Fundamentals of Nursing and First Aid
Theoretical Part
For
Second year students in
Health Prevention and Community Health Departments
2015 - 2016
Prepared by
Dr. Hoshyar Amin Ahmed
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Fundamentals of Nursing / Theoretical part 2015-2016
Definitions
Nursing:
Nursing encompasses autonomous and collaborative care of individuals of all ages,
families, groups and communities, sick or well and in all settings.
Nursing includes the promotion of health, prevention of illness, and the care of ill,
disabled and dying people. Advocacy, promotion of a safe environment, research,
participation in shaping health policy and in patient and health systems management, and
education are also key nursing roles.
Holistic nursing:
It is nursing practice that has as its goal the healing of the whole person.
Community Health Nurse:
Prepared nurse with a focus in community health, and knowledge of population-based public
health science and practice.
Measurement of the vital signs
Vital signs
They are indicators for body functions. These signs may be watched, measured, and
monitored to check an individual's level of physical functioning. Vital signs include:
1. Body temperature (T)
2. Pulse (heart beat) (P)
3. Respiration (breathing) (R)
4. Blood pressure (BP)
Other vital signs
1. Pain
2. Oxygen saturation
Normal vital signs change with age, sex, weight, exercise tolerance, and condition. The
normal vital sign ranges for the average healthy adult while resting are:
 Blood pressure: 90/60 mm/Hg to 120/80 mm/Hg
 Breathing: 12 - 20 breaths per minute
 Pulse: 60 - 100 beats per minute
 Temperature: 36.6 – 37.4 degrees Celsius (° C) average 37 degrees Celsius (° C)
Purposes of measuring Vital Signs
1. Make diagnosis
2. Planning of care
3. Showing progress of patient health
4. Identify reactions to medications, treatment, and care.
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Vital Signs are recorded in the following situations:
1. On admission
2. Beginning of each shift
3. Change in patient's status
4. Before/after invasive procedures
5. Before/after certain medications
6. Before/after nursing interventions
Body Temperature
Body temperature reflects the balance between the heat produced and the heat lost from
the body.
Factors Affecting Temperature
1- Age:
 The infant is greatly influenced by the temperature of the environment and must
be protected from extreme changes.
 Children’s temperature continues to be more labile than those of adults until
puberty.
 Elderly people are at risk of hypothermia for variety of reasons. Such as lack of
central heating, inadequate diet, loss of subcutaneous fat, lack of activity, and
reduced thermoregulatory efficiency.
2- Exercise: Hard work or strenuous exercise can increase body temperature.
3- Diurnal variation:
 This refers to the sleep – wake rhythm of the body, a pattern that varies slightly
from person to person.
 Body temperature normally changes throughout the day, varying as much as 1 oC
between the early morning and the late afternoon
4- Hormone:
 Women usually experience more hormone fluctuations than men do.
 Progesterone secretion at the time of ovulation raises body temperature above
basal temperature.
5- Stress: Stimulation of the CNS can increase the production of epinephrine and
norepinephrine, thereby increasing metabolic activity and heat production.
6- Environment: Extremes in environmental temperatures can affect a person’s
temperature regulatory systems.
Methods of measuring body temp.
1- Glass
2- Electronic
3- Temperature sensitive tape
4- Automated monitoring
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Sites of measurement of body temp.
1. Mouth – Oral temp.
2. Rectum – Rectal temp.
3. Axilla (armpit) – Axillary temp.
4. Ear – Tympanic temp.
5. Forehead – temporal temp.
Types of clinical thermometers
1- Glass thermometer
2- Electronic and digital thermometer
3-Tympanic thermometer
4- Temporal thermometer.
Mercury thermometer:
Digital thermometer:
Thermometer for reading temperatures through tympanic membrane:
Body temperature is measured in degrees Celsius (° C) or degrees Fahrenheit (° F)
C = F – 32 X 5/9
F = (C X 9/5) + 32
Alteration in body temperature
A. Pyrexia: a body temperature above the usual range is called pyrexia, hyperthermia
or fever.
 very high fever such as 41oC is called hyperpyrexia
 febrile: client who has a fever
 afebrile: a person who has not fever
Signs and symptoms of fever:
1. Dry skin 2. Skin rashes 3. Sweating 4. Anorexia 5. Tachycardia 6. Vomiting
7. Constipation 8. Headache 9. Backache 10. Extremity pain 11. Chilling 12. Delirium
Nursing Interventions for Clients with fever:
1. Monitor vital signs.
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2. Assess skin color and temperature.
3. Monitor white blood cell count, hematocrit value, and other pertinent
laboratory records.
4. Remove excess blankets when the client feels warm, but provide extra warmth
when the client feels chilled.
5. Provide adequate food and fluids to meet the increased metabolic demands and
prevent dehydration, if health permits. Clients who sweat profusely can
become dehydrated.
6. Measure intake and output.
7. Maintain prescribed intravenous fluids.
8. Reduce physical activity to limit heat producing, especially the flush stage.
9. Administer antipyretics as ordered.
10. Provide oral hygiene to keep the mucous membranes moist. They can become
dry and cracked because of excessive fluid loss.
11. Provide a tepid sponge bath to increase heat loss through conduction.
12. Provide dry clothing and bed linens to increase heat loss through conduction.
13. Prevention of bed sores (decubitus ulcer).
B. Hypothermia: It is a condition when the body temperature is under 35° C.
Causes of Hypothermia
1. Cold exposure
2. Shock
3. Alcohol or drug use
4. Metabolic disorders: diabetes and hypothyroidism.
5. Infection in: newborns, older adults, weak people.
Signs and symptoms of hypothermia
1. Loss of consciousness
2. Shivering due to vasoconstriction
Pulse
It is the wave of blood that can be palpated at major arteries produced by contraction of
left ventricle.
Cardiac Output: Amount of blood pumped per minute.
Stroke Volume: Amount of blood pumped into aorta with each ventricular contraction,
approximately 70cc.
CO = SV x Beats per Minute (bpm)
Factors affecting pulse
1. Age (as age increases pulse gradually decreases)
2. Gender (after puberty the males pulse rate is slightly lower than the female’s).
3. Exercise
4. Fever
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5. Medications
6. Hemorrhage
7. Stress
8. Pain
9. Position change
Assessing Pulse
 Rate (beats/min.): Bradycardia, Tachycardia
 Rhythm (pattern of beats): Sinus Rhythm versus Dysrhythmia (regular vs. irregular
pulse)
 Volume/strength/amplitude: scale 0 ± 4 (strong vs. weak pulse)
Pulse Sites
1. Temporal,
2. Carotid
3. Apical
4. Brachial
5. Radial
6. Femoral,
7. Popliteal,
8. Poserior tibial
9. Pedal (dorsalis pedis)
Alternative assessment techniques
 Doppler
 Stethoscope for apical pulse at apex of heart: Apical Heart Rate (AHR)
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Normal pulse
Adult
60 to 100 beats per minute
Children - age 1 to 8 years
80 to 100
Infants - age 1 to 12 months
100 to 120
Neonates - age 1 to 28 days
120 to 160
Respiration
Respiration is the process through which oxygen is inhaled and carbon dioxide is
exhaled.
Types of Respiration
1. External respiration: Exchange of O2 and CO2 between the alveoli and pulmonary
blood.
2. Internal respirations: Exchange of gases between the blood and the cells throughout
the body.
Ventilation
It is movement of air in and out of the lungs.
Types of breathing
1. Costal (thoracic)
2. Diaphragmatic (abdominal)
Inspiration lasts 1 to 1.5 seconds but expiration lasts 2 to 3 seconds.
Factors influence respiratory rate:
1. Exercise
2. Stress
3. Increased environmental temperature
4. Lowered oxygen concentration
Factors decrease respiratory rate
1. Decrease environmental temperature
2. Certain medication(narcotic)
3. Increased intracranial pressure
Assessing respirations
 Rate: 1- apnea 2- bradypnea 3- tachypnea
 Depth: 1- deep 2- shallow
 Rhythm/pattern: 1- regular 2- irregular
 Quality: 1- quiet 2- labored
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Normal respiration
Adult
12 to 20 breaths per minute
Children - age 1 to 8 years
15 to 30
Infants - age 1 to 12 months
25 to 50
Neonates - age 1 to 28 days
40 to 60
Blood Pressure
Pressure (force) exerted by the blood as it moves through the arteries; moves in waves
with the pumping action of the heart.
Korotkoff sounds: arterial sounds heard through a stethoscope applied to the brachial
artery distal to the cuff of a sphygmomanometer that change with varying cuff pressure
and that are used to determine systolic and diastolic blood pressure. (Tapping, Swishing,
Knocking, and Muffling sounds). Find the sounds at http://vimeo.com/8068713
Systolic pressure: is pressure of the blood as result of contraction of the ventricles.
Diastolic pressure: is the pressure when the ventricles are at rest.
Pulse pressure: is the difference between systolic and diastolic pressures.
Hypertension: BP that is persistently above normal contributing factor to Myocardial
Infarction (MI).
Primary hypertension: If cause of hypertension is unknown.
Secondary hypertension: If cause of hypertension is known.
Hypotension: Systolic reading between 85 and 110 in an adult whose BP is normally
higher than this.
Causes of orthostatic hypotension: 1- Peripheral dilation
2- Analgesics 3- Bleeding
4- Severe burns
5- Dehydration.
Nursing care for Hypotension:
1. Place pt in supine position for 2-3 min
2. Record BP & P
3. Assist pt to slowly sit or stand
4. After 1 min recheck BP & P
A rise of 40 BPM in pulse or drop in BP of 30 mm Hg indicates abnormal orthostatic
vital signs.
Physiological factors (body functions) which affect BP:
1- Hemodynamic factors
2- Circulating blood volume
3- Cardiac output
4- Peripheral resistance
5- Blood viscosity
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BP sites: 1- Arm – brachial artery 2- Thigh – popliteal artery
Methods of measuring BP:
1- Directly (invasive) in the inner blood vessels.
2- Indirectly (noninvasive) by Sphygmomanometer.
Auscultory BP: assessing BP by stethoscope
Palpatory BP: assessing BP by palpation without using stethoscope.
Classification of blood pressure:
Normal
90–119/60–79 mmHg
Prehypertensive
120–139/80–89 mmHg
Hypertensive
≥ 140/ ≥ 90 mmHg
Hypotensive
< 90/60 mmHg
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Administration of medications
Drug (medication) (medicine): is a substance used in the diagnosis, treatment, cure,
relief of symptoms, prevention of diseases, placebo.
The 10 rights to avoid medication errors
1. Right Medication. 2. Right Dose. 3. Right Time. 4. Right Route 5. Right Patient. 6.
Follow any manufacturer’s instructions. 7. Observe the patient taking oral meds to be
sure he has swallowed them. 8. Observe the patient for how well the medication and the
procedure (especially if invasive such as an injection) is tolerated. 9. Document
medication, dose, time, route, and immediate response. 10. Notify the physician
immediately of any adverse situations, including errors.
Routes of administration:
1. Oral routes:
a- Oral: Medications are taken by mouth (in tablet or pill, capsule, liquid).
Advantages:
 Easy route
 Less expensive
 Slow action
 More prolonged effect
 Preferred by clients
b- Sublingual: eg. Nitroglycerin. The drug must not be swallowed or chewed.
Liquids must not be taken until dissolved.
2. Parenteral routes: Medications are taken by injection into body tissues.
Injection: Forcing a fluid into the body by means of a needle and syringe into a
tissue, vessel, canal, or organ.
Types of Injection:
a- ID: Intradermal (under the epidermis)
b- SQ: Subcutaneous(below the dermis
of the skin)
c- IM: Intramuscular (into the muscle)
d- IV: Intravenous (into the vein)
e- Body cavity: (given by practiced physicians)
1. Epidural: catheter to the epidural space.
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2. Intrathecal: catheter implanted to subarachnoid space or one of the ventricles
of the brain.
The difference between an epidural and intrathecal is that an epidural is a catheter
that sits down next to the spinal sack that holds the cerebral spinal fluid. An
intrathecal is a single injection that goes through that sack into the cerebral spinal
fluid and administers medicine.
3. Intraosseous: directly into bone marrow usually into the Tibia.
4. Intraperitoneal: into the peritoneal cavity.
5. Plueradesis (Thoracentesis): injection through chest tube for treatment of
pleural effusion or giving analgesics.
6. Intraarterial: for arterial clots by giving clot dissolving agents.
7. Intracardiac: Injection directly to the heart.
8. Intraarticular: injection directly to the joint.
3. Topical routes:
a- Skin: application of drugs or moist dressing to the skin.
b- Mucous membrane:
1. Liquid: gargle, swabbing the throat.
2. Body cavity: suppository in the rectum or vagina.
3. Instillation: (slow introduction of fluid into body cavity) ear drops, nose
drops, bladder and rectal fluids.
4. Irrigation: (washing out of body cavity) eye, bladder, rectum, vagina.
5. Spraying: instillation of medication into nose and throat.
4. Inhalation: nasal, oral
Intravenous Injection
Intravenous Therapy (IV therapy): is the administration of liquid substances directly
into a vein used for medication or blood transfusion.
Sites of IV therapy:1. Medial cubital vein 2. Cephalic vein 3. Basilic vein 4. Dorsal
metacarpal veins. 5. Scalp vein for infants.
Peripheral IV lines: it is a short catheter (a few centimeters long) inserted through the
skin into a peripheral vein.
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Peripheral vein: is any vein that is not in the chest or abdomen.
Central IV line: insertion of a catheter through subclavian, internal jugular or femoral
vein toward the heart until it reaches the superior vena cava or right atrium.
Types of IV therapy: 1. Intermittent 2. Continuous ( intravenous drip).
Intravenous drip: is the continuous infusion of fluids, with or without medications,
through an IV access device. eg. Treatment of dehydration or an electrolyte imbalance,
medications, blood transfusion.
Note: Intravenous fluids must always be sterile.
Intermittent Infusion: is used when a patient requires medications only at certain times,
and does not require additional fluid.
IV push: Injecting medication to the IV access device to avoid irritation of veins and
avoid rapid effect.
Risks of intravenous therapy
1. Infection: a. Local infection with swelling, redness, fever b. Septicemia: Infection
in the central circulation.
2. Phlebitis: irritation of a vein that is not caused by infection, but from the presence of
a foreign body (the IV catheter) or the fluids or medication being given.
Symptoms: 1. swelling 2. pain 3. redness around the vein.
Treatment: 1. warmth 2. elevation of the affected limb 3. change in the rate of flow.
3. Infiltration: occurs when the tip of the IV catheter withdraws from the vein or pokes
through the vein into surrounding tissue, or when the vein's wall becomes permeable
and leaks fluid.
Symptoms: 1. pain
2. swelling
4. Fluid overload: occurs when fluids are given at a higher rate or in a larger volume
than the system can absorb or excrete.
Complications: 1. hypertension 2. heart failure 3. pulmonary edema.
5. Electrolyte imbalance: disruption of the balance of sodium, potassium and other
electrolytes due to administering a too-dilute or too-concentrated solution.
6. Embolism: blocking a blood vessel by blood clot, solid mass, air bubble. The risk is
greater with a central IV.
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Blood transfusion
Blood transfusion is taking of blood or blood-based products from one individual and
inserting them into the circulatory system of another. It can be considered a form of organ
transplant.
Indications: 1. massive blood loss due to trauma, surgery, shock 2. Blood diseases
Blood borne infectious diseases:
1. AIDS
2. Hepatitis B, C, D
3. Viral Hemorrhagic Fever
Contraindications
The contraindications to a blood donor include:





Previous malaria or hepatitis.
History of drug abuse
Donors who have received human pituitary hormone.
Donors with high risk sexual behavior
Donors who have previously been transfused (depending on geographic location)
Sometimes only parts of the blood are taken as a donation.
Principles of Health
Health
Is a state of complete physical, mental, and social well-being, not merely the absence of
disease or infirmity (WHO).
Total health includes the following aspects:
(1) Social health.
(2) Mental health.
(3) Emotional health.
(4) Spiritual health.
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The health-illness continuum
Positive health habits
1. A balanced diet with adequate caloric intake.
2. Efficient elimination.
3. Regular exercise.
4. Adequate sleep, rest periods, and relaxation periods.
5. Regular medical checkups.
6. Regular dental checkups.
7. Maintenance of good posture.
8. Good grooming habits.
Wellness
State of well-being in behaviors that enhance quality of life and maximize personal
potential.
Illness
Personal state, in which the person feels unhealthy or ill, may or may not be related to
disease.
Stages of the Life Cycle
Prenatal period
Conception to birth
Neonatal period Birth to 28 days of life
Infancy
First month to first year of life
Toddler period
12 to 18 months to 3 years
Preschooler
3 to 6 years
School-age child 6 to 12 years
Preadolescent
10 to 12 years
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Adolescent
13 to 20 years
Young adult
21 to 40 years
Middle adult
40 to 65 years
Older adult
66 years and beyond
Maslow’s Hierarchy of Needs
Psychologist Abraham Maslow defined basic human needs as a hierarchy, a progression
from simple physical needs to more complex emotional needs
(1) Physiological--food, shelter, water, sleep, oxygen.
(2) Safety--security, stability, order, physical safety.
(3) Love and belonging--affection, identification, companionship.
(4) Esteem and recognition--self-esteem, self-respect, prestige, success, esteem of
others.
(5) Self-actualization--self-fulfillment, achieving one's own capabilities.
(6) Aesthetic--beauty, harmony, spiritual.
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Nursing Process
An organized sequence of problem-solving steps used to identify and to manage the
health problems of clients.
Steps in the Nursing Process
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Nursing care plan
It is a set of actions the nurse will implement to resolve nursing problems identified
by assessment. It outlines the nursing care to be provided to a patient. The creation of
the plan is an intermediate stage of the nursing process. It guides in the ongoing
provision of nursing care and assists in the evaluation of that care.
Nursing diagnosis Expected outcome Nursing intervention
Basic daily care of the patient
1. Care of the patient unit
2. Feeding
3. Medication
4. Measurement of the Vital Signs
The adult patient care unit
The patient care unit is the area of the hospital in which the patient receives medical and
nursing care and treatment as well as the place in which he/she lives during hospital stay.
Characteristics of the patient care unit
1. Safe
2. Pleasant
3. Clean
4. Orderly environment for the patient's physical and mental well being.
Principles of Patient Hygiene
Providing for a patient's hygiene is the most important thing not only for the patient's
physical needs, it also contributes immeasurably to the patient's feeling of emotional
well-being.
Bed ulcer (Bed sore) (Decubitus ulcer):
An ulcerated area of skin caused by continuous pressure on part of the body.
Causes of bed ulcers
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1. Immobility
2. Incontinence
3. Emaciation
4. Obesity
5. Age-Related Skin Changes
6. Any disease or condition that affects circulation
Nursing intervention to prevent bed ulcers
1. Observe the pt. during bathing.
2. Give care at the first sign of redness.
3. Report any signs of pressure to the charge nurse.
4. Keep sheets under the patient clean, smooth, and tight to help eliminate skin
irritation.
5. Ensure adequate nutrition and fluid intake.
6. Keep urine and feces off the patient's skin
7. Obese patients may need assistance washing and drying areas under skin folds
(groin, buttocks, under breasts)
8. For the patient with very dry skin, various bath oils may be added to the bath
water.
9. Soap is not used because of its drying effect.
10. Lotions and oils may be used after the bath.
11. Change the pt’s position.
Basic principles of mouth care 9/12/2014
Purposes of mouth care:
(1) Provide oral care of the teeth, gums, and mouth.
(2) Remove odors and food debris.
(3) Promote patient comfort and a feeling of well-being.
(4) Preserve the integrity and hydration of the oral mucosa and lips.
(5) Alleviate pain and discomfort
General Guidelines of Mouth Care:
(1) Oral hygiene should be performed before breakfast, after each meal, and at bedtime.
(2) Oral hygiene is especially important for patients receiving oxygen therapy, patients
who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much
faster than normal due to their mouth-breathing.
Furniture for the patient basic unit includes
1. Bed. 2. Bedside cabinet. 3. Overbed table. 4. Chair.
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Methods of bed making
1. Unoccupied (Closed) Bed.
An unoccupied bed is one that is made when not occupied by a patient.
2. Occupied (Open) Bed.
An occupied bed is one that is made while occupied by a patient.
3. Anesthetic, Surgical, or Post-Operation Bed. This is a bed that is prepared to receive
a patient from the operating room.
Recording the height and weight of the patient
The patient's height and weight are recorded on admission for the following reasons:
a. Diet Management. The patient's ideal weight may be determined. The health care
team will also be able to monitor weight loss or gain.
b. Observation of Medical Status. Taking the patient's height and weight may indicate
that the patient is overweight, underweight, or is retaining fluids (edema). The health care
team can observe changes in weight caused by specific disease processes and determine
the effectiveness of nutrition supplements prescribed to maintain weight.
c. Calculation of Medication Dosages. Drug dosage is often prescribed in relation to a
patient's weight when a specific blood concentration of the drug is desired. Larger doses
may be required in a heavier person.
Principles related to weighing the patient.
1. Weigh the patient before breakfast, at the same time each day.
2. Use the same scale each time.
3. Ensure that the scale is properly balanced.
4. Weigh the patient in the same amount of clothing each day (i.e., hospital gown or
pajamas).
5. Have the patient void before weighing.
Admission and discharge of the patient
Patient admission: the formal acceptance of a patient for care into a clinic, hospital, or
extended care facility.
The admission assessment is the fundamental baseline assessment which begins the
nursing process. A patient may be admitted with pneumonia, but during the assessment
the nurse notes that the patient has experienced significant weight loss and is at risk for
skin breakdown because she has poor skin turgor, and is immobile and incontinent.
Elements of discharge process:
1. Discharge planning: process that seeks to determine the appropriate level of services
required by the patient and then match the patient to an appropriate site of care.
2. Medication reconciliation: is the process of verifying patient medication lists at a
point of care transition.
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3. Discharge summary: important elements in the discharge summary include:



The outcome of the hospitalization
The disposition of the patient
Provisions for follow-up care
4. Patient instructions: instructions and patient education materials to help in
successful transition from the hospital.
5. Discharge checklist: checklists provide an effective mechanism for ensuring that
discharge communications (the discharge summary and direct communication with
both aftercare providers and patients/families) reliably incorporate all key elements.
Discharge teaching goals:
1. Understands his illness
2. Complies with his drug therapy
3. Carefully follows his diet
4. Manages his activity level
5. Understands his treatment
6. Recognize his need for rest
7. Knows when to seek follow –up care
Pre and Post Operative Nursing Management (First Examination) ‫تاوةكو ئيرة تاقيكردنةوةى‬
‫وةرزى يةكةم‬
Preoperative Phase: The period of time from when decision for surgical intervention is
made to when the patient is transferred to the operating room table.
Intraoperative Phase: Period of time from when the patient is transferred to the
operating room table to when he or she is admitted to the postanesthesia care unit.
Postoperative Phase: Period of time that begins with the admission of the patient to the
postanesthesia care unit and ends after follow-up evaluation in the clinical setting or
home.
Perioperative Period: Period of the time that constitute the surgical experience, include
the preoperative, intraoperative, postoperative phases.
Preoperative Phase
Begins with decision to proceed with surgical intervention
Baseline evaluation
Preparatory education
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Intraoperative Phase
Begins when patient is transferred to operating room table
Provide for patient safety
Maintain aseptic environment
Provide surgeon with supplies and instruments
Documentation
Postoperative Phase
Admission to PACU
Maintain airway
Monitor vital signs
Assess effects of anesthesia
Assess for complications of surgery
Provide comfort and pain relief
Ends with follow-up evaluation in clinical setting or home
Preoperative Nursing Management:
I- Patient Education:
1. Teaching deep breathing and coughing exercises.
2. Encouraging mobility and active body movement.
3. e.g Turning(change position),foot and leg exercise.
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4. Explaining pain management.
5. Teaching cognitive coping strategies.
 Managing nutrition and fluids.
− The major purpose of withholding food and fluid before
surgery is to prevent aspiration.
− A fasting period of 8hours or more is recommended for
a meal that includes fried or fatty foods or meat
 Preparing the bowel for surgery.
Enema is not commonly ordered, unless the patient is undergoing
abdomen or pelvic surgery. e.g (cleansing enema, laxative).
 Preparing the skin.
The goal of preoperative skin preparation is to decrease bacteria without
injuring the skin.
II- Immediate preoperative nursing intervention:
 Administering preanesthetic medication.
 Maintaining the preoperative record.
e.g. Final checklist, consent form, identification.
Nursing management in the post anesthesia care unit:
I-Assessing the patient:
Frequent assessment of the patient oxygen saturation, pulse volume and regularity,
depth and nature of respiration, skin color, depth of consciousness.
II- Maintaining a patent airway:
− The primary objectives are to maintain pulmonary ventilation and prevent
hypoxia and hypercapnia.
− The nurse applies oxygen, and assesses respiratory rate and depth, oxygen
saturation.
III- Maintaining cardiovascular stability:
− The nurse assesses the patient’s mental status, vital signs, cardiac rhythm, skin
temperature, color and urine output.
− Central venous pressure, arterial lines and pulmonary artery pressure.
− The primary cardiovascular complications include hypotension, shock,
hemorrhage, hypertension and dysarrythmias.
IV- Relieving pain and anxiety:
− Opioid analgesic.
V- Assessing and managing the surgical site:
− The surgical site is observed for bleeding, type and integrity of dressing and
drains.
VI- Assessing and managing gastrointestinal function:
− Nausea and vomiting are common after anesthesia.
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− Check of peristalsis movement.
VII- Assessing and managing voluntary voiding:
− Urine retention after surgery can occur for a variety of reasons.
- Opioids and anesthesia interfere with the perception of bladder fullness.
- Abdominal, pelvic ,hip may increase the like hood of retention secondary to
pain.
VIII- Encourage activity:
Most surgical are encouraged to be out of bed as soon as possible. Early
ambulation reduces the incidence of post operative complication as, atelectasis,
pneumonia, gastrointestinal discomfort and circulatory problem.
Post Operative Complications:
1- Shock:
Is the response of the body to a decrease in the circulating volume of blood, tissue
perfusion impaired, cellular hypoxia and death.
2- Hemorrhage:
Is the escape of blood from a blood vessel.
3- Deep vein thrombosis. (DVT).
Occur in pelvic vein or in lower extremities, and it’s common after hip surgery.
4- Pulmonary embolism.
It’s the obstruction of one or more pulmonary arterioles by an embolus originating
some where in the venous system or in the right side of heart.
5- Urinary Retention.
6- Intestinal obstruction.
Result in partial or complete impairment to the forward flow of intestinal content.
Potential intraoperative complications:
1. Nausea and vomiting
2. Anaphylaxis
3. Hypoxia and other respiratory complication
4. Hypothermia
Health Assessment
Components of Health Assessment
A. INTERVIEW
B. PHYSICAL ASSESSMENT
C. DOCUMENTATION
A. INTERVIEW
Purposes of interview:
1. To formulate a complete data base by incorporating current and historical data.
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2. To provide an opportunity for the nurse to begin the development of a trusting
relationship with the patient.
3. Help to obtain information on the patient’s perception of their health, concerns,
and learning needs.
A. PHYSICAL ASSESSMENT
Physical examination of the patient is a process that can be performed by the nurse to
obtain subjective and objective data that will be used to formulate a Nursing Diagnosis
and Care Plan.
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Integument.
Head and neck.
Thorax and lungs.
Cardiovascular and peripheral vascular systems.
Breasts and axilla.
Abdomen.
Female and male genitalia.
Musculoskeletal system.
Neurological system.
Types of physical assessment:
— head- to- toe sequence,
— or systems sequence.
The purposes of physical assessment
1. to obtain baseline data about the client's functional abilities.
2. to supplement, confirm, or refute data obtain in nursing history.
3. to obtain data that will help to establish nursing diagnoses and plan for care.
4. to evaluate the physiologic outcome of the care and thus the progress of the client
health.
5. to make clinical judgment about client's health status.
6. to identify area for health promotion and disease prevention.
Methods of physical examination:
a) Inspection.
b) Palpation.
c) Percussion.
d) Auscultation.
a) Inspection:
Is the visual examination by using the sense of sight.
b) Palpation:
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It is the examination of the body using a Sense of touch. The pads of finger are used because
their concentration of nerve ending makes them highly sensitive.
Palpation is used to determine:
 Texture (e.g. hair)
 Moisture (e.g. skin)
 Temperature (skin)
 Vibrations (e.g. of joint)
 Distention
 Pulsation
 Presence of pain upon pressure
 Position size, consistency and mobility of organ or masses
Types of palpation:
 Light (superficial).
 Deep (heavy pressure of finger tip).
Guideline for palpation:
 The nurse hand should be clean and warm and the finger nail should be short.
 Area of tenderness should be palpated last.
 Deep palpation should be done after superficial palpation.
c) Percussion:
Is the act of striking the body surface to elicit sound that can be heared or vibration that
can be felt.
Percussion is used to determine the size and shape of internal organ by establishing their
borders. It is indicated whether tissue is fluid filled, air filled or solid.
Types of percussion:
 Direct: the nurse strikes the area to be percussed directly with the pad or two three
or fourth finger or with the pad of middle finger.
 Indirect: pleximeter is placed firmly in the client skin; the nurse strikes the
pleximeter by plexor.
Percussion elicits five types of sounds:
1- Flatness: over the muscle or bone.
2- Dullness: over the organ as the liver, spleen or heart.
3- Resonance: over the lung filled with air.
4- Hyprresonance: booming (e.g. emphysematous lung) abnormal.
5- Tympany: air filled stomach.
d) Auscultation:
Is the act of listening with a stethoscope to sounds produced within the body.
Auscultation is performed by placing the stethoscope diaphragm or bell against the body
part being assessed. This method uses the stethoscope to augment the sense of hearing.
The stethoscope must be constructed well and must fit the user. Earpieces should be
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Fundamentals of Nursing / Theoretical part 2015-2016
comfortable, the length of the tubing should be 25 to 38 cm (10–15 inches), and the head
should have a diaphragm and a bell. The bell is used for low-pitched sounds such as
certain heart murmurs. The diaphragm screens out low-pitched sounds and is good for
hearing high-frequency sounds such as breathe sounds.
C. Documentation
Information obtained from the interview and physical examination must be documented
in the patient’s chart. Appropriate chart forms may vary, depending upon the time,
purpose, and setting of the physical assessment. In addition to documentation of
subjective and objective data, the nursing diagnosis and assessment must be included.
Specific plans and goals of nursing care related to problems identified by the physical
assessment will be recorded. This will include specific information about referrals made
to other members of the Multidisciplinary Health Care Team.
Fluid, electrolyte, and acid-base balance (Canceled)
About 46% to 60%of the average adult's weight is water, which is vital to health and
normal cellular function.
Distribution of body fluid
The body fluid is divided into two major components:
 Intracellular fluid.
 Extra cellular fluid.
Characteristics of intracellular fluid:
 is found within the cell of the body
 constitute approximately two third of the total body fluid in adult
 is vital to normal cell function
 it contain solute such as oxygen, electrolyte and glucose
 it provides medium in which metabolic process of the cell take place
Characteristics of extra cellular fluid:
 found outside the cell
 accounts for about one-third of the total body fluid
 divided into:
o intravascular fluid( plasma) is found within the vascular system
o interstitial surrounding the cell
o lymph and trance cellular fluid include cerebrospinal, pericardial
Regulation of body fluid
Fluid intake:
The average adult needs 2.500 ml /day. About 1.500 ml drinks and 1000ml from the food
Routes of fluid output:
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Fundamentals of Nursing / Theoretical part 2015-2016
1. Urine: normal urine output from an adult is 1.400 to 1.500 ml per 24 hrs . If fluid loss
through perspiration is large, urine volume decreases to maintain fluid balance in the
body.
2. Insensible loss through the skin and through the lung
3. Noticeable loss through the skin
4. Loss through the intestine in feces
Average daily output from an adult is 2.300 to 2.600 ml.
Electrolytes:
Electrolytes are important for:
1. Maintaining fluid balance contributing to acid base regulation.
2. Facilitating enzyme reaction.
3. Transmitting neuromuscular reaction.
Acid- base balance
Acid is substance that releases hydrogen ions in solution. Base or alkalis have low
hydrogen ions concentration and can accept hydrogen ions in solution. PH reflects the
hydrogen ions in solution. The higher hydrogen ions are the lower pH.
Regulation of acid base balance
Buffers: bicarbonate (HCO3); prevent excessive changes in pH by removing or releasing
hydrogen ions.
Respiratory regulation: lung help regulating acid- base balance by eliminating or
retaining carbon dioxide (CO2).
Renal regulation: the renal are the ultimate long term regulation of acid base balance by
selectively excreting or conserving bicarbonate and hydrogen ions.
Factors affecting body fluid, electrolyte, and acid base balance
1. Age: in elderly people the thirst response is blunted.
2. Gender and body size: water account for approximately 60% of an adult man and
52% of adult women.
3. Environment temperature.
4. Lifestyle.
Disturbance in fluid volume, electrolyte, and acid base balance
Fluid imbalance:
Fluid volume deficit: condition when the body loses both water and electrolyte from the
ECF in similar proportion, it is often called hypovolemia.
FVD occur as a result of abnormal loses through the skin, gastrointestinal tract or kidney
due to the following causes:
1. Decrease intake of fluid.
2. Bleeding movement of fluid into a third space.
Disturbance in fluid volume, electrolyte, and acid base balance
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Fluid volume excess (FVE) occur when the body retain both water and sodium in similar
proportion to normal ECE (hypervolemia).
Edema:
Edema is an abnormal accumulation of fluid in the interstitium, which are locations
beneath the skin or in one or more cavities of the body. It is topically most apparent in
area where the tissue pressure is low such as around the eye and independent tissue.
Disturbance in fluid volume, electrolyte, and acid base balance
Dehydration: occur when the water is lost from the body without significance loss of
electrolyte.
Over hydration: (water intoxication) occur when water is gained in excess of electrolyte
result in low serum sodium level.
Nursing management
Assessing:
Take nursing history
Physical assessment
Clinical measure: daily weight, Vital signs
Fluid intake and output
Laboratory test (serum electrolyte, complete blood count CBC, osmolality, urine pH,
urine specific gravity.. etc)
Diagnoses
Deficit fluid volume
Excessive fluid volume
Risk for imbalance fluid volume
Risk for deficit fluid volume
Impaired gas exchange
Planning:
Maintaining or restoring normal fluid balance
Maintaining or restoring normal balance of electrolyte
Maintaining pulmonary ventilation
Prevent associated risks
Implementation:
Promoting wellness
Fluid and electrolyte replacement
Fluid intake modification
Dietary changes
Oral electrolyte supplement
Parentral fluid and electrolyte replacement
Evaluation
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