D. Conservation of Social
repair itself. Client’s integrity
environment is manipulated to - involvement of family and
include appropriate noise, community of the client
nutrition, hygiene, socialization
Betty Health Care system Model
and hope.
Neuman - Stress reduction is a goal
Virginia - 14 Basic Needs
of system model of nursing
Henderson - assisting the patient whether practice
sick or well to regain
Dorothea Theory of Self-Care and Self-
INDEPENDENCE as soon as
Orem Care Deficit
possible
Faye Glen - nursing as having a problem- 3 systems:
Abdellah solving approach, with key Wholly Compensatory
nursing problems related to - nurse does nearly all
health needs of people self-care activities for the
- Introduced Patient – client
Centered Approaches to
Nursing Model Partially Compensatory
- Typology of 21 Nursing - patient requires assistance
Problems from the nurse when doing
Dorothy Behavioral System Model self-care activities
Johnson
Imogene Goal Attainment Theory Supportive-Educative

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 - requires assistance Cure : collaborative
decision making, behavior interventions to improve the
control and acquisition condition of the patient
knowledge and skills. Ida Jean Dynamic Nurse-Patient
Orlando Relationship Model
Hildegard Interpersonal Model - nurse helps patients meet a
Peplau - Defined nursing as a perceived need that the
therapeutic, interpersonal patient cannot meet for
process which strives to themselves
develop a nurse- patient Ernestine Clinical Nursing - A Helping Art
relationship in which the nurse Weidenba Model
serves as a resource person, ch - assisting the patient in
counselor and surrogate. identifying and addressing
need as well as validating
FOUR PHASES: whether the interventions
1. Orientation were helpful.
- the nurse and the client Jean Human caring Model
initially do not know each Watson
other’s goals and testing the Rosemarie Human Becoming Theory
role each will assume. Rizzo - emphasized free choice of
- identifies needs Parse personal meaning in relating
value priorities, co – creating
2. Identification the rhythmical patterns, in
- Both the client and the exchange with the
nurse plan together an environment, and co
appropriate program to foster transcending in many
health; dimensions as possibilities
unfold.
3. Exploitation Joyce Interpersonal aspects of
- utilization of available Travelbee Nursing Model
resources to regain or - goal of nursing individual or
maintain OLOF; family in preventing or coping
with illness, regaining health
4. Resolution finding meaning in illness, or
- termination phase maintaining maximal degree of
-goal of care is met and moves health.
on to another plan
Martha Science of Unitary Human Josephine Humanistic Nursing Practice
Rogers Beings Peterson Theory
-Nursing is connected to and - Nursing as a lived dialogue
research Loretta that involves the coming
Sister Adaptation Model Zderad together of the nurse and the
Callista - viewed each person as a person to be nursed.
Roy unified biopsychosocial system - Nurturance : essential
in constant interaction with a characteristic of nursing
changing environment Dorothy - Focuses on how the client
Lydia Hall Model on Nursing: CARE, Johnson adapts to illness;
CORE, CURE - GOAL of care: Reduce stress
Care : nurturance and is - Behavioral system model
exclusive to nursing.
Core : therapeutic use of self *7 subsystems:

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 1. Ingestive -Theory of Moral Development
2. Eliminative Pre-conventional stage (Toddlers - 10 yrs)
3. Affiliative - punishment and MOTIVATION
4. Aggressive reward
5. Dependence
6. Achievement Conventional stage: (10-13 yrs)
7. Sexual role identity behavior - Good boy, Nice girl orientation to gain
conformity of parents
MORAL THEORIES - obeys rules and regulations

SIGMUND FREUD Post Conventional (adolescence)

-Concept of right or wrong is influenced by - highest level
id, ego and superego - develops sense of moral values and
-Psychoanalytical Theory conscience

JEAN PIAGET’S COGNITIVE THEORY OF

DEVELOPMENT

Sensorimotor (0-2 yrs)

- repetition of actions
- object permanence (8 mos)
- Imitation

Preoperational Stage (2-7 yrs)

- Animism : inanimate objects are alive
ERIC ERIKSON - Realism: cannot accept realities of life
-Psychosocial Theory - Egocentrism: self-centered
- development of virtues - Artificialism: natural phenomenons are
Age Group Psychosocial Virtue created by humans
Task
Infancy (0-12 Trust vs. Hope Concrete Operational (7-11 yrs)
months) Mistrust - Class Inclusion
Toddler Autonomy vs. Will - decentering
(1-3 yrs) Shame and - Conservation Theory (7 yrs old): more
Doubt logical reasoning
Pre-schooler Initiative vs. guilt Purpose
(3-5 years) Formal Operational
School Age Industry vs. Competency - abstract thinking
(6-12 yrs) Inferiority
Adolescence Identity vs. Role Fidelity
(13-21 yrs) Confusion EVOLUTION OF NURSING
Early Adulthood Intimacy vs. Love
(21-39 yrs) Isolation  Period of Intuitive Nursing (Prehistoric
Middle Generativity vs. Care to Early Christian Era)
Adulthood Stagnation - nursing was untaught and instinctive
(40-65 yrs) - performed out of compassion for others
Late Adulthood Ego Integrity vs. Wisdom and desire to help others
(65 and above) Ego Despair - nursing was a function of women
-believed in shaman and witch doctors

Contributions to Medicine and Nursing

KOHLBERG  Babylonia

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 -Code of Hammurabi
 Egypt
-embalming
 Israel
-Moses as Father of sanitation
- circumcision
- nurses were referred to as midwives
 Period of Apprentice Nursing
-founding of religious nursing orders
-period of on-the-job training
HISTORY OF NURSING IN
PHILIPPINES
Early Beliefs and Practices
- disease is caused by another a.) person or
b.) evil
-spirits can be driven away by persons with
powers
-people believed in gods, priest-physicians
(word doctors) and herb doctors (herbolarios)
Early Care of the Sick
- subscribed to superstitions
- believed in herbmen (herbicheros)
- diseases
THE EARLIEST HOSPITALS ESTABLISHED
IN THE PHILIPPINES
A. Hospital Real de Manila (1577)
- established mainly to care for the
Spanish King’s soldiers, but also admitted
Spanish civilians. Founded by Gov. Francisco de
Sande
B. San Lazaro Hospital (1578)
- built exclusively for patients with
leprosy. Founded by Brother Juan Clemente
C. Hospital de Indio (1586)
- Established by the Franciscan Order;
Service was in general supported by alms and
contribution from charitable persons
D. Hospital de Aguas Santas (1590)
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- Established in Laguna, near a
medicinal spring, Founded by Brother J.
Bautista of the Franciscan Order.
E. San Juan de Dios Hospital (1596)
- Founded by the Brotherhood de
Misericordia and support was derived from
alms and rents. Rendered general health
service to the public.
Nursing During the Philippine Revolution
The prominent persons involved in the
THE nursing works were:
a. Josephine Bracken – wife of Jose
Rizal. Installed a field hospital in an
estate house in Tejeros. Provided
nursing care to the wounded night
and day.
b. Rosa Sevilla De Alvero –
converted their house into quarters
for the filipino soldier,during the
Philippine-American war that broke
out in 1899.
c. Dona Hilaria de Aguinaldo –
Wife of Emilio Aguinaldo; Organized
the Filipino Red Cross under the
inspiration of Apolinario Mabini.
d. Dona Maria de Aguinaldo-
second wife of Emilio Aguinaldo.
Provided nursing care for the
Filipino soldier during the
revolution. President of the Filipino
Red Cross branch in Batangas.
e. Melchora Aquino (Tandang
Sora) – Nurse the wounded
Filipino soldiers and gave them
shelter and food.
f. Captain Salome – A revolutionary
leader in Nueva Ecija; provided
nursing care to the wounded when
not in combat.
g. Agueda Kahabagan –
Revolutionary leader in Laguna,
also provided nursing services to
her troop.
h. Trinidad Tecson – “Ina ng Biac na
Bato”, stayed in the hospital at Biac
na Bato to care for the wounded
soldier.
Hospitals and Nursing Schools
5
1. Iloilo Mission Hospital School of
Nursing (Iloilo City, 1906)
 It was ran by the Baptist Foreign
Mission Society of America.
 Miss Rose Nicolet, a graduate
of New England Hospital for
woman and children in Boston,
Massachusetts, was the first
superintendent.
 Miss Flora Ernst, an American
nurse, took charge of the school
in 1942.
2. St. Paul’s Hospital School of Nursing
(Manila, 1907)
 The hospital was established by
the Archbishop of Manila, The
Most Reverend Jeremiah Harty,
under the supervision of the
Sisters of St. Paul de Chartres.
 It was located in Intramuros and
it provided general hospital
services.
3. Philippine general Hospital School of
Nursing (1907)
 In 1907, with the support of the
Governor General Forbes and the
Director of Health and among
others, she opened classes in
nursing under the auspices of
the Bureau of Education.
 Anastacia Giron-Tupas, was
the first Filipino to occupy the
position of chief nurse and
superintendent in the Philippines,
succeded her.
4. St. Luke’s Hospital School of Nursing
(Quezon City, 1907)
 The Hospital is an Episcopalian
Institution. It began as a small
dispensary in 1903. In 1907, the
school opened with three Filipino
girls admitted.
 Mrs. Vitiliana Beltran was the
first Filipino superintendent of
nurses.
5. Mary Johnston Hospital and School of
Nursing (Manila, 1907)
 It started as a small dispensary on Calle
Cervantes (now Avenida)
 It was called Bethany Dispensary and
was founded by the Methodist Mission.
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 Miss Librada Javelera was the first
Filipino director of the school.
6. Philippine Christian mission Institute
School of Nursing.
The United Christian Missionary of
Indianapolis, operated Three schools of
Nursing:
1. Sallie Long Read Memorial Hospital
School of Nursing (Laoag, Ilocos Norte,1903)
2. Mary Chiles Hospital school of Nursing
(Manila, 1911)
3. Frank Dunn Memorial hospital
7. San Juan de Dios hospital School of
Nursing (Manila, 1913)
8. Emmanuel Hospital School of Nursing
(Capiz,1913)
9. Southern Island Hospital School of
Nursing (Cebu, 1918)
 The hospital was established under the
Bureau of Health with Anastacia
Giron-Tupas as the organizer.
The First Colleges of Nursing in the
Philippines
 University of Santo Tomas .College of
Nursing (1946)
 Manila Central University College of
Nursing (1948)
 University of the Philippines College of
Nursing (1948). Ms. Julita Sotejo was
its first Dean
MODULE 2: THE NURSING PROCESS
Nursing Process
- A deliberate, problem-solving approach to
meet the health care & nursing needs of
patients” -Sandra Nettina
 The most efficient way to accomplish
personalized care in a time of exploding
knowledge and rapid social change
 assists in solving or alleviating both
simple and complex nursing problems
Steps in the Nursing Process (ADPIE)
1. Assessment : Collection of personal,
social, medical, and general data
a. Sources: Primary (client and
diagnostic test results) and secondary
(family, colleagues, Kardex, literature
6
 b. Types of Data (Objective and -Time bounded
Subjective) IDENTIFY GOALS
b.1) Objective  GOALS are general statements that
- observable and measurable direct nursing interventions, provide
- overt; signs broad parameters for measuring results
- e.g: vital signs, skin and stimulate motivation.
changes  LONG term goal - one that will take
b.2) Subjective time to achieve
- verbalization  SHORT term goal - can be achieved
- covert relatively quick
- symptoms 4. IMPLEMENTATION
- “I’m nauseated: Actions that you take in the care of your client.
c. Methods - Implementation includes:
 Interview (Pre-interaction, Orientation,  Assisting in the performance in ADLs
Working and Termination)  Counseling and educating the patient
 Observation and family
 Review of records  Giving care to patients
 Performing a physical assessment  Supervising and evaluating the work of
other members of the health team
2. Nursing Diagnosis : Definition of client's  Can be: dependent: with doctor’s order
problem: making a nursing diagnosis Independent: without DO
 “A nursing diagnosis is a definitive Collaborative: referrals with
statement of the client's actual or other members of the health care team
potential difficulties, concerns, or
deficits that are amenable to nursing 5. EVALUATION
interventions .  Final step of the nursing process
 This step is to organize, analyze and  Measures the patient’s response to
summarize the collected data. There nursing intervention
are two components to the statement of  it indicates the patient’s progress
a nursing diagnosis joined together by  toward achieving the goals established
the phrase "related to"”  in the care plan.
 PES: problem, etiology, signs/symptoms  It is the comparison of the observed
 PE: Problem, Etiology results to expected outcomes

Types of Diagnosis  COMMUNICATION IN NURSING

 Actual: “problem-based” diagnosis
- verified by presence of signs and
symptoms
 Risk : problem does not exist yet but may
occur if interventions aren’t made
 Wellness : patient is able to move towards
a higher level of wellness
3. Planning: the nursing care plan, a
blueprint for nursing action; client-centered
 The nursing care plan is formulated.
 Elements: SMART
-Specific
-Measurable
-Attainable
-Realistic
COMMUNICATION
 Refers to reciprocal exchange of
information, ideas, beliefs, feelings and
attitudes between 2 persons or among
a group.
 The need to communicate is universal.
People communicate to satisfy needs.
 Clear and accurate communication
among members of the health team,
including the client, is vital to support
the client's welfare”
 Is the means to establish a helping-
healing relationships

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  Communication is essential to the nurse-
patient relationship for the following
reasons:
 Is the vehicle for establishing a
therapeutic relationship
 It the means by which an individual
influences the behavior of another,
which leads to the successful
outcome of nursing intervention.
 Basic Elements of the Communication
Process
1. SENDER – is the person who encodes
and delivers the message
2. MESSAGES – is the content of the
communication. It may contain verbal,
nonverbal, and symbolic language.
3. RECEIVER – is the person who receives
the decodes the message.
4. FEEDBACK – is the message returned by
the receiver. It indicates whether the
meaning of the sender’s message was
understood.
 Modes of Communication
1. Verbal Communication – use of
spoken or written words.
2. Nonverbal Communication – use of
gestures, facial expressions,
posture/gait, body movements, physical
appearance and body language
 Characteristics of Good
Communication
1. Simplicity – includes uses of
commonly understood, brevity, and
completeness.
2. Clarity – involves saying what is meant.
The nurse should also need to speak
slowly and enunciate words well.
3. Timing and Relevance – requires
choice of appropriate time and
consideration of the client’s interest and
concerns. Ask one question at a time
and wait for an answer before making
another comment.
4. Characteristics of Good Communication
5. Adaptability – Involves adjustments
on what the nurse says and how it is
said depending on the moods and
behavior of the client.
6. Credibility – Means worthiness of
belief. To become credible, the nurse
requires adequate knowledge about the
topic being discussed. The nurse
should be able to provide accurate
information, to convey confidence and
certainly in what she says.
 Communicating With Clients Who
Have Special Needs
1.Clients who cannot speak clearly
(aphasia, dysarthria, muteness)
1. Listen attentively, be patient, and do
not interrupt.
2. Ask simple question that require “yes”
and “no” answers.
3. Allow time for understanding and
response.
4. Use visual cues (e.g., words, pictures,
and objects)
5. Allow only one person to speak at a
time.
6. Do not shout or speak too loudly.
7. Use communication aid:
-pad and felt-tipped pen, magic slate,
pictures denoting basic needs, call bells or
alarm.
2. Clients who are cognitively impaired
1. Reduce environmental distractions
while conversing.
2. Get client’s attention prior to speaking
3. Use simple sentences and avoid long
explanation.
4. Ask one question at a time
5. Allow time for client to respond
6. Be an attentive listener
7. Include family and friends in
conversations, especially in subjects
known to client.
3. Client who are unresponsive
1. Call client by name during interactions
2. Communicate both verbally and by
touch
3. Speak to client as though he or she
could hear
4. Explain all procedures and sensations
5. Provide orientation to person, place,
and time
6. Avoid talking about client to others in
his or her presence

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 7. Avoid saying things client should not 2. Nurses may not discuss a client’s
hear examination, observation, conversation,
or treatment with other clients or staff
4. Communicating with hearing impaired not involved in the client’s care.
client
1. Establish a method of communication Only staff directly involved in a
(pen/pencil and paper, sign-language) specific client’s care have legitimate
2. Pay attention to client’s non-verbal cues access to the record.
3. Decrease background noise such as 1. Clients frequently request copies of
television their medical record, and they have
4. Always face the client when speaking the right to read those records.
5. It is also important to check the family 2. Nurses are responsible for
as to how to communicate with the protecting records from all
client unauthorized readers.
6. It may be necessary to contact the 3. When nurses and other health care
appropriate department resource person professionals have a legitimate
for this type of disability reason to use records for data
gathering, research, or continuing
 Documentation education, appropriate
1. Is anything written or printed that is authorization must be obtained
relied on as record or proof for according to agency policy.
authorized person. 4. Maintaining confidentiality is an
2. Nursing documentation must be: important aspect of profession
3. accurate behavior.
4. comprehensive 5. It is essential that the nurse safe-
5. flexible enough to retrieve critical data, guard the client’ right to privacy by
maintain continuity of care, track client carefully protecting information of a
outcomes, and reflects current sensitive, private nature.
standards of nursing practice 6. Sharing personal information or
6. Effective documentation ensures gossiping about others violates
continuity of care saves time and nursing ethical codes and practice
minimizes the risk of error. standards.
7. As members of the health care team, 7. It sends the message that the
nurses need to communicate nurse cannot be trusted and
information about clients accurately and damages the interpersonal
in timely manner relationships.
8. If the care plan is not communicated to
all members of the health care team,  Guidelines of Quality Documentation
care can become fragmented, repetition and Reporting
of tasks occurs, and therapies may be
delayed or omitted. 1.Factual
9. Data recorded, reported, or  a record must contain descriptive,
c0mmunicated to other health care objective information about what a nurse
professionals are CONFIDENTIAL and sees, hears, feels, and smells.
must be protected.  The use of vague terms, such as appears,
seems, and apparently, is not acceptable
 CONFIDENTIALITY because these words suggests that the
1. Nurses are legally and ethically nurse is stating an opinion.
obligated to keep information about  Example: “the client seems anxious”
clients confidential. (the phrase seems anxious is a
conclusion without supported facts.)

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2. Accurate
 The use of exact measurements
establishes accuracy. (example: “Intake
of 350 ml of water” is more accurate
than “ the client drank an adequate
amount of fluid”
 Documentation of concise data is clear
and easy to understand.
 It is essential to avoid the use of
unnecessary words and irrelevant details
3. Complete
- The information within a recorded entry or
a report needs to be complete, containing
appropriate and essential information.
Example:
 The client verbalizes sharp,
throbbing pain localized along lateral
side of right ankle, beginning
approximately 15 minutes ago after
twisting his foot on the stair. Client
rates pain as 8 on a scale of 0-10.
4. Current
- Timely entries are essential in the client’s
ongoing care. To increase accuracy and
decrease unnecessary duplication, many
healthcare agencies use records kept near
the client’s bedside, which facilitate
immediate documentation of information as
it is collected from a client
5. Organized
- The nurse communicates information in a
logical order.
 For example, an organized note
describes the client’s pain, nurse’s
assessment, nurse’s interventions,
and the client’s response
5. Avoid rushing to complete charting, be
sure information is accurate.
6. Do not leave blank spaces in nurse’s notes.
7. Chart consecutively, line by line; if space is
left, draw line horizontally through it and
sign your name at end.
8. Record all entries legibly and in black ink
 Never use pencil, felt pen.
 Black ink is more legible when
records are photocopied or
transferred to microfilm.
9. If order is questioned, record that
clarification was sought.
 If you perform orders known to be
incorrect, you are just as liable for
prosecution as the physician is.
10. Chart only for yourself
 Never chart for someone else.
 You are accountable for information
you enter into chart.
11. Avoid using generalized, empty phrases
such as “status unchanged” or “had good
day”.
12. Begin each entry with time, and end with
your signature and title.
13. Do not wait until end of shift to record
important changes that occurred several
hours earlier. Be sure to sign each entry.
14. For computer documentation keep your
password to yourself.
 Maintain security and confidentiality.
 Once logged into the computer do not
leave the computer screen unattended.
MODULE 3: CONCEPT OF HEALTH AND
ILLNESS

 Legal Guidelines for recording The Basic Human Needs

 Each individual has unique
1. Draw single line through error, write word characteristics, but certain needs are
error above it and sign your name or initials. common to all people.
Then record note correctly.  A need is something that is desirable,
2. Do not write retaliatory or critical comments useful or necessary.
about the client or care by other health care  Human needs are physiologic and
professionals. psychologic conditions that an
3. Enter only objective descriptions of client’s individual must meet to achieve a state
behavior; client’s comments should be of health or well-being.
quoted.
4. Correct all errors promptly, errors in
recording can lead to errors in treatment

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 4. The need for spiritual fulfillment

Characteristics of Basic Human Needs

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

Concepts of health and Illness

HEALTH
Maslow’s Hierarchy of Basic Human Needs 1. Is the fundamental right of every
human being. It is the state of
Physiologic integration of the body and mind
1. Oxygen 2. Health and illness are highly
2. Fluids individualized perception. Meanings
3. Nutrition and descriptions of health and illness
4. Body temperature vary among people in relation to
5. Elimination geography and to culture.
6. Rest and sleep 3. Health - is the state of complete
7. Sex physical, mental, and social well-being,
and not merely the absence of disease
Safety and Security or infirmity. (WHO)
1. Physical safety 4. Health – is the ability to maintain the
2. Psychological safety internal milieu. Illness is the result of
3. The need for shelter and freedom from failure to maintain the internal
harm and danger environment.(Claude Bernard)
5. Health – is the ability to maintain
Love and belonging homeostasis or dynamic equilibrium.
1. The need to love and be loved Homeostasis is regulated by the
2. The need to care and to be cared for. negative feedback mechanism.(Walter
3. The need for affection: to associate or Cannon)
to belong 6. Health – is being well and using one’s
4. The need to establish fruitful and power to the fullest extent. Health is
meaningful relationships with people, maintained through prevention of
institution, or organization diseases via environmental health
factors.(Florence Nightingale)
Self-Esteem Needs 7. Health – is viewed in terms of the
1. Self-worth individual’s ability to perform 14
2. Self-identity components of nursing care unaided.
3. Self-respect (Henderson)
4. Body image 8. Positive Health – symbolizes
wellness. It is value term defined by
the culture or individual. (Rogers)
Self-Actualization Needs 9. Health – is a state of a process of
1. The need to learn, create and being becoming an integrated and
understand or comprehend whole as a person.(Roy)
2. The need for harmonious relationships 10. Health – is a state the characterized
3. The need for beauty or aesthetics by soundness or wholeness of

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 developed human structures and of Stages of Illness
bodily and mental functioning.(Orem) 1. Symptoms Experience- experience
11. Health- is a dynamic state in the life some symptoms, person believes
cycle; illness is interference in the life something is wrong
cycle. (King) 3 aspects –physical, cognitive,
12. Wellness – is the condition in which all emotional
parts and subparts of an individual are 2. Assumption of Sick Role – acceptance
in harmony with the whole system. of illness, seeks advice
(Neuman) 3. Medical Care Contact
13. Health – is an elusive, dynamic state Seeks advice to professionals for
influenced by biologic, psychologic, and validation of real illness, explanation of
social factors. Health is reflected by the symptoms, reassurance or predict of
organization, interaction, outcome
interdependence and integration of the 4. Dependent Patient Role
subsystems of the behavioral  The person becomes a client
system.(Johnson) dependent on the health professional
for help.
Illness and Disease  Accepts/rejects health professional’s
suggestions.
Illness  Becomes more passive and accepting.
 Is a personal state in which the person 5. Recovery/Rehabilitation
feels unhealthy. Gives up the sick role and returns to
 Illness is a state in which a person’s former roles and functions.
physical, emotional, intellectual, social,
developmental, or spiritual functioning is Risk Factors of a Disease
diminished or impaired compared with
previous experience. 1. Genetic and Physiological Factors
 Illness is not synonymous with disease.  For example, a person with a family
history of diabetes mellitus is at risk in
Disease developing the disease later in life.
 An alteration in body function resulting 2. Age
in reduction of capacities or a  Age increases and decreases
shortening of the normal life span. susceptibility ( risk of heart diseases
increases with age for both sexes
Common Causes of Disease 3. Environment
1. Biologic agent – e.g. microorganism  The physical environment in which a
2. Inherited genetic defects – e.g. cleft person works or lives can increase the
palate likelihood that certain illnesses will
3. Developmental defects – e.g. occur.
imperforate anus 4. Lifestyle
4. Physical agents – e.g. radiation, hot and  Lifestyle practices and behaviors can
cold substances, ultraviolet rays also have positive or negative effects
5. Chemical agents – e.g. lead, asbestos, on health.
carbon monoxide
6. Tissue response to irritations/injury – Classification of Diseases
e.g. inflammation, fever 1. According to Etiologic Factors
7. Faulty chemical/metabolic process – e.g. a. Hereditary – due to defect in the
inadequate insulin in diabetes genes of one or other parent which
8. Emotional/physical reaction to stress – is transmitted to the
e.g. fear, anxiety i. offspring

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 b. Congenital – due to a defect in the
development, hereditary factors, or
prenatal infection
c. Metabolic – due to disturbances or
abnormality in the intricate
processes of metabolism.
d. Deficiency – results from
inadequate intake or absorption of
essential dietary factor.
e. Traumatic- due to injury
f. Allergic – due to abnormal
response of the body to chemical
and protein substances or to
physical stimuli.
g. Neoplastic – due to abnormal or
uncontrolled growth of cell.
h. Idiopathic –Cause is unknown;
self-originated; of spontaneous
origin
i. Degenerative –Results from the
degenerative changes that occur in
the tissue and organs.
j. Iatrogenic – result from the
treatment of the disease
2. According to Duration or Onset
a. a. Acute Illness – An acute illness
usually has a short duration and is
severe. Signs and symptoms appear
abruptly, intense and often subside
after a relatively short period.
b. Chronic Illness – chronic illness
usually longer than 6 months, and
can also affects functioning in any
dimension. The client may fluctuate
between maximal functioning and
serious relapses and may be life
threatening. Is is characterized by
remission and exacerbation.
 Remission- periods during
which the disease is controlled
and symptoms are not obvious.
 Exacerbations – The disease
becomes more active given
again at a future time, with
recurrence of pronounced
symptoms.
c. Sub-Acute – Symptoms are
pronounced but more prolonged
than the acute disease.
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3. Disease may also be Described as:
a. Organic – results from changes in
the normal structure, from
recognizable anatomical changes in
an organ or tissue of the body.
b. Functional – no anatomical
changes are observed to account
from the symptoms present, may
result from abnormal response to
stimuli.
c. Occupational – Results from
factors associated with the
occupation engage in by the
patient.
d. Venereal – usually acquired
through sexual relation
e. Familial – occurs in several
individuals of the same family
f. Epidemic – attacks a large number
of individuals in the community at
the same time. (e.g. SARS)
g. Endemic – Presents more or less
continuously or recurs in a
community. (e.g. malaria, goiter)
h. Pandemic –An epidemic which is
extremely widespread involving an
entire country or continent.
i. Sporadic – a disease in which only
occasional cases occur. (e.g.
dengue, leptospirosis)
Leavell and Clark’s Three Levels of
Prevention
a. Primary Prevention – seeks to
prevent a disease or condition at
a prepathologic state; to stop
something from ever happening.
 Health Promotion
-health education
-marriage counseling
-genetic screening
-good standard of nutrition
adjusted to developmental
phase of life
 Specific Protection
-use of specific immunization
-attention to personal hygiene
-use of environmental sanitation
-protection against occupational
hazards
-protection from accidents
13
 -use of specific nutrients The balance between the heat
-protections from carcinogens produced by the body and the heat loss
-avoidance to allergens from the body.
b. Secondary Prevention – also Types of Body Temperature
known as “Health Maintenance”. Seeks Core temperature –temperature of
to identify specific illnesses or conditions the deep tissues of the body.
at an early stage with prompt Surface body temperature
intervention to prevent or limit disability; Alteration in body Temperature
to prevent catastrophic effects that Pyrexia – Body temperature above
could occur if proper attention and normal range ( hyperthermia)
treatment are not 1. Hyperpyrexia – Very high fever,
provided. 41ºC(105.8 F) and above
 Early Diagnosis and Prompt 2. Hypothermia – Subnormal temperature.
Treatment
-case finding measures Factors affecting Heat production
-individual and mass screening 1. Basal metabolism
survey 2. Muscular activity
-prevent spread of 3. Thyroxine and Epinephine
communicable disease 4. Temperature effect on cell
-prevent complication and
sequelae Normal Adult Temperature Ranges
-shorten period of disability Oral 36.5 –37.5 ºC
 Disability Limitations Axillary 35.8 – 37.0 ºC
- adequate treatment to arrest Rectal 37.0 – 38.1 ºC
disease process and prevent Tympanic 36.8 – 37.9ºC
further
complication and sequelae. Methods of Temperature-Taking
-provision of facilities to limit Oral – most accessible and convenient
disability and prevent death. method.
c. Tertiary Prevention – occurs after 1. Put on gloves, and position the tip of
a disease or disability has occurred and the the thermometer under the patients
recovery process has begun; Intent is to tongue on either of the frenulum as
halt the disease or injury process and assist far back as possible. It promotes
the person in obtaining an optimal health contact to the superficial blood vessels
status. To establish a high-level wellness. and ensures a more accurate reading.
“To maximize use of remaining capacities’ 2. Wash thermometer before use.
 Restoration and 3. Take oral temp 2-3 minutes.
Rehabilitation 4. Allow 15 min to elapse between client’s
-work therapy in hospital food intakes of hot or cold food,
- Use of shelter colony smoking.
5. Instruct the patient to close his lips but
Vital Signs not to bite down with his teeth to avoid
Vital Signs or Cardinal Signs are: breaking the thermometer in his
Body temperature mouth.
Pulse
Respiration Contraindications
Blood pressure Young children an infants
Pain Patients who are unconscious or disoriented
Level of consciousness Who must breath through the mouth
Seizure prone
I. Body Temperature Patient with N/V

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Patients with oral lesions/surgeries
Nursing Interventions in Clients with
2. Rectal- most accurate measurement of Fever
temperature a. Monitor V.S
a. Position- lateral position with his top legs b. Assess skin color and temperature
flexed and drapes him to provide privacy. c. Monitor WBC, Hct and other pertinent lab
b. Squeeze the lubricant onto a facial tissue to records
avoid contaminating the lubricant supply. d. Provide adequate foods and fluids.
c. Insert thermometer by 0.5 – 1.5 inches e. Promote rest
d. Hold in place in 2minutes f. Monitor I & O
e. Do not force to insert the thermometer g. Provide TSB
h. Provide dry clothing and linens
Contraindications i. Give antipyretic as ordered by MD
Patient with diarrhea
Recent rectal or prostatic surgery or injury II. Pulse – It’s the wave of blood created by
because it may injure inflamed tissue contractions of the left ventricles of the
Recent myocardial infarction heart.
Patient post head injury
Normal Pulse rate
3. Axillary – safest and non-invasive 1 year 80-140 beats/min
a. Pat the axilla dry 2 years 80- 130 beats/min
b. Ask the patient to reach across his chest 6 years 75- 120 beats/min
and grasp his opposite shoulder. This 10 years 60-90 beats/min
promote skin contact with the thermometer Adult 60-100 beats/min
c. Hold it in place for 9 minutes because the Tachycardia – pulse rate of above 100
thermometer isn’t close in a body cavity beats/min
Bradycardia- pulse rate below 60 beats/min
4. Tympanic thermometer Irregular – uneven time interval between
a. Make sure the lens under the probe is beats.
clean and shiny What you need:
b. Stabilized the patient’s head; gently pull the a. Watch with second hand
ear straight back (for children up to age 1) b. Stethoscope (for apical pulse)
or up and back (for children 1 and older to c. Doppler ultrasound blood flow detector
adults) if necessary
c. Insert the thermometer until the entire ear Radial Pulse
canal is sealed  Wash your hand and tell your client
d. Place the activation button, and hold it in that you are going to take his pulse
place for 1 second  Place the client in sitting or supine
position
5. Chemical-dot thermometer  with his arm on his side or across his
a. Leave the chemical-dot thermometer in chest
place for 45 seconds  Gently press your index, middle, and
b. Read the temperature as the last dye dot ring fingers on the radial artery, inside
that has change color, or fired. the patient’s wrist.
c. Store chemical-dot thermometer in a cool  Excessive pressure may obstruct blood
area because exposure to heat activates the flow distal to the pulse site
dye dots.  Counting for a full minute provides a
Note: more accurate picture of irregularitie
Use the same thermometer for repeat Apical Pulse
temperature taking to ensure more consistent  Perform hand hygiene.
result

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  Use alcohol swab to clean the
diaphragm of the stethoscope. Use
another swab to clean the earpieces if
necessary.
 Place patient in sitting or reclining
position and expose the chest area.
Expose only the apical side.
 Palpate the space between then fifth
and sixth ribs and move to the left
midclavicular line.
 Place the diaphragm over the apex of
the heart.
 Count the rate.
 Using a watch with a second hand,
count the heartbeat for 1 minute.
 Cover the patient and help him/her to a
position of comfort.
 Clean the diaphragm of the stethoscope
with alcohol swab for the next use.
Doppler device
a. Apply small amount of transmission gel
to the ultrasound probe
b. Position the probe on the skin directly
over a
c. selected artery
d. Set the volume to the lowest setting
e. To obtain best signals, put gel between
the skin and the probe and tilt the probe
45 degrees from the artery.
f. After you have measure the pulse rate,
clean the probe with soft cloth soaked in
antiseptic. Do not immerse the probe
III. Respiration - is the exchange of oxygen
and carbon dioxide between the atmosphere
and the body
Assessing Respiration
 Rate – Normal 14-20/ min in adult
 The best time to assess respiration is
immediately after taking client’s pulse
 Count respiration for 60 second
 As you count the respiration, assess and
record breath sound as stridor, wheezing, or
stertor.
 Respiratory rates of less than 10 or more
than 40 are usually considered abnormal
and should be reported immediately to the
physician.
Breathing Pattern
Volume
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 Hyperventilation- overexpansion of the
lungs characterized by rapid deep
breaths.
 Hypoventilation- underexpansion of the
lungs characterized by shallow
respirations.
Rate
 Tachypnea quick, shallow breaths
 Bradypnea- slow respiration
 Apnea- cessation of breathing
Rhythm
 Cheyne- stokes breathing- rhythmic
breathing; from very deep to very
shallow breathing and temporary
apnea.
 Biot’s respiration- varying in depth and
rate followed by periods of apnea;
irregular.
Normal Breath sound
1. Bronchial
 Loud and high pitched w/ hollow
quality.
 Expiration lasts longer than inspiration.
 Best heard over the trachea
 Created by air moving through the
trachea close to chest wall.
2. Bronchovesicular
 Blowing sounds that are moderate in
pitch and intensity. Inspiration is equal
to expiration.
 Best heard posteriorly between scapula
& anteriorly over bronchioles lateral to
sternum at first & second intercostal
spaces.
 Created by air moving to large airways.
Abnormal Breath Sounds
1. Stridor
 A loud, high-pitched crowing sound that is
heard, usually w/o a stethoscope, during
inspiration. Stridor caused by an
obstruction in the upper airway requires
immediate attention
2. Rhonchi (also called gurgles)
 Low-pitched, snoring sounds that occur
when the patient exhales, although they
may also be heard when the patient
inhales.
 Usually changes or disappear w/ coughing
16
 Sounds occur as a result of air passing e. Position the arm at the level of the
through fluid-filled, narrow passages, heart, if the artery is below the heart
diseases where there is increased mucus level, you may get a false high reading
production such as: f. Use the bell of the stethoscope since
 Pneumonia the blood pressure is a low frequency
 Bronchitis sound.
 bronchiectasis. g. If the client is crying or anxious, delay
3. Crackles ( Rales ) measuring his blood pressure to avoid
 Soft, high pitched discontinuous popping false-high BP
sounds that occur during inspiration Electronic Vital Sign Monitor
 Can be produced by rubbing a lock of a. An electronic vital signs monitor allows
hair between the thumb and finger close you to continually tract a patient’s vital
to the ear. sign without having to reapply a blood
 Fluid in the airways pressure cuff each time.
 Obstructive disease in early inspiration b. Example: Dinamap VS monitor 8100
 Bronchitis c. Lightweight, battery operated and can
 Pneumonia be attached to an IV pole
 CHF d. Before using the device, check the
4. Wheeze client7s pulse and BP manually using
 deep, low-pitched sounds heard during the same arm you’ll using for the
exhalation monitor cuff.
 due to narrowed tracheobronchial passages e. Compare the result with the initial
from secretions reading from the monitor. If the results
 Continuous, musical, high-pitched, whistle - differ call the supply department or the
like sounds heard during inspiration and manufacturer’s representative.
exhalation
 narrow bronchioles, associated with V. Pain
bronchospasm, asthma and buildup of -Is both a protective and an unpleasant
secretions sensory and emotional experience associated
5. Friction Rub with actual and potential tissue
 Like 2 pieces of rubber rubbed together, damage.(Porth.2nd ed.)
inspiration and exhalation Classification of Pain
 Inflammation and loss of fluid in the pleural Location
space Cutaneous and deep Somatic
 Associated with: Visceral
 Pleurisy Referred
 Pneumonia Assessment
 pleural infarct.  Nature
 Location
IV. Blood Pressure  Severity
Adult – 90- 132 systolic  Radiation of pain
60- 85 diastolic How to assess Pain
Elderly 140-160 systolic a. You must consider both the patient’s
70-90 diastolic description and your observations on
a. Ensure that the client is rested his behavioral responses.
b. Use appropriate size of BP cuff. b. First, ask the client to rank his pain on
c. If the b/p cuff is narrow an loosely a scale of 0-10, with 0 denoting lack of
applied- false high BP pain and 10 denoting the worst pain
d. Position the patient on sitting or supine imaginable.
position Ask:
c. Where is the pain located?

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For exclusive use of Medical Colleges of Northern Philippines
 d. How long does the pain last?
e. How often does it occur?
f. Can you describe the pain?
g. What makes the pain worse
h. Observe the patient’s behave
i. oral response to pain (body language,
moaning, grimacing, withdrawal, crying,
restlessness muscle twitching and
immobility)
j. Also note physiological response, which
may be sympathetic or parasympathetic
Wong’s Pain Scale
Managing Pain
1. Giving medication as per MD’s order
2. Giving emotional support
3. Performing comfort measures
4. Use cognitive therapy
Height and weight
a. Height and weight are routinely measured
when a patient is admitted to a health care
facility.
b. It is essential in calculating drug dosage,
contrast agents, assessing nutritional status
and determining the height-weight ratio.
c. Weight is the best overall indicator of fluid
status, daily monitoring is important for
clients receiving a diuretics or a medication
that causes sodium retention.
d. Weight can be measured with a standing
scale, chair scale and bed scale.
e. Height can be measured with the measuring
bar, standing scale or tape measure if the
client is confine in a supine position.
Pointers:
a. Reassure and steady patient who are at
risk for losing their balance on a scale.
b. Weight the patient at the same time
each day. (Usually before breakfast), in
similar clothing and using the same
scale.
c. If the patient uses crutches, weigh the
client with the crutches or heavy
clothing and subtract their weight from
the total determined patient’ weight.
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 Laboratory and Diagnostic
examination
Urine Specimen
1.Clean-Catch mid-stream urine specimen
for routine urinalysis, culture and sensitivity
test
a. Best time to collect is in the morning,
first voided urine
b. Provide sterile container
c. Do perineal care before collection of
the urine
d. Discard the first flow of urine
e. Label the specimen properly
f. Send the specimen immediately to the
laboratory
g. Document the time of specimen
collection and transport to the lab.
h. Document the appearance, odor, and
usual characteristics of the specimen.
2. 24-hour urine specimen
a. Discard the first voided urine.
b. Collect all specimen thereafter until the
following day
c. Soak the specimen in a container with
ice
d. Add preservative as ordered according
to hospital policy
3. Second-Voided urine – required to assess
glucose level and for the presence of albumen
in the urine.
a. Discard the first urine
b. Give the patient a glass of water to
drink
c. After few minutes, ask the patient to
void
4. Catheterized urine specimen
a. Clamp the catheter for 30 min to 1
hour to allow urine to accumulate in
the bladder and adequate specimen
can be collected.
b. Clamping the drainage tube and
emptying the urine into a container are
contraindicated after a genitourinary
surgery.
Stool Specimen
18

1. Fecalysis – to assess gross appearance of
stool and presence of ova or parasite
a. Secure a sterile specimen container
b. Ask the pt. to defecate into a clean, dry
bed pan or a portable commode.
c. Instruct client not to contaminate the
specimen with urine or toilet
paper( urine inhibits bacterial growth
and paper towel contain bismuth which
interfere with the test result.
2. Stool culture and sensitivity test
To assess specific etiologic agent causing
gastroenteritis and bacterial sensitivity to
various antibiotics.
3. Fecal Occult blood test
are valuable test for detecting occult blood
(hidden) which may be present in colo-rectal
cancer, detecting melena stool
Instructions:
a. Advise client to avoid ingestion of red meat
for 3 days
b. Patient is advise on a high residue diet
c. avoid dark food and bismuth compound
d. If client is on iron therapy, inform the MD
e. Make sure the stool in not contaminated
with urine, soap solution or toilet paper
f. Test sample from several portion of the
stool.
Venipuncture
 Venipuncture involves piercing a vein with a
needle and collecting a blood sample in a
syringe or evacuating tube.
 Typically using the antecubital fossa
 A plebhotomist from the laboratory usually
perform the procedure.
 Strict asepsis to prevent infection.
 If client has clotting disorder or under
anticoagulant therapy, apply pressure on
the site for 5 minutes to prevent hematoma
formation
Pointers
a. Never collect a venous sample from the
arm or a leg that is already being use d
for I.V therapy or blood administration
because it mat affect the result.
b. Never collect venous sample from an
infectious site because it may introduce
pathogens into the vascular system
Fundamentals of Nursing Practice Manual
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c. Never collect blood from an edematous
area, AV shunt, site of previous
hematoma, or vascular injury.
d. Don’t wipe off the povidine-iodine with
alcohol because alcohol cancels the
effect of povidine iodine.
e. If the patient has a clotting disorder or
is receiving anticoagulant therapy,
maintain pressure on the site for at
least 5 min after withdrawing the
needle.
Arterial puncture for ABG test
a. Before arterial puncture, perform
Allen’s test first.
b. If the patient is receiving oxygen, make
sure that the patient’s therapy has
been underway for at least 15 min
before collecting arterial sample
c. Be sure to indicate on the laboratory
request slip the amount and type pf
oxygen therapy the patient is having.
d. If the patient has just received a
nebulizer treatment, wait about 20
minutes before collecting the sample.
Blood specimen
a. No fasting for the following tests:
- CBC, Hgb, Hct, clotting studies, enzyme
studies, serum electrolytes, HbA1C
b. Fasting is required:
- FBS, BUN, Creatinine, serum lipid
(cholesterol, triglyceride), blood uric
acid
Sputum Specimen
1. Gross appearance of the sputum
a. Collect early in the morning
b. Use sterile container
c. Rinse the mount with plain water
before collection of the specimen
d. Instruct the patient to hack-up sputum
e. Send the specimen immediately
2. Sputum culture and sensitivity test
a. Use sterile container
b. Collect specimen before the first dose
of antibiotic
3. Acid-Fast Bacilli
a. To assess presence of active pulmonary
tuberculosis
19
 b. Collect sputum in three consecutive POST-PROCEDURE NURSING CARE
morning  V/S
4. Cytologic sputum exam-   Fowler’s
 -to assess for presence of abnormal or  Check gag reflex
cancer cells.  NPO until gag reflex return
 Collect sputum in three consecutive  Monitor for bloody sputum
morning  Monitor respiration
 Monitor for complications
Diagnostic Test  Notify the MD if complications occur
1. PPD test
 read result 48 – 72 hours after injection. 4. Thoracentesis – aspiration of fluid in the
 For HIV positive clients, induration of 5 mm pleural space.
is considered positive a. Secure consent, take V/S
 Induration of more than 10 for non-HIV b. Position upright leaning on overbed table
client is considered positive c. Avoid cough during insertion to prevent
pleural perforation
d. Turn to unaffected side after the procedure
to prevent leakage of fluid in the thoracic
cavity
e. Check for expectoration of blood. This
indicate trauma and should be reported to
MD immediately.

2. Bronchography
 a radiopaque medium is instilled directly
into the trachea and bronchi through
bronchoscope and the entire bronchi
tree or selected areas may be visualized
through X-ray.
 Secure consent
 Check for allergies to seafood or iodine
or anesthesia
 NPO 6-8 hours before the test 5. LUNG BIOPSY
 NPO until gag reflex return to prevent PRE-PROCEDURE NURSING CARE
aspiration  Secure consent
 Check coagulation
3. BRONCHOSCOPY  Have vit K at bedside
direct visualization of the larynx, trachea and  Maintain sterile technique
bronchi through a flexible fiber-optic  Local anesthetic required
bronchoscope  Pressure during insertion and
 Informed consent aspiration
 NPO 6-12 hrs prior to test  Administer analgesics & sedatives as Rx
 Coagulation studies POST-PROCEDURE NURSING CARE
 Remove dentures or eyeglasses  Pressure dressing to prevent bleeding
 IV Sedatives to relax the client  Monitor for bleeding
 Lidocaine spray to suppress the gag  Monitor for respiratory distress
reflex  Monitor for complications
 Resuscitation equipment available  Prepare for CXR

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6. PULSE OXIMETRY
- NORMAL VALUE: 95%-100%
 A sensor is placed: finger, toe, nose,
earlobe or forehead
 Don’t select an extremity with an
impediment to blood flow
 Lower than 91% - immediate treatment
 Lower than 85% - hypo-oxygenation
 Lower than 70% - life-threatening
situation
7.Holter Monitor
 it is continuous ECG monitoring, over 24
hours period
 The portable monitoring is called
telemetry unit
 Avoid magnets, metal detectors, high-
voltage areas, and electric blankets.
 Stress the importance of logging his
usual activities, emotional upset,
fatigue, chest pain, and ingestion of
medication
8. Echocardiogram –
 ultrasound to assess cardiac structure
and mobility
 Client should remain still, in supine
position slightly turned to the left side,
with HOB elevated 15-20 degrees
 The conductive gel is applied to the to
the left of the sternum, third or fourth
intercostal space
 The test takes about 30-45 minutes
9. Electrocardiography-
a. If the patient’s skin is oily, scaly, or
diaphoretic, rub the electrode with a dry
4x4 gauze to enhance electrode contact.
b. If the area is excessively hairy, clip it
Fundamentals of Nursing Practice Manual
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c. Remove client’s jewelry, coins, belt or
any metal
d. Tell client to remain still during the
procedure
10. Cardiac Catheterization
 Secure consent
 Assess allergy to iodine, shellfish
 V/S, weight for baseline information
 Have client void before the procedure
 Monitor PT, PTT, ECG prior to test
 NPO for 4-6 hours before the test
 Shave the groin or brachial area
 After the procedure: bed rest to
prevent bleeding on the site, do not
flex extremity
 Elevate the affected extremities on
extended position to promote blood
supply back to the heart and prevent
thromboplebitis
 Monitor V/S especially peripheral pulses
 Apply pressure dressing over the
puncture site
 Monitor extremity for color,
temperature, tingling to assess for
impaired circulation.
11. MRI
 secure consent,
 the procedure will last 45-60 minute
 Assess client for claustrophobia
 Remove all metal items
 Client should remain still
 Tell client that he will feel nothing but
may hear noises
 Client with pacemaker, prosthetic
valves, implanted clips, wires are not
eligible for MRI.
 Client with cardiac and respiratory
complication may be excluded
21
  Instruct client on feeling of warmth or
shortness of breath if contrast medium
is used during the procedure
 Tattoo pigments (body arts), eyeliner,
eyebrow or lip liner may contain metals
which create an electrical current that
can cause redness and swelling to a first
degree burn at the site of the tattoo.
12.UGIS – Barium Swallow
 instruct client on low-residue diet 1-3 days
before the procedure
 administer laxative evening before the
procedure
 NPO after midnight
 instruct client to drink a cup of flavored
barium
 x-rays are taken every 30 minutes until
barium advances through the small bowel
 film can be taken as long as 24 hours later
 force fluid after the test to prevent
constipation/barium impaction
13.LGIS – Barium Enema
 instruct client on low-residue diet 1-3 days
before the procedure
 administer laxative evening before the
procedure
 NPO after midnight
 administer suppository in AM
 Enema until clear
 force fluid after the test to prevent
constipation/barium impaction
14. Liver Biopsy
a. Secure consent,
b. NPO 2-4 hrs before the test
c. Monitor PT, Vit K at bedside
d. Place the client in supine at the right
side of the bed
e. Instruct client to inhale and exhale
deeply for several times and then exhale
and hold breath while the MD insert the
needle
f. Right lateral post procedure for 4 hours
to apply pressure and prevent bleeding
g. Bed rest for 24 hours
h. Observe for S/S of peritonitis
Fundamentals of Nursing Practice Manual
For exclusive use of Medical Colleges of Northern Philippines
15. Paracentesis
a. Secure consent
b. check V/S
c. Weigh the client before and after the
procedure
d. Measure abdominal girth before the
procedure
e. Let the patient void before the
procedure to prevent puncture of the
bladder
f. Use gauge 18 trochar or cannula
g. Check for serum protein. Excessive loss
of plasma protein may lead to
hypovolemic shock.
h. Position:
 sitting on a chair with feet
supported with footstool or
 Place in high Fowlers position
i. Strict aseptic technique to prevent
peritonitis
j. Local anesthetic is injected
k. The procedure takes about 45 minutes
l. Monitor urine output for 24 hours as
watch out for hematuria which may
indicate bladder trauma.
16. Lumbar Puncture
a. obtain consent
b. instruct client to empty the bladder and
bowel
c. position the client in lateral recumbent
with back at the edge of the examining
table
d. instruct client to remain still
e. Spinal needle in inserted in the midline
between the spinous process between
the 3rd and 4th lumbar vertebrae
f. Using 18G or 20G in adult, 22G in
children
g. obtain specimen per MDs order
Post procedure
 instruct client to remain still during needle
insertion to prevent trauma on the spinal
cord
 Instruct the client to remain in flat position
for 8 hours to prevent spinal headache
 obtain specimen per MDs order
 Headache is the most common adverse
effects of a lumbar puncture..
22
Mgt. for spinal headache A. Upper Airways
 Bed rest - Nasal cavity
 Place patient in dark and quiet room - Pharynx
 Administer analgesics - Larynx
 Fluids Functions:
 note: -Transport gases to lower airways
If the headache continues, epidural patch - Protects lower airways
maybe required. Blood is withdrawn from the - Warming, filtration and humidification of
client’s vein and injected into the epidural air
space, usually at the LP site. B. Lower Airways
- trachea
17.Queckenstedt’s Test - Bronchi
 Lumbar manometric test - Pleura
 Compressing the jugular vein on each - Lungs
side of the neck during the lumbar Functions:
puncture. - clearance mechanism (coughing)
 The increase in pressure caused by the - immunologic response
compression is noted; then pressure is - exchange of gases
released and pressure reading are made Respiratory Centers: medulla and pons
at a 10-seconds intervals.
 Normally – CSF pressure rises rapidly in MEASURES TO PROMOTE ADEQUATE
response to compression of the jugular RESPIRATORY FUNCTION
vein and returns quickly to normal when
the compression is released. 1. Man requires 21% of oxygen from the
 A slow rise and fall in pressure indicates environment. The higher the altitude, the
a partial block due to a lesion lower the oxygen concentration
compressing the spinal subarachnoid 2. Deep breathing and coughing exercises
pathways. (DBCE) to promote lung expansion and loosen
 If there is no pressure change, a mucous secretions.
complete bloc is indicated. PROCEDURE: inhale deeply through the nose,
 This test is not performed if an hold breath for few seconds and exhale
intracranial lesion is suspected. through mouth slowly. On the third breath,
hold breath and cough to expectorate
INTERVENTIONS TO IMPROVE: secretions
 OXYGENATION 3. Positioning. Semi-Fowler’s or high-fowler’s
 NUTRITION position promotes maximum lung expansion.
 ELIMINATION By gravity, the diaphragm moves down and
 ACTIVITY AND EXERCISE abdominal organs do not compress the
 SLEEP AND COMFORT diaphragm.
 HYGIENE 4. Maintain a patent airway to promote
 SAFETY AND COMFORT adequate gaseous exchange.
Causes of Airway Obstruction:
 OXYGENATION - tongue
- mucous secretions
-Respiratory system replenishes the body’s - edema of the airways
oxygen supply and eliminates waste (CO2) - spasm of airways
- foreign bodies (aspiration)
5. Maintain adequate hydration to maintain
Overview of the Anatomy and Physiology of moisture of the mucous membrane. This is to
Respiratory System liquefy retained secretions. Intake should be
atleast 8 glasses a day.

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For exclusive use of Medical Colleges of Northern Philippines
6. Avoid environmental pollutants such as
alcohol and smoking. These factors inhibit Nursing considerations during CPT:
mucociliary function - the entire procedure should last for 30
7. Perform Chest Physiotherapy minutes only
Procedure: - do gradual change in position to prevent
exhaustion and postural hypotension
PERCUSSION - administer bronchodilator as ordered
- “clapping” before CPT
- forceful striking of the back with cupped - Best done in the morning upon waking
hands to mechanically dislodge tenacious up, before meals and before bedtime
secretions - offer oral hygiene after the procedure
- Contraindicated in patients with:
- increased ICP
- active bleeding
- hemoptysis
- head and neck injury

8. BRONCHIAL HYGIENE MEASURES

STEAM INHALATION
VIBRATION
- vigorous quivering produced by hands - to liquefy secretions
that are placed flat against chest wall or back to - to warm and humidify
loosen secretions inspired air
- to relieve edema of the
airways
- to soothe irritated airways
- to administer medications
- dependent nursing fxn
- Inform client and explain
the procedure
- Position: SF or HF
- Cover eyes with washcloth
- place spout 12-18 inches away from the
POSTURAL DRAINAGE client
- expulsion of secretions from various lung - WOF first degree burns
segments by gravity. - render therapy for 15-20 minutes
- involves positioning based on the location - instruct pt to do DBCE post procedure
of secretions - provide oral hygiene
- each position is maintained for 10-15
mins

9. SUCTIONING

- to clear airways from secretions

Fundamentals of Nursing Practice Manual 24

For exclusive use of Medical Colleges of Northern Philippines
 Procedure: - rapid, shallow respiration
- assess indications for suctioning - dyspnea
(audible secretions during respiration and - light-headedness
adventitious breath sounds upon - flaring of nares
auscultation) - intercostal retractions
- Position: For conscious pts: SF - cyanosis
Unconscious pts: Lateral
- Identify proper pressure on the
suction machine/ identify appropriate
catheter size:

GROUP PORTABL WALL SIZE (Fr)

E
ADULT 10-15 100-120 12-18
mmHg
CHILD 5-10 mmHg 95-110 8-10
INFANT 2-5 mmHg 50-95 5-8

- don sterile gloves to prevent introduction

of microorganisms
- lubricate catheter using a water soluble
lubricant/ sterile water
- apply suction during withdrawal of the
suction catheter to prevent trauma to the
mucous membranes
- apply suction for 5-10 seconds, with 20-
30 second interval in between suctions
- hyperoxygenate pt before and after OXYGEN DELIVERY SYSTEMS
suctioning to prevent hypoxia 1. LOW FLOW DEVICES
- provide oral and nasal hygiene - Nasal cannula (24-45% at 2-6 LPM)
- assess effectiveness of suctioning - Simple Face mask (40-60% @ 5-8 LPm)
- Partial Rebreather (60-90% @ 6-10 LPM)
10. Incentive spirometry to enhance deep -Non rebreather (95-100% @ 6-15 LPm)
inspiration and to prevent atelectasis 2. HIGH FLOW DEVICES
- venturi mask ( for patients with COPD)
- oxygen hood
- Isolette
(see attached document for detailed
discussion)

Nursing considerations:
- assess signs of hypoxemia
- verify DO
- Position: SF or HF
- Regulate O2 flow accurately
-Place a NO SMOKING sign at the bedside
11. Administer supplemental oxygen (oxygen supports combustion)
- indication: HYPOXEMIA - avoid oil, greases, alcohol near the client
Signs of hypoxemia: - avoid materials that generate static electricity
- restlessness such as wool blankets. Use cotton blankets
- increased PR instead

Fundamentals of Nursing Practice Manual 25

For exclusive use of Medical Colleges of Northern Philippines
- humidify oxygen by placing sterile water in APNEUSTIC
the O2 humidifier - prolonged gasping inspiration followed by a
- provide oral hygiene to prevent dryness of very short, usually inefficient expiration
mucous membrane BIOT’S
-assess effectiveness of O2 therapy by checking - shallow breaths interrupted by apnea
VS especially RR
 NUTRITION
ALTERATION IN RESPIRATORY - study of nutrients and the processes by
FUNCTION which they are used by the body

HYPOXIA TERMINOLOGIES:
- insufficient oxygenation of tissues DIGESTION
-process by which food is broken down for
EARLY SIGNS LATE SIGNS the body to use in growth, development,
- tachycardia - Bradycardia healing and prevention of diseases
- Increased RR -Dyspnea ABSORPTION
-Slight increase in SBP - decrease SBP -process by which digested CHO, CHON,
-Cough fats, minerals and vitamins are actively and
-Hemoptysis passively transported into organs and tissues
METABOLISM
Other signs of Acute Other signs of -process by which nutrients are converted
Hypoxia: Acute Hypoxia: to energy to support cellular growth and repair

- N&V - fatigue, lethargy (PLS REVIEW ANATOMY AND PHYSIOLOGY OF

-Oliguria, anuria -polycythemia GIT)
-headache -increased Hgb
-apathy concentration MACRONUTRIENTS: CHO,CHON, FAT
-dizziness - clubbing of finger MICRONUTRIENTS: VITAMINS AND MINERALS
-irritability
-memory loss CALORIE (KILOCALORIE)
- 1 g (CHO) - 4 CAL
Altered Breathing Patterns: - 1 G (CHON) - 4 CAL
Tachypnea - 1 G (FAT) - 9 CAL
Bradynea
Apnea Variable affecting Caloric Needs
1. Age and growth
Volume: 2. Gender (higher BMR in males)
HYPERVENTILATION 3. Climate (cold=higher BMR)
- excessive amount of air in the lungs 4. Sleep (lower BMR)
-results from deep, rapid respirations 5. Activity
HYPOVENTILATION 6. Fever
- decreased rate and depth of respiration 7. Illness
-causes retention of carbon dioxide
Food and Fluid Regulatory Center:
Rhythm HYPOTHALAMUS
CHEYNE-STOKES
-waxing and waning respirations (very deep to (SEE ATTACHED DOCUMENT FOR LIST OF
shallow breathing with episodes of apnea) VITAMINS )
KUSSMAUL’S RESP
-increased rate and depth of respiration

Fundamentals of Nursing Practice Manual 26

For exclusive use of Medical Colleges of Northern Philippines
MINERALS
1. CALCIUM
- necessary for bone and teeth formation
-promotes muscular contraction
- promotes blood coagulation
- activates other enzymes for biological
reactions
- deficiency: rickets, osteomalacia, tetany
- excess: calcium rigor (tonic contraction)
SOURCES: milk and dairy prod, greean and
leafy vegetables, whole grains, nuts, legumes,
carrots, seafood, tofu
2. POTASSIUM
-promotes fluid and electrolyte balance
-major cation in the intracellular fluid
-affects muscular and cardiac activities
Hypokalemia: loss of K; manifested by
apathy, muscular weakness, mental confusion,
abdominal distention, nausea, lack of appetite,
nervous irritability, dysrhythmias
Hyperkalemia: excess K; weakened cardiac
contraction, mental confusion, numbness of
extremities
SOURCES: Banana, Avocado, Oranges,
Strawberries, Cantaloupe, Raisins,
tomatoes, Carrots, Mushroom, Pork, Beef, Fish
3. SODIUM
-maintains fluid balance
-major extracellular cation
-maintain acid-base balance
-allows passage of glucose through the cell wall
-maintains normal muscle excitability
4. IRON
- most abundant trace element
-constituent of hemoglobin and myoglobin
necessary in maintaining adequate oxygenation
in the blood
- contributes to antibody formation, collagen
synthesis
SOURCES: pork liver, organ meats, enriched
rice, kamote leaves, soybeans, sea weeds,
clams, malunggay, ampalaya leaves, peanuts,
pechay, sitaw leaves, eggs
-Iron deficiency leads to anemia
-excess Fe leads to hemosiderosis
Fundamentals of Nursing Practice Manual
For exclusive use of Medical Colleges of Northern Philippines
5. IODINE
-synthesis of thyroxine (thyroid gland)
-Cretinism: congenital disorder due to
decrease Iodine during pregnancy
-Hypothyroidism/Hyperthyroidism
SOURCES: iodized salt, seafood, milk, eggs,
bread
ASSESSMENT OF NUTRITIONAL STATUS
 ANTHROPOMETRIC MEASUREMENTS
-height
-weight (best indicator of nutritional
status)
-Skin folds (Fat folds)
-Arm Muscle circumference
-BMI = wt in kg / (ht in meter)2
-
BMI result:
20-25%- Normal
27.5-30%- mild obesity
30-40%- moderate obesity
Above 40%- severe obesity
 Biochemical data
- Hgb and Hct indices
-Serum Albumin
Raw -Nitrogen Balance
-Creatinine Excretion
 Clinical signs
- hair, skin, tongue, mucous membrane,
abdominal girth
 Dietary History
- 24 hr diet recall; 72 hr diet recall
MEASURES TO STIMULATE APPETITE
1. Serve food in pleasant and attractive
manner
2. Place patient in a comfortable position
(SF/HF to prevent aspiration)
3. Provide good oral hygiene measures
4. Promote comfort
5. Remember that color affects color
6. Engage in pleasant conversation
7. Assist weak patient in feeding
27
NURSING INTERVENTIONS FOR NAUSEA
AND VOMITING 2. FULL LIQUID
1. Position conscious clients in SF or HF - includes all fluids and food that become
position; unconscious patients in lateral position liquid at room temperature; with residue
to prevent aspiration Ex: plain ice cream strained
2. Provide good oral hygiene measures soup
3. Suction the mouth as needed if the client is Sherbet strained vegetable
unable to expel vomitus juices
4. Relieve nausea by offering the client: Milk
- ice chips Pudding/custard
- hot tea with lemon/ lime
- hot ginger ale 3. SOFT DIET
- dry toast or crackers - soft food with reduced fiber content
- cold cola beverage which require less energy for digestion (puree,
5. Replace loss fluid by hydration and IV chopped meat, mashed potato, scrambled egg,
therapy porridge)
6. Observe for potential complications: Related Nursing procedures
a. DEHYDRATION Alternative Feeding Methods
- Thirst (first sign)
- dry mouth and mucous membrane A. NASOGASTRIC TUBE
- warm, flushed, dry skin - commonly used tube: LEVIN TUBE
- fever, tachycardia, low bp Purposes:
- weight loss -to provide feeding (gastric gavage)
- sunken eyeballs -to irrigate stomach (gastric lavage)
- oliguria -For decompression
- dark, concentrated urine -administration of meds
- high urine SG -administer supplemental fluid
- poor skin turgor
- altered LOC Insertion procedure:
- elevated BUN, Crea 1. Inform pt and explain procedure
-elevated Hct 2. Place in HF position to facilitate insertion
b. Acid-base balance 3. Measure length of tube to be inserted
Metabolic Alkalosis: excessive vomiting starting from the tip of the nose to the tip of
Metabolic Acidosis: excessive diarrhea the earlobe, to the xiphoid process)
7. Administer antiemetic as ordered by the 4. Lubricate tip of catheter with water-soluble
physician for vomiting lubricant to reduce friction. Oil based lubricant
Metoclopramide (Plasil) may cause lipid pneumonia
Trimethobenzamide (Tigan) 5. Hyperextend the neck and gently advance
Promethazine (Phenergan) the catheter toward the nasopharynx
Prochlorperazine maleate (Compazine) 6. Tilt the patient’s head forward once the
tube reaches the oropharynx (throat)and ask
SPECIAL DIETS the patient to swallow or sip fluid as tube is
advanced.
1. CLEAR FLUIDS 7. Secure the NGT by taping it to the bridge of
-include only liquids that lack residue the nose after checking the tube’s placement
Ex: water lemonade
Bouillon coffee/tea without
dairy
Clear broth hard candy
Gelatin carbonated beverage
Popsicles

Fundamentals of Nursing Practice Manual 28

For exclusive use of Medical Colleges of Northern Philippines
  Amount: depends on the bulk of the food
intake (150-300 g/day)
 Consistency: soft, formed
 Shape: cylindrical
 Frequency: variable; usual range 1-2 per
day to 1 every 2-3 days

 Alteration on the characteristics of

Stool

Alcoholic Stool
- gray, pale or clay colored stool due to
Administering Tube Feeding (gastric absence of stercobilin caused by biliary
gavage) obstruction
1. Position pt in SF Hematochezia
2. Assess tube placement and patency -passage of stool with bright red blood
- introduce 5-20 ml of air into NGT and due to lower GI bleeding
auscultate at the epigastric area. Gurgling Melena
sound indicates patency -passage of black,tarry stool due to UGIB
-aspirate gastric content Steatorrhea
(yellowish/greenish) -greasy, bulky, foul-smelling stool due to
-immerse tip of the tube in water, no undigested fats like in hepato-biliary
bubbles should be produced obstructions
-measure pH of aspirated fluid (acid)
Note: the most effective method of checking Common Fecal Elimination Problems
the NGT placement is radiograph verification.
3. Assess residual feeding contents. To assess 1. CONSTIPATION
absorption of the last feeding, should be less - passage of small, dry, hard
than 50ml stools
4. Introduce feeding slowly to prevent Nursing interventions:
flatulence, cramping and vomiting -increase OFI (1500-2000 ml/day)
5. Height of tube should be 12 inches above -increase fiber intake to provide bulk
insertion point. of the stool (fresh or cooked fruits and
6. Instill 30-60 ml of water into the NGT after vegetables, whole grain, breads and
feeding to cleanse the lumen of the tube cereals, fruit and vegetable juices)
7. Clamp the NGT to prevent entry of air into - establish regular pattern of
the stomach defecation
8. Maintain Fowler’s position for atleast 30 mins -respond stat to urge to defecate
to prevent aspiration. -minimize stress. SNS activation
9. Document decreases peristalsis
- maintain exercise to promote muscle
BOWEL AND BLADDER ELIMINATION tone and stimulate peristalsis
- assume sitting or semi-squatting
 Defecation position. Allows gravity to assist the
- expulsion of feces from the rectum elimination of feces and easier contraction
of abdominal and pelvic muscles
Characteristics of Stool -administer laxatives as ordered
 Color: yellow or golden brown (due to bile
pigment)
 Odor: aromatic upon defecation

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TYPES OF LAXATIVES
1. CHEMICAL IRRITANTS
-provide chemical stimulation to intestinal
wall thereby increasing peristalsis. Ex. Dulcolax
(Bisacodyl), castor oil, Senokot (Senna)
2. STOOL LUBRICANT
- lubricates feces and facilitates expulsion
(mineral oil)
3. STOOL SOFTENERS
- Na Docussate
4. BULK FORMERS
-increases bulk of stool, increasing
mechanical pressure and distention of the
intestine, thereby increasing peristalsis (ex.
Psyllium)
5. OSMOTIC AGENTS
- attract fluids from the intestinal capillaries
(Lactulose, Magnesium Hydroxide)
2. FECAL IMPACTION
- mass or collection of hardened,
putty-like feces in the folds of the rectum.
- inability to evacuate stool voluntarily
S/sx:
- absence of bowel movement for 3-5 days
- passage of liquid fecal seepage
- hardened fecal mass palpated during DRE
- nonproductive desire to defecate and
rectal pain
- anorexia, body malaise
- subjective feeling of abdominal fullness or
bloating
- apparent abdominal distension
- N&V
MNGT:
- manual extraction or fecal disimpaction as
ordered
- Increase OFI
- Sufficient bulk in the diet
- Adequate activity and exercise
3. DIARRHEA
- frequent evacuation of watery stool
due to increased gastric motility
MNGT:
- replace fluid and electrolyte losses
- provide good perianal care. Diarrheal
stool is oftentimes acidic and can cause
soreness and irritation in the area
- promote rest
Fundamentals of Nursing Practice Manual
For exclusive use of Medical Colleges of Northern Philippines
-eat small amount of bland food
-low fiber diet
-BRAT diet (Banana, Rice Am, Apple,
Toast)
-avoid excessively hot or cold fluid
-increase intake of K-rich food
-administer antidiarrheal drugs as ordered
- Demulcents: mechanically coat the
irritated bowel and act as protectives
- Absorbents: absorbs gas or toxic
substances from the bowel
- Astringents: shrink swollen or
inflamed tissues in the bowel
Note: Do not administer antidiarrheal at the
start of diarrhea as it is the body’s protective
mechanism to get rid of toxins or bacteria
4. FLATULENCE
- presence of excessive gas in the
intestines
Common causes:
- constipation
-codein, barbiturates and other meds
that decrease intestinal motility
-anxiety
-eating gas forming food (cabbage,
onions, rootcrops, legumes)
-rapid food or fluid ingestion
-excessive drinking of carbonated
drinks
-gum chewing, candy sucking,
smoking
-abdominal surgery
MNGT:
-avoid gas forming food
-provide warm liquids to drink to increase
peristalsis
-promote early ambulation among post op
pts
-promote adequate rest and activity
-limit carbonated beverages
-Rectal tube insertion as ordered
- position: left lateral
-insert 3-4 inches of lubricated tube in
rotating motion
-use appropriate size (Fr. 22-30)
-retain rectal tube for 30 minutes
-administer carminative enema as
ordered
30
 -administer cholinergics as ordered
(neostigmine) 3. RETENTION ENEMA
-introduces oil into the rectum
5. FECAL INCONTINENCE and sigmoid colon; oil is retained in
-involuntary elimination of bowel contents the colon for 1-3 hrs
often associated with neurologic, mental or -softens feces and lubricates the
emotional impairments rectum and anal canal to facilitate
-seen in patients with injury to cerebral passage of stool
cortex
(pt is unable to perceive that rectum is 4. RETURN FLOW ENEMA/HARRIS
distended or unable to initiate the motor FLUSH/COLONIC IRRIGATION
response required to inhibit defecation - done also to expel flatus
voluntarily) -300-500 ml of fluid is introduced
-pts with spinal cord injury (sacral region) into and out of the large intestine
-solution container is lowered so
ENEMAS that the fluid backs out through the
rectal tube container
-the inflow-outflow process is
repeated 5-6 times
-replace the sol’n several times as
it becomes thick with feces
-procedure may take 15-20 mins
to be effective

NON RETENTIO
Purposes: RETENTION N
-relieve constipation and fecal SOLUTIONS -Tap water Carminative
impaction USED (500-1000 mls) enema
-relieve flatulence
-administer medication -Soap suds (20 Oil (90-120
-evacuate feces in prepartion for ml of castile of mineral
diagnostic procedure or surgery soap in 500- oil, olive or
1000 ml of cottonseed
TYPES OF ENEMAS water) oil)

1. CLEANSING ENEMA -Normal saline

- stimulates peristalsis by irritating (9ml of NaCl to
the colon and rectum and or by 1000ml of
distending the intestine with the water)
volume of fluid introduced
A. HIGH cleansing enema: cleanse -Hypertonic
as much of the colon as possible; 1000 Solution/Fleet
ml of sol’n is administered in adults enema (90-120
B. LOW cleansing enema: to ml)
cleanse the rectum and sigmoid colon HT OF SOL. 18 inches above 12 inches
only; 500 ml of sol’n is administered in rectum above
adults rectum
TEMP OF 115-125 F 105-110 F
2. CARMINATIVE SOL
- to expel flatus TIME 5-10 mins 1-3 hrs
-60-80 ml of fluid is introduced REQUIRED

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For exclusive use of Medical Colleges of Northern Philippines
 Normal Characteristics of Urine:
Nursing considerations when Color: Amber/straw
administering enema: Odor: Aromatic
Transparency: Clear
-check the doctor’s order pH: slightly acidic (4.6 - 8; average: 6)
-provide privacy Specific gravity: 1.010- 1.025
-promote relaxation to facilitate insertion of
tube ALTERATION IN URINE COMPOSITION
-position the pt (adult: left lateral position; RBC in the urine - hematuria
children: dorsal recumbent) Pus in the urine - pyuria
-identify appropriate catheter size: Bacteria - bacteriuria
Adult: Fr 22-32 (signs of UTI)
Children: Fr. 14-18 Albumin in the urine: Albuminuria
Infant: Fr. 12 Protein in the urine: Proteinuria
-lubricate 5 cm (2in) of the rectal tube Glucose: - Glycosuria
-allow solution to flow through the tube to Ketones: - Ketonuria
expel air before insertion.
-insert 7-10 cm (3-4 inches) of rectal tube in ALTERED URINE PRODUCTION
gentle rotation motion to prevent irritation of Polyuria
anal and rectal tissues - excessive urine production; more that
-introduce solution slowly to prevent sudden 100 ml/hr or 2500 ml/day; diuresis
stimulation of peristalsis
-change the position to distribute solution well Oliguria
in the colon (high enema), if low, remain in - decreased amount of urine; less than 30
LLP. ml/hr or less than 500ml/day
-if abdominal cramps occur, temporaily stop the
flow of solution by clamping the tube Anuria
-after the procedure, press the buttocks to - little to no urine production; 10 ml/hr;
inhibit the urge to defecate urinary suppression
-assist pt to the toilet
-do perianal care ALTERED URINARY FREQUENCY
-document Frequency
-Voiding at frequent intervals
Nocturia
URINARY ELIMINATION -Increased frequency at night
Urgency
Function/s of the urinary tract: -Strong feeling that the person wants to
- maintains homeostasis by maintaining void
body fluid composition and volume Dysuria
-painful or difficult voiding
(PLS REVIEW ANATOMY AND PHYSIOLOGY OF Hesitancy
THE URINARY SYSTEM AND URINE -difficulty initiating voiding
FORMATION AS WELL) Enuresis
-repeated involuntary voiding beyond 4-5
years of age
Micturition Pollakuria
-act of expelling urine from the bladder -Frequent, scanty urination
-urination, voiding Urinary Incontinence
-initiated by parasympathetic nervous  Total Incontinence:
system activation -continuous and unpredictable
loss of urine

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 Stress Incontinence Urinary Catheterization
- leakage of less than 50 ml of
urine as a result of a sudden increase
in intra-abdominal pressure
 Urge Incontinence
- follows a sudden strong desire to
urinate and leads to involuntary
detrusor contraction
 Functional Incontinence Purposes:
- involuntary unpredictable -to relieve bladder distension
passage of urine -to instill medications into the bladder
 Reflex Incontinence -to irrigate the bladder
- Involuntary loss of urine -to measure hourly urine output accurately
occurring at somewhat predictable -to collect urine specimen
intervals when specific bladder volume -to empty bladder in preparation for
is reached diagnostic procedure and surgery
Retention
- accumulation of urine in the bladder with Nursing considerations:
associated inability of the bladder to empty -verify doctor’s order and identify the pt
itself -explain procedure and provide privacy
(240-450 ml triggers micturition) -do perineal care
-use appropriate catheter size:
Clinical Signs of Bladder Retention Male: 16-18
A. Discomfort in the pubic area Female: 12-14
B. Bladder distension (palpation and -position: Male> supine with legs
percussion) abducted
C. Inability to void or frequent voiding of small Female> dorsal recumbent
volumes (25-50 ml) -don sterile gloves
D. A disproportionately small amount of output -locate meatus: Male> tip of glans penis
in relation to fluid intake Female> between clitoris
E. Increasing restlessness and feeling of need and vaginal orifice
to void -cleanse the meatus with antiseptic sol’n
from front to back
NURSING INTERVENTIONS TO INDUCE -lubricate cathete with water-soluble sol’n
VOIDING -insert the catheter and advance until
urine flows through the tubing
-provide privacy -anchor the catheter by inflating the
-provide fluids to drink unless contraindicated balloon with 5-10 ml of sterile water
-assist pt in anatomical position of voiding -anchor the tubing: M>laterally upward
-serve clean, warm and dry bedpan or urinal over the lower abdomen to prevent
-allow the patient to listen to the sound of penoscrotal pressure
running water F>inner aspect of the thigh
-dangle fingers in warm water
-pour warm water over the perineum
-promote relaxation
-provide adequate time for voiding
-perform crede’s maneuver as ordered. Apply
pressure on the suprapubic area
-administer cholinergics as ordered
-LAST RESORT: URINARY CATHETERIZATION

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ACTIVITY, MOBILITY AND EXERCISE
BODY MECHANICS
- efficient, coordinated and safe use of the
body to produce motion and maintain balance
during the activity. It prevents injury to self and
clients
PRINCIPLES OF BODY MECHANICS
1. Balance is maintained and muscle strain is
avoided as long as the line of gravity passes
through the base of support
a) Start body movement with proper
alignment
b) Stand as close as possible to the object
to be moved
c) Avoid stretching, reaching and twisting
2. The wider the base of support and the lower
the center of gravity, the greater the stability.
Before moving objects put your feet apart, flex
the hips, knees and ankles
3. Balance is maintained with minimal effort
when the base of support is enlarged in the
direction in which the movement will occur
Fundamentals of Nursing Practice Manual
For exclusive use of Medical Colleges of Northern Philippines
-when pushing an object, enlarge the base
of support by moving the front foot forward
-when pulling an object, enlarge the base
of support by either moving the rear leg back
if facing the object or moving the front foot
forward if facing away from the object
4. Objects that are close to the center of
gravity are moved with least effort
5. The greater the preparatory isometric
tensing or contraction of muscles before
moving an object, the less energy required to
move it and the less musculoskeletal strain
injury.
6. The synchronized use of as many large
muscle groups as possible during an activity
increases overall strength and prevents muscle
fatigue and injury
7. The closer the line of gravity to the center
of the base of support the greater its stability
-when moving or carrying objects, hold
them as close as possible to the center of
gravity
-pull an object toward self whenever
possible rather than pushing it away
8. The greater the friction against the surface
beneath an object, the greater the force
required to move the object. Provide a firm,
smooth, dry bed foundation when moving the
client
9. Pulling creates less friction than pushing
10. The heavier an object, the greater the
force needed to move an object
-encourage the client to assist as much as
possible by pushing or pulling\
-use own body weight to counteract the
weight of the object
-obtain the assistance of other persons or
use mechanical devices to move objects that
are too heavy
34
11. Moving an object along a level surface Stage IV
requires less energy than moving an object up >Full thickness skin loss involving damage
an inclined surface or lifting it against the force
of gravity
12. Continuous muscle exertion can result in
muscle strain and injury. Alternate rest periods
with periods of muscle use to help prevent
fatigue

PHYSIOLOGIC RESPONSES TO
IMMOBILITY
Decrease in muscle strength
Muscle atrophy
Disuse osteoporosis
Fibrosis and ankylosis to muscle,bone or supporting structures such
Contracture as tendon or joint capsule

PATHOGENESIS OF PRESSURE ULCERS PREVENTING AND TREATING PRESSURE

-also known as Pressure sores, decubitus SORES
ulcers, bedsores or distortion sores >Provide smooth, firm, wrinkle free foundation
-reddened areas, sore or ulcers of the skin on which the client can lie
occurring over bony prominences >use foam, rubber pads, egg crate mattress
-occurs due to interruption of the blood under pressure areas
circulation to the tissue >apply thin layer of cornstarch to the
bedsheet
CAUSES OF PRESSURE SORES >reduce shearing force by elevating the head
1. Pressure of the bed to no more than 30 degrees
- primary cause; perpendicular force >frequent position changes
exerted on the skin by gravity >provide meticulous hygiene
2. Friction >keep skin clean and dry
-parallel force acting on the skin >avoid massaging bony prominences with
3. Shearing Force soap
-combination of friction and pressure
TREATMENT
STAGES OF PRESSURE ULCERS >clean pressure sore daily
>clean and dress pressure sore using surgical
Stage I asepsis
>Non-blanchable erythema of intact skin >if sore is not infected, cover it with occlusive
Stage II dressing
>Partial thickness skin loss involving >if sore is infected, obtain sample for C&S
epidermis and or dermis. The ulcer is superficial >reposition client q 2 hours
and presents clinically as abrasion, blister. >encourage ambulation in post op patients
Stage III >provide ROM exercises
>Full thickness skin loss involving damage
or necrosis of subcutaneous tissue that may
extend down to but not through underlying TYPES OF EXERCISES
fascia. Active ROM
>deep crater Done by the client
Passive ROM
Done for the client by health care
providers

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Active-Resistive ROM PHYSIOLOGY OF PAIN
-Done by the client against a weight or
force Stimuli Nerve Fibers
Active Assistive ROM (nociceptors)
-done by the stronger arm and leg to the
weaker arm and leg
Isotonic
-involves change in muscle strength and
tension(running, walking) A Delta fibers C fibers
Isometric
-involves change in muscle tension only (large, myelinated) (small, unmyelinated)
(kegel’s exercise)
- conduct impulses -conduct impulses
rapidly slowly
COMFORT, REST AND SLEEP
- sharp, pricking pain -dull, aching, burning
PAIN sensation
>sensation of physical or mental hurt or - superficial somatic
suffering that causes distress or agony to the pain -deep, somatic and
one experiencing it visceral pain
Spinal Cord
THEORIES OF PAIN (Substantia Gelatinosa)
1. Pattern Theory
- states that pain is perceived whenever
the stimulus is intense enough
2. Specificity Theory Thalamus
- states that there are specific nerve (Center of Awareness for pain)
receptors for particular stimuli
-nociceptor: noxious stimuli
-thermoreceptors: heat or cold
-mechanoreceptore: pressure Cerebral Cortex
-chemoreceptor: chemicals (Center for interpretation for pain)

3. Gate Control Theory

-there is a gate in the spinal cord called Responses
substantia gelatinosa. When gate is open, pain
is transmitted and is perceived. TYPES OF RESPONSES TO PAIN
4. Affect Theory 1. INVOLUNTARY RESPONSES
- it avers that pain is emotional. The - mediated by the autonomic nervous
intensity of pain perceived depends on the system.
value of the organ affected to the individual -mild to moderate: SNS
5. Parallel Processing Model -severe: PNS
- the physiologic or neurologic deciphering 2. VOLUNTARY RESPONSE
-Behavioral responses: crying, grimacing,
splinting area, tossing in bed
-Emotional responses: depression,
withdrawal, social isolation

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STAGES OF PAIN RESPONSE NURSING INTERVENTIONS TO RELIEVE
 ACTIVATION PAIN
- begins with the perception of pain; body
assumes a fight or flight response 1. Techniques that stimulate the skin
 REBOUND Rationale: enhances secretion of serotonin
-pain is intense but brief. PNS dominates which blocks transmission of pain impulses
 Adaptation  Therapeutic touch
-person adapts to pain may be due to  Contralateral stimulation: stimulating the
endorphins. skin in an area opposite to the painful
area
CLASSIFICATION OF PAIN  Vibration
A. TYPES OF PAIN  Heat and cold application
 CUTANEOUS/SUPERFICIAL  Acupuncture/ Acupressure
-occurs over the body surface or skin  TENS (Transcutaneous Electrical Nerve
segment Stimulation)
 SOMATIC 2. Techniques to distract attention
- may be deep or superficial  Staring
-occurs in the skin, mucles, joints  Slow, rhythmic breathing
 VISCERAL PAIN  Recite, sing
-arises from stimulation of pain receptors in  Listening to music
the abdominal cavity or thorax 3. Techniques to promote relaxation
 REFERRED PAIN  Conventional Methods
- pain is perceived at an area other than -relax muscles
the site of injury -listen to music
 INTRACTABLE -guided imagery
- resistant to cure or relief -meditation, yoga
 PHANTOM  Analgesics
-actual pain felt in a body part that is no  Placebo
longer present
 RADIATING REST AND SLEEP
-felt at the source and extends to
surrounding tissues REST
 PSYCHOGENIC - diminished state of activity, calmness,
- primarily due to emotional factors with no relaxation without emotional stress; freedom
physiologic basis from anxiety
 INTERMITTENT
-pain stops and starts again SLEEP
-state of consciousness in which the
B. LOCATION individual’s perception and reaction to the
C. DURATION environment are decreased
Acute: lasts for less than 6 months
Chronic: lasts for more than 6 months >RETICULAR ACTIVATIONG SYSTEM:
D. CHARACTER/QUALITY maintains wakefulness
E. INTENSITY/SEVERITY >Serotonin: neurotransmitter associated with
F. AGGRAVATING/ALLEVIATING FACTORS sleep

Stages of Sleep

1. NREM (NON-RAPID EYE MOVEMENT)

STAGE
(body restoration)

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 STAGE 1 -difficulty in falling asleep
- very light sleep -premature awakening
- drowsy, relaxed
- readily awakened 2. Hypersomnia
-excessive sleep
STAGE 2 -r/t psychological problems, CNS
- light sleep damage
- eyes are still
- HR and RR decreases slightly
- body temperature falls 3. Narcolepsy
- sleep attack
STAGE 3 - overwhelming sleepiness
- domination of PNS - REM uncontrolled
- body process slows further
- difficult to arouse 4. Sleep Apnea
-periodic cessation of breathing
STAGE 4 during asleep characterized by snoring
- deep sleep
- difficult to arouse 5. Parasomnias
- decrease BP, RR, PR, Temp Somnambolism - sleep walking
- decrease metabolism, brain waves, Night Terrors - child bolts upright in
muscles relaxed bed, shakes, screams, appears pale and
terrified
2. REM (RAPID EYE MOVEMENT) STAGE Nocturnal Enuresis- bed wetting
(increase in systhetic processes in the Soliloquy - Sleep talking
brain) Nocturnal Erections - “wet dreams”
Eyes appear to roll Bruxism - clenching and grinding of
Close to wakefulness but difficult to arouse teeth during sleep
Dreamstate of sleep
SNS dominates CONCEPT OF DEATH AND DYING
Flow of gastric acid increases
Sleeper’s reviews the day’s events and Coping with Loss, Grieving and Death
processes and stores information
Loss- an actual or potential situation in which
Nursing interventions to Promote a valued object, person or the like is
Sleep inaccessible or changed so that it is no longer
1. Promote comfort and relaxation perceived as valuable
2. Create a restful environment
3. Attend to bedtime rituals Bereavement- subjective response to a loss
4. Provide adequate exercise atleast 2 through the death of a person with who there
hours before sleep to enhance NREM has been a significant relationship
5. Encourage intake of high Protein food. It
contains Tryptophan which enhances sleep Grief- Total response to the emotional
6. Avoid caffeine and alcohol in the evening experience of the loss and is manifested in
7. Go to bed when sleepy thoughts, feelings and behaviors
8. Use the bed mainly for sleep
Mourning- the behavioral process through
which grief if eventually resolved or altered; it
Common Sleep Disorders is often influenced by culture and custom.

1. Insomnia Development of the Concept of Death

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 matters normally would not
1. Infancy to 5 years old bother them
 No understanding of the concept 3. Bargaining
of death  Seeks to bargain to avoid loss
 Believes that death is  May express feelings of guilt or
REVERSIBLE, TEMPORARY or fear of punishment for past
SLEEP sins, real or imagined
2. 5-9 years old 4. Depression
 Understands that death is final  Grieves over what has
 Believes that own death can be happened and what cannot be
avoided  May talk freely or may withraw
 Associate death with aggression 5. Acceptance
or violence  Comes to term with loss
3. 9-12 years old  May have decreased interest in
 Understands death as the surroundings and support
inevitable end of life persons
 Begins to understand own  May wish to begin making plans
mortality Symptoms of Grief
4. 12-18 years old 1. Repeated somatic distress
 Fears of lingering death 2. Tightness in the chest
 May fantasize that death can be 3. Choking or shortness of breath
defied, acting out defiance 4. Sighing
through reckless behavior 5. Empty feeling in the abdomen
 Views death in religious and 6. Loss of muscular power
philosophic terms 7. Intense subjective distress
5. 18-45 years old
 Attitude towards death is Assisting clients with their grief
influenced by religious and 1. Provide opportunity for the person to
cultural beliefs “tell their story”
6. 45-65 years old 2. Recognize and accept the varied
 Accepts own mortality emotions that people express in
 Encounters death of parents and relation to a significant loss
some peers 3. Provide support for the expression of
 Experience peak of death anxiety difficult feelings such as anger and
7. 65 years and above sadness
 Fears prolonged illness 4. Include children in their grieving
 Sees death as having multiple process
meanings 5. Encourage the bereaved to maintain
established relationships
Stages of Grieving (Kubler-Ross) DABDA 6. Acknowledge the usefulness of mutual-
1. Denial help group
 Refuses to believe that loss is 7. Encourage self-care by family members
happening particularly the primary caregivers
 Unready to deal with practical 8. Acknowledge the usefulness of
problems counseling for especially difficult
 May assume artificial problems
cheerfulness
2. Anger Signs of Impending Clinical Death
 Client or family may direct anger 1. Loss of muscle tone
at a nurse or hospital about  Relaxation of the facial muscles
m(the jaw may sag)

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  Difficulty in speaking Advance Directives
 Difficulty in swallowing and  Decide who will make decisions for the
gradual loss of the gag reflex patient in case he or she is unable.
 Decreased activity of the  Decide the kind of medical treatment
gastrointestinal tract the patient wants or doesn’t want.
 Possible urinary and rectal  Decide how comfortable the patient
incontinence wants to be.
 Diminished body movement  Decide how the patient will be treated
by others.
2. Slowing of circulation  Decide what the patient wants loved
 Diminished sensation ones to know.
 Mottling and cyanosis of the
extremities
 Cold skin, first in the feet and
later in the hands, ears and nose Nursing Interventions for the Dying
3. Changes in vital signs Clients
 Decelerated and weaker pulse 1. Assist the client achieve a dignified and
 Decreased blood pressure peaceful death
 Rapid shallow, irregular or  Provide relief from loneliness,
abnormally slow respirations; fear and depression
cheyne-strokes respirations;  Maintain the client’s sense of
noisy breathing (death rattle); security, self confidence,
mouth breathing dignity, and self worth
4. Sensory impairment  Maintain hope
 Blurred vision  Help the client accept his or her
 Impaired sense of taste and losses
smell  Provide physical comfort
2. Maintain physiologic and psychologic
Indication of Death comfort
1. Total lack of response to stimuli  Personal hygiene measures
2. No muscular movement  Pain control
3. No reflexes  Relief of respiration difficulties
4. Flat encephalogram (ECG). This is the  Assistance with movement,
most accurate indication of death nutrition, hydration and
Components of a Good Death elimination
 Pain and symptom management 3. Provide spiritual support
 Clear decision-making  Search for meaning
 Preparation for death  Sense of forgiveness
 Affirmation of the whole person  Need for love
 Need for hope
Five Principles of Palliative Care
 Respects goals, likes, and choices of the Hospices are healthcare facilities designed
dying person and his loved ones to care for terminally ill clients and other
 Looks after the medical, emotional, social, families by providing supportive and
and spiritual needs of the dying person palliative services
 Supports the needs of family members
 Helps to gain access to needed healthcare Care of the body after death
providers and care setting Body Changes
 Builds ways to provide excellent care at 1. Rigor Mortis
end of life

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 Stiffening of the body that  Allow the family to view the patient’s
occurs about 2-4 hours after body
death  Apply identification tags, one to the
 Results from lack of ATP, which ankle and one to the wrist
is not synthesized due to lack of  Wrap the body in shroud. Apply
oxygen in the body another identification tag to the outside
 Nursing intervention: position of the shroud
the body, place dentures in the  Bring the body to the morgue for
mouth, close the eyes and cooling.
mouth before rigor mortis sets in
2. Algor mortis Types of Loss
 Gradual decrease in body Actual loss — can be recognized by others
temperature (e.g. death of a loved one)
 Results from termination of the Perceived loss — is felt by person but
blood circulation and when the intangible to others (e.g Loss of money,
hypothalamus stops to function, death of pet)
body temperature falls about 1°C Maturational loss — experienced as a result
(1.8°F) per hour until it reaches of natural developmental process
room temp. Situational loss — experienced as a result
3. Livor Mortis of an unpredictable event
 Discoloration of the skin after Anticipatory loss — loss has not yet taken
death when circulation ceased. place
 Red Blood cells break down,
releasing hemoglobin which TERMINOLOGIES
discolors the surrounding tissues Grief — emotional reaction to loss
Bereavement — state of grieving; person
Nursing Interventions for the Body after goes through grief reaction; total response
Death Mourning — acceptance of loss; person
 Make the environment as clean and as learns to deal with loss
pleasant as possible Traditional heart-lung — irreversible
 Make the body appear natural and cessation of spontaneous respiration and
comfortable circulation
 Remove all equipment and supplies Whole brain — irreversible cessation of all
from the bedside functions of the entire brain
 Place the body in supine position, the Higher brain — irreversible loss of all
arms at the sides, palms down “higher” brain function
 Place one pillow under the head and
shoulders to prevent blood from Engel’s Six Stages of Grief
discoloring the face Shock and disbelief
 Close the eyelids, insert the dentures Developing awareness
and close the mouth Restitution
 Wash soiled areas of the body Resolving the loss
 Place absorbent pads under the Idealization
buttocks to take up any feces and urine Outcome
released because of relaxation of the
sphincter muscles Kubler-Ross’s Five Stages of Grief
 Provide clean gown, brush/ comb the Denial and isolation
hair Anger
 Remove all jewelries. All the client’s Bargaining
valuables are listed and placed in a safe Depression
storage area for the family to take away Acceptance

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Fundamentals of Nursing Practice Manual 42
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