Fundamentals of Nursing
THEORETICAL FOUNDATIONS OF NURSING
Theory – set of concepts to explain a phenomenon
Paradigm – pattern
4 Metaparadigms of Nursing

Person - Most important because knowing the client will
make your nursing care individualized, holistic, ethical, and
humane.
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Health

Environment

Nursing
Concepts of Man

Man is a bio-psychosocial and spiritual being who is in
constant contact with the environment.

Man is an open system in constant interaction with a
changing environment.

Man is a unified whole composed of parts, which are
interdependent and interrelated with each other.

Man is composed of parts, which are greater than and
different from the sum of all his parts.
o
Simply saying, you cannot remove 1 system from
man.

Man is composed of subsystems and suprasystems.
o
Subsystem (within) Example: biological,
psychological, emotional.
o Suprasystem (outside) Example: Family,
community, population
CONCEPTS OF NURSING
Florence Nightingale

Act of utilizing the environment of the patient to assist him
in his recovery.
Sister Callista Roy

Theoretical system of knowledge that prescribes a process
of analysis and action related to the care of the ill person.
Martha Rogers

Nursing is a humanistic science dedicated to the
compassionate concern with maintaining and promoting
health and preventing illness and caring for and
rehabilitating the sick and disabled.
o
Levels of prevention

Primary – Health promotion and disease
prevention
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Secondary – Treatment, curative

Tertiary – Rehabilitation
Dorothea Orem (Self-care and Self-care deficit theory)

Helping or assisting service to persons who are wholly or
partly dependent, when they, their parents and guardians,
or other adults responsible for their care are no longer able
to give or supervise their care.
o
I.e. – completely assisted, partially assisted, and
self-assisted.
ANA (American Nurses Association)

Nursing is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and
advocacy in the care of individuals, families, communities,
and populations (2003).
Abraham Maslow’s Hierarchy of needs

Self-actualization
University of Santo Tomas – College of Nursing / JSV

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Self-esteem
Love and belongingness

Safety and Security
o
Being free from harm or danger
o
2 forms: Physical safety (free from physical harm)
and Psychological safety (explaining the
procedure to the patient)
Physiologic (priority)
o
If all the needs are within the physiologic level
High Priority needs – (life threatening needs) Airway,
Breathing, Circulation
Medium priority needs – (Health threatening needs)
Elimination, Nutrition, Comfort,
Low Priority needs – (Person’s developmental needs)
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NURSING THEORISTS
Florence Nightingale
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Environment Theory

May 12, 1830 – August 13, 1910
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Environmental sanitation
Hildegard Peplau

Psychodynamic Theory of Nursing

Interpersonal Process

Phases of Nurse-patient relationship:
1. Orientation (client seeks)
2. Identification (independence, dependence)
3. Exploitation (accept service of nurse)
4. Resolution
Virginia Henderson

14 Fundamental needs of the person
Faye Abdellah

Typology of 21 Nursing problems

Patient-centered approach
o
The client’s needs are the basis of the nursing
problems
Lydia Hall

3 C’s:
1. Core (therapeutic use of self) – Patient
2. Care (nursing function) – Nurse
3. Cure (medical) – Doctor
Jean Watson

Human Caring Theory

Caring is an innate characteristic of every nurse.

10 Carative factors
Ida Jean Orlando-Pelletier

Dynamic Nurse-Patient Relationship Model

Nursing Process Theory
o
Nursing as a process involved in interacting with
an ill individual to meet an immediate need.

Four Practices Basic to Nursing
o
Observation, reporting, recording, and actions
Madeleine Leininger

Transcultural Theory of Nursing
Myra Levine

4 Principles of Conservation
1. Conservation of energy
2. Conservation of structural integrity of the body
3. Conservation of personal integrity
4. Conservation of social integrity
Fundamentals of Nursing
Sister Callista Roy

Adaptation Model

Individuals cope through biophysical social adaptation

4 mode of adaptation
o
Role function, interdependence, physiological,
self-concept
Dorothea Orem

Self-care and Self-care Deficit Theory

Universal self-care requirement (nutrition, oxygenation),
developmental self-care requirement (developmental
tasks), health care deviation self-care requirement

3 Nursing systems: wholly compensatory ,partially
compensatory, supportive-educative compensatory
Dorothy Johnson

Behavioral Systems Theory

Man is composed of subsystems and these systems exist in
dynamic stability.
Martha Rogers

Science of Unitary Human Being

Unitary man is an energy field in constant interaction with
the environment.
Imogene King

Goal Attainment Theory

Interacting systems framework

Nurses purposefully interact with the patient and mutually
set the goal, explore, and agree to means to achieve the
goals.
Betty Neuman

Total Person Model
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3 types of stressors: intra-personal, extra personal,
interpersonal

Primary, secondary, tertiary levels of prevention

The goal of nursing is to assist individual families and groups
in attaining and maintaining a maximal level of total
wellness by purposeful interventions.
Parse
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Theory of Human Becoming
emphasizes how individual chose and bear responsibility
for patterns of personal health
Patricia Benner

Novice – Expert Theory
Stage 1: Novice
Stage 2: Advance beginner
Stage 3: Competent (2-3 years)
Stage 4: Proficient (3-5 years)
Stage 5: Expert

Skills acquisition
Joyce Travelbee

Human to Human Relationship
Ernestein Weidenbach

Clinical Nursing: A Helping Art
Nola Pender

Health Promotion Model
University of Santo Tomas – College of Nursing / JSV
FILIPINO NURSING THEORISTS
Carmencita Abaquin

Chairman of Board of Nursing

PREPARE ME intervention

P – presence which in
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RE – reminisce therapy
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P - prayer
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Re - relaxation

ME – medication
Sr. Caroline Agravante
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The CASAGRA Transformative Leadership model
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5 C’s for Transformational leadership: creative, caring,
critical, contemplative, collegial
Carmelita Divinagracia
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COMPOSURE Behavior for wellness

COMpetence

Presence of Prayer, Open mindedness, Stimulation,
Understanding, Respect, Relaxation, Empathy
Mila Delia Llanes

Conceptual model on Core Competency Development
Ma. Irma Bustamante
The effects of the Nursing Self-Esteem Enhancement
(NurSe) Program to the Self-Esteem of Filipino Abused
Women
Sr. Letty Kuan
Retirement and Role Discontinuity
St. Elizabeth of Hungary - Patroness of nurses
St. Catherine of Siena – The 1st lady with the lamp
Clara Barton – Founder of American Red Cross
Fabiola – Wealthy Matron who donated her wealth to build a
hospital the Christian world
T. Fliedner – Founder of the first organized school of nursing
Rose Nicolet – Helped establish the first school of nursing in the
Philippines
Lilian Wald – Founder of Public Health Nursing
HISTORICAL DEVELOPMENT OF NURSING
Intuitive
Practiced during the prehistoric, nursing was untaught,
rendered by the mothers (by intuition, it is the woman who
is more caring).
Out of love, sickness caused by black spirits, based on
instinct
Shamans, spells, rituals
*Trephining – boring a hole into a skull without anesthesia to release
evil spirits
*Egyptians – art of embalming, anatomy and physiology
*Moses – Father of Sanitation, asepsis, art of circumcision
*China – material medica – book of pharmacology
*Babylonians – Bill of Rights, Code of Hammurabi (made by King
Hammurabi which include freedom to refuse treatment), medical
fee
*India – Shushurutu – list of function of the nurse – combination of
masseur, caregiver
Fundamentals of Nursing
*Romans – Fabiola – a rich matron who contributed her home to
serve as first hospital
Apprentice
Known as the “on the job training” period, under the
supervision of a more experienced person, but yet there is
no formal education.
Experienced (through trial and error) nurse teaches new
volunteer nurses who usually came from religious orders
Nursing the sick and wounded from the wars
Charles Dickens – novel “Martin Chuzzlewit” about Sairy
Gump and Betsy Prag (exemplification of nurses in the Dark
Period of Nursing)
Pastor Theodore Fliedner (Protestant) – first training school
for Nursing, “Deaconess School of Nursing”, 6 months
program at Kaiserswerth,Germany
Educated
Florence Nightingale School of Nursing
First theory author, first nurse-researcher
Lady with a Lamp/ Mother of Modern Nursing
3 months of study from Kaiserswerth
Developed her own training “Nightingales System of
Nursing Education” which is implemented in St. Thomas
Hospital in London
Correlate theory and practice, updates, continuing
education, research, self-supporting nursing school
(separate from hospital)
Changed image of nursing, revolutionized practice
Professionalized as a nursing
Notes of Nursing: What it is, What it is not, Notes on
Hospitals
Nursing as a profession is not as old as mankind but nursing as an act
itself is.
Contemporary
Modern nursing practice
Anastacia Giron-Tupas
Grand lady of Philipine Nursing
Founded PNA
Hilaria Aguinaldo – Development of Red Cross
Loreto Tupas – Florence Nightingale of Iloilo
Melchora Aquino – Tandang Sora
HISTORY OF NURSING IN THE PHILIPPINES
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First hospital – Hospital de Real de Manila (1577)
1578 – San Lazaro Hospital, Intramuros – leprosy and mental
illness
Hospital de San Gabriel – Chinese General Hospital
Aliping sagigilid and aliping namamahay – first volunteer
nurses who served as apprentice in the first hospitals
1878 – Escuela de Practicantes (UST)
– First school for Nursing (short-lived)
1906 – Iloilo Mission Hospital School for Nursing
– 6 months training, no board exam (NON-EXISTENT)
Mission Hospital (1901) – still existent
1907 – PGH Hospital, St. Lukes Hospital, St. Paul Hospital
Normal Hall in PNU is used as training ground – Same
instruction (central school idea) for 6 months then go back
to hospital
Act 2493 (1915) – Medical act which included Sec.7 & 8
about nursing practice which mandated registration and
examination
Act 2808 (1919)
University of Santo Tomas – College of Nursing / JSV
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First true nursing law
Board of Examiner for Nurses (BEN)
1 Doctor and 2 Nurses
1920 – First board examination
Anna Dulgent – first board exam topnotcher
GN Program (Graduate Nurse) – 1 year
After World War II, BSN degree for four years was given by
UST (1946). Managerial, teaching and supervision position.
Equal to Master’s degree.
RA 877 – BEN is composed of BSN
1966 – Master’s degree needed
RA 6136 – can administer intravenous meds as long as
physician, violaion of professional autonomy; did not
materialize but instead nurse prepared medication and
doctor administered until 1992 but it had conflict with the
drug administration principle of “administer what you
prepare”
1960s – 5-year curriculum
1976 – 4-year curriculum; GN program was phased out,
practicing GNs must go back to 4th year to earn a BSN
degree but they won’t take board exam anymore since
they are already licensed
1980 – overlapping of 4 and 5 year curriculum graduates
RA 7164 (1992) – IV training for nurses by ANSAP, signed by
Cory Aquino, valid only after 2 months
RA 9173 (2002) – New Nurse Practice Act
HEALTH, DISEASE, AND ILLNESS
Health – Defined as the merely the absence or presence of disease
or infirmity. WHO defined health is a state of complete physical,
mental, and social well-being and not just merely the absence of
disease or infirmity.
Disease – Malfunctioning of the body system.
Illness – It is a state wherein the person’s physical, emotional, and
social well-being is thought to be diminishing. Felt by the patient. It is
highly subjective.

2 types
o
Acute – Sudden onset, short duration, may or
may not require immediate intervention.
o
Chronic – Gradual/slow onset, long duration,
lessen complications or debilitating effects of the
condition for the client to be able to function
given the limitations of the condition.
Models of Health
Judith Smith
Clinical Model
Absence of the signs and symptoms of a disease.
Narrowest
Role Performance Model
Able to perform job
Adaptive Model
Capable of adjusting
Although there is infirmity, he is able to find ways to cope.
Eudemonistic Model
Individual is able to achieve the apex of Maslow’s
Hierarchy of needs (self-actualization).
Maximization of potential and mission in life
Fulfillment of his purpose in life
Levell and Clark
Ecologic Model of Health
Epidemiological triad –agent, host, environment
Fundamentals of Nursing
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Any of these triad must be manipulated or enhanced to
maintain health
Multiple Causation Theory of Disease
health is affected by different factors in the environment
Rosenstoch – Becker’s Health Belief Model
Individual perception affect modifying factors which may
influence likelihood of action
Travis’ Illness-Wellness Continuum
Health is in a spectrum which moves into polarity of
directions
Premature of death  Disability/Disease  Symptoms 
Signs  Awareness  Education  Growth  High level
wellness
Dunn’s High Level Wellness Grid
Health-illness Continuum
health axis “Favorable/Unfavorable environment”
Quadrants:
1. High level wellness in a favorable environment
2. Emergent high levels in Level Wellness in an
unfavorable environment
3. Poor Health in an Unfavorable Environment
4. Poor health in a favorable environment
Schumann’s Stages of Illness Behaviors
1. Symptom experience
2. Assumption of sick role
3. Medical care contact
4. Dependent client role
5. Convalescence/ Rehabilitation
Opposite of health is illness, not disease
STRESS


Organisms reacts as a unified whole
Fabric of life
Models of Stress
Response Based Model (Selye)
– Non-specific response of the body to any demand made upon it
Transaction-based Model
– Individual perceptual response rooted in psychological and
cognitive process
Stimulus Based Model
– Disturbing or disruptive characteristics within the environment
Adaptation Model
– Anxiety provoking stimulus
– People experience anxiety and increased stress when they are
unprepared to cope with stressful situations
CRISIS
Stressor
-
disequilibrium, not merely psychological but physiologic as
well (shock)
spontaneous resolution is 6 weeks
grieving process: 4 years
Internal/ intrinsic
External / extrinsic
Developmental/ Maturational
Situational
Eustress – helpful stress
University of Santo Tomas – College of Nursing / JSV
Distress – harmful to health
Body adapts to the changes in the environment which leads to
Homeostasis (Walter B. Cannon)
Cloud Bernard – called homeostasis as “therapeutic milieu”
Adaptation - change to maintain integrity of the environment
Models of Adaptation
Biological/Physiological – GAS and LAS; compensatory physical
changes
Emotional/Psychological – involves a change in attitudes or
behavior
Socio-cultural – changes in the person’s behavior in accordance
with norms, conventions and beliefs of various groups.
Technological – involves the use of modern technology
Principles of Homeostatic Mechanisms
Automatic, self-regulatory
Compensatory
Negative feedback except for uterine contraction during
labor
Has limits
One physiologic error is corrected by several homeostatic
mechanisms
STRESS RESPONSE
Lazarus’ Stress Response Theory
General Adaptation Syndrome (GAS) – a physiological response is a
systemic response
Local Adaptation Syndrome (LAS) - Only a part of the body
General Adaptation Syndrome Stages

Alarm
Awareness of stressor
Increase in vital signs
Mobilization of defense
Decreased body resistance
Increased hormone level

Resistance
Repel of stressor; overcome
Adaptation
Normalization of hormone levels and vital signs
Increase in body resistance
Going back to pre-stress state

Exhaustion
Unable to overcome stressor
Decreased energy level
Breakdown in feedback mechanism
Organ/tissue damage; decreased physiological
function
Exaggeration of
General Adaptation Response
Sympathoadreno-medullary Response (SAMR)
activation of sympathetic system which stimulated adrenal
medulla
Release of epinephrine and norepinephrine ---- > inc.
physiological activities
Sympathetic stimulation (inc. HR, RR, BP, visual perception,
metabolism – glycogenolysis in liver, dec. GI, GU)
Propanolol (Inderal) – bronchoconstriction
Adrenocortical Response
Anterior pituitary gland Adreno corticotropic hormone  adrenal
cortex
(1) release of aldosterone  kidneys  increase Na
reabsorption
(2) release of cortisol  fats & CHON catabolism  glucose
Fundamentals of Nursing
Neurohypophyseal Response
Posterior pituitary gland release
(1) Antidiuretic hormone  kidneys  inc. Na, H2O
reabsorption  dec. urine output, inc. blood volume, inc.
BP
(2) Inc. oxytocin (aids in ejaculation/sperm motility)  uterine
contraction
Methods to decrease stress:
Progressive relaxation – muscle tension
Benzon relaxation method – dimming the light, music
Yoga, meditation
Ventilation of feelings
Local Adaptation Syndrome
Inflammatory Response
All infections cause an inflammatory response
Not all tissue damage results to inflammation
Inflammation can heal spontaneously as long as the body can
manage
I. Vascular Stage
(1) Vasoconstriction which limits injury and contain damage
(transient)
(2) Release of chemical mediators – kinins
a. Bradykinin – most potent vasodilator/ universal
pain stimulus, inc. chemical activity  warmth
(calor), redness (rubor)
b. Prostaglandin
(3) Capillary permeability  swelling (tumor), pain (dulor),
temporary loss of function (function laesa)
II. Cellular Stage
(1) Neutrophils – bands and segmenters in differential count;
first one to arrive. If elevated, it suggests acute infection
(2) Lymphocytes, Monocytes, or Macrophages – suggests
chronic infection.
(3) Eosinophils – allergy
(4) Basophils – healing
III. Exudating
Types of Exudate

Serous – plasma (watery)

Sanguinous/hemorrages – blood

Serosaguinous – pink

Pus – purulent/ suppurative

Catarrhal – mucin

Fibrin fibers – fibrinous
IV. Reparative
Phagocytosis – ingestion of foreign substances
Macrophages  Monocytes
Chemotaxis – movement of substances to a chemical signal
Healing methods:

Cold compress for first hours then warm compress after

Nutrition and fluid intake
Types of wound healing
Primary Intention – Wound edges are well approximated (closed),
minimal tissue damage i.e. surgically created wound; this can be
done with stitches, staples, etc.
Secondary Intention – Wound edges are not well approximated,
moderate to extensive tissue damage and edges can’t be brought
together i.e. Decubitus ulcer
University of Santo Tomas – College of Nursing / JSV
Tertiary Intention – “Delated primary intention”, suturing or closing of
the wound is delayed i.e. due to poor circulation in the area
NURSING PROCESS
A – Assessment
D - Diagnosis
P – Planning
I - Implementation
E – Evaluation
An overlapping of process can be noted since it is cyclic
ASSESSMENT
Types
-
Initial assessment
Problem focused assessment
Emergency assessment
Time-lapsed assessment
Data Collection – first step in assessment

Primary/ Secondary

Object (over)/ Subjective (covert)
Methods of Gathering Data
Interview

Therapeutic and non-communication

Health history
o
Medical history – disease focused (physiological)
o
Nursing history – needs, psychosocial dimension,
spiritual aspects

Personal space
o
Intimate Space – 1 ½ foot
o
Personal Space – 1 ½ - 4 feet
o
Social Space – 4 –12 feet
o
Public Space – 12–15 feet
Observation

Use of senses to gather data

Clinical eye – comes with practice and experience
Examination

Inspection, Palpation, Percussion, Auscultation (general)
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Inspection, Auscultation, Percussion, Palpation
(abdominal)
Steps in assessment
1. Collection of data
2. Validation of data
3. Organization of data
4. Categorizing or identifying patterns of data
5. Making influences or impressions of data
After data collection, synthesis, analysis and validation are
performed
DIAGNOSIS
Problem + etiology +defining symptoms
*Guided by the NANDA
Knowledge deficit – kulang sa kaisipan
Knowledge deficiency – kulang sa kaalaman (preferred)
Self-care deficit – acceptable
Types of Nursing Diagnosis

Actual
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Risk for/ Potential for
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Wellness - readiness and enhancement/ achieve higher
level of functioning
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Syndrome – “syndrome”
Fundamentals of Nursing
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Possible – vague/ unclear – possible/probable
Prioritization of Nursing Diagnosis

Airway, breathing, circulation
5.
Charting by Exception (CBE) – only significant change is
documented
Case Management done with a Critical Pathway Variance
– Comprehensive and make sure that it won’t legally be implicated
PLANNING

Short Range
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Long Range
*Must be SMART (Specific, Measurable, Attainable, Realistic, Time
bound)
Classify as dependent, interdependent, and collaborative
IMPLEMENTATION

Reassess if the patient still needs intervention

Determine if you need assistance

Carry out intervention, ensure that we have background

Document
Process of implementing
Reassess client
Determine nurses’ needs for assistance
Implementing nursing interventions
Supervising the delegated care
Documenting nursing activities
EVALUATION
Purposes of evaluation
Determine the:
Client’s progress or lack of progress
Overall quality of care provided
Promote nursing accountability
Guidelines for evaluation
Systemic process
On-going basis
Revision of the plan of care when needed
Involve the client, significant others, and other
members of the health team
Must be documented
Process - nurse
Structure - system
Outcome – patient
DOCUMENTATION or CHARTING
 STAT – now
 Ad lib – as desired
 PRN – as required
 OD – right eye/ once a day
 OS – left eye
 OU – both
 AD – right ear
 AS – left ear
 AU – both ears
 Ss – half
ERROR: draw a straight line, signature, initials
Types of Documentation
1. Source Oriented Recording – narrative account by nurse;
all the sheets in the patient’s chart (Standing Order,
Physician’s Order etc.)
2. Problem Oriented Recording (POR) – problems ranked
according to priority by the health care team, date
dissolved, progress notes, problem list
a. FDAR – Focus, Data, Action, Response (patient)
b. SOAPIER – subjective, objective, assessment,
planning, implementation, evaluation, revision
3. Computer Assisted Recording – problem with privacy
4. Flow Chart
University of Santo Tomas – College of Nursing / JSV
PHYSICAL EXAM (Plan Order)
Cephalo-caudal
o
Inspect, palpation percussion, auscultation
o
Inspection, auscultation, percussion, and
palpation sequence on abdomen to prevent
stimulation of peristalsis and for the patient to
follow a more comfortable to least comfortable
examination
Focused Assessment – on specific part/symptom
Bruit – normal if with AV fistula, abnormal in other since it may signify
arterial occlusion
Auscultate the scrotum in inguinal hernia since it may have bowel
sounds
Compare each body part to the other
POSITIONING
 Sitting
 High Fowlers (90%)
 Orthopneic position (leaning on a table, hands extended)
 Supine, Back Lying, Dorsal, Horizontal Recumbent
 Flat on Bed – no pillow
 Dorsal Recumbent – legs flexed to relax abdominal
muscles, abdominal palpation/ exam – followed by
diagonal draping
 Standing/Errect – curvature of the spine
 Prone/ Face – lying position
 Sim’s Position, Left lateral, Side-lying
– Rectal exam, suppository insertion, enema administration
 Knee Chest position/ Geno-pectoral position/ Jack Knife
position
– Rectal exam, dysmenorrhea
 Kraaske – inverted V
 Lithototomy – stirrups
 Trendelenburg – foot up; head down
 Reverse trendelenburg – head up, foot down
 Modified trendelenburg – only 1 leg up for shock: L
MCNAP – training to perform internal examination
Chest
Posture
Skin
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Pectus excavatum – funnel chest (congenital);
compression of heart and breathing
Pectus carinatum – pigeon chest – deformity for rickets (Vit
D deficiency); AP diameter decreased
Kyphosis
Lordosis
Scoliosis – lateral
Capillary refill test = 1-2 seconds
Icteric sclera
Cyanosis – late sign of oxygen deprivation
Vitiligo
Erythema
Pallor
Nail Beds
Clubbing - Beyond 180 degree due to dec. oxygen
Fundamentals of Nursing
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Koilonychia -Spoon shaped nail due to iron deficiency
anemia
Onycholysis/Oncolysis – separation of nail
Paronychia – severe inflammation of nail
Unguis incartatus - ingrown toenail
PALPATION
Light (indentation half an inch)
o
Fontanels, buldges, pulses, lymph nodes, thyroids,
symmetry, neck veins, edema
Deep
IE is a form of palpation
Chest expansion must be symmetrical
Tactile fremitus - sound that is palpable
Increase in consolidation, pneumonia
Decrease in pneumothorax
Thrill – palpable murmur
Edema – on dependent area and may occur in legs
Pitting/Non-Pitting
Anasarca – generalized edema
Peri-orbital edema – about the eye
PERCUSSION
Touch and healing
Tuning Fork
Weber’s test/ Lateralization test – conduction hearing
Rhinne’s Test – bone-air conduction
Indirect Palpation
Flexor – Hiitting
Pleximeter – Receiving
Sounds
Dull – organ
Flat – bones, muscles
Tympany – abdoment
Resonant – lungs
Hyperresonance – abnormal (emphysema)
Typanism – “kabag”
DTR - +2: NORMAL, above it hyper resonant, below it is hyporesonant
Parts of the Stethoscope
Diaphragm – high pitched; lung sounds
Bell – low pitched; heart sounds
Adventitious breath sounds – no abnormal sounds
Respiratory Sounds
Normal Breath Sounds
Vesicular – Soft intensity, low pitched
T5 onward
Peripheral lung, base of the lung
Bronchovesicular – Moderate intensity, moderate pitch
T3-T5
Between scapulae lateral to the sternum
Bronchial – High pitch, loud harsh sounds
T1-T3
Anteriorly over the trachea
Adventitious Breath Sounds
Wheeze – Continuous, high-pitched, squeaky musical sounds
narrowed airway; asthma, bronchitis
Crackles (rales) – Fine, short, interrupted crackling sounds
rubbing hair in small airways; retained secretions;
University of Santo Tomas – College of Nursing / JSV
Gurgles (rhonchi) – Continuous, low-pitched, course, gurgling, harsh
sounds with moaning / snoring quality
rubbing hair in wide airway
Friction rub – Superficial grating or creaking sounds
Vocal (tactile) fremitus – Faintly perceptible vibration felt through
the chest wall when the client speaks
Stridor – noisy breathing
Stertor – laryngeal spasm
Cardiac Sounds
5th ICL MCL at the PMI
Llllleft – Pulmonic valve
Rrrrrr- Aortic valve
NPH – Ntrmediate
Humulin R- rapid
Glargular – rapid
Bowel Sounds
Normoactive: 5-30 bowel sounds per minute
Wait 3-5 mins before concluding that bowel sounds are
absent
Hyperactive – Borborygmus
Paralytic ileus – paralysis after surgery
Voice Transmitted Sounds
Egophony – say “E” but hears “A”
Whispered Pertoriloquy – whisper but we hear it loudly,
secondary to consolidation
Vocal fremitus
Shifting dullness to check for ascites
LABORATORY EXAMS
Properly collect the specimen
Give instructions correctly
Urinalysis
Color: Amber, tea-colored (biliary d/o), urobilinogen
Odor: Aromatic/ Ammoniacal (decomposed urine)
pH: Acidic – does not favor bacterial growth
Specific gravity: 1.050-1.025, if elevated urine is
concentrated, suspect dehydration
Phosphates/Urates: Normal
Glycosuria – Diabetes (BS is more than 200mg)
Hematuria – Stones, BPH, renal diseases, UTI
Albuminemia – protein in urine, eccampsia
Pyuria – UTI
Cyllinduria – cast in urine (stones)
First voided urine, mid-stream to clean the urethra first
Sterile specimen
Indwelling catheter – wait in the end of the catheter for 30
mins
Indwelling catheter – aspirate from 10ml syringe
Wee bag (*)
Urine Culture & Sensistivity Test
Exact microbe
Result is final only after 5-7 days
Same collection process but less amount
Ideal is catheterized cath
Chemical Tests for Urine
Clinitest – way to determine sugar in urine (glycosuria)
Benedict’s test – used Benedict’s solution then heat to
check for potency: must remain blue; if not blue, discard
NO BOILING
o
Then add 3-10 drops of urine then heat
o
Negative results
o
Negative: Blue
o
+1 - Green
o
+2 - Yellow
Fundamentals of Nursing
-
o
+3 – Orange
o
+4 - Red
o
Collected before meals
Heat and Acetic Acid Test – test of albuminuria; divide into
3 parts then add 2/3 urine, then 1/3 acetic acid
o
o
o
Turbid/Cloudy – positive
Not reliable since no microscopic instruments
were used
Done mostly in the community, NO BOILING
Quantitative Urine Exam
24-hour Urine Collection – HCG, urinary amylase, urinary
catecholamines, urinary creatinine, urine albumin,
corticosteroids
o
6pm order, discard urine on 6pm, start on 6:01pm
o
Whole amount of urine, need not be midstream
o
Preserve in ice – cold storage
o
Leeway of 15-30mins; get urine after deadline as
long as not too far
Fractional Urine Collection – shorter span; time determined
by doctor
Fecalysis
Color of stool is influenced by stercobilin
Clay colored = acholic stool = biliary track obstruction
Hematochezia = red = lower GI bleeding
Melena = blood = upper GI bleeding
Steatorrhea = fat = gall bladder rpoblem
Foul smelling – indole and skatole
Soft/formed
Dead bacteria, fibers, amorphous phosphates – normal
Live bacteria – abnormal
After 1 hour, the stool cannot be used for fecalysis
Collect abnormal looking feces, not the one which is well
formed
Stool Culture and Sensitivity
Determining exact microorganism
Result also final after 5-7 days
Sterile container
Guiac Test
Occult blood test
No meat, highly colored food, iron preparation, Vit. C in
diet
3 days occult blood sample
Sputum Exam
Done in early morning since secretions already pooled
Sputum C &S – may give oral hygiene to remove mouth
bacteria
Acid Fast Bacilli – 3 consecutive days
Sputum Cytology – cancer cells
Eosinophil determination – to determine allergic reaction
If unconscious, suction may be done: mucus trap
Blood Examinations
FASTING
o
Triglyceride (1-12 hours), BUN (6-8 hours), HDL,
LDL, FBS, Total Protein, Albumin Globulin ration,
uric acid
NON FASTING
o
Crea, Na, K, Ca, CBG (but pre meals)
CBG
-
before meals
University of Santo Tomas – College of Nursing / JSV
-
prick at the side since low blood vessels
Thoracentesis
aspiration of pleural fluid through a needle
orthopneic position
informed consent
Fluid - 7-8 or 8-9 in intercostal posterior axillary line
Air - 2-3, 3-4 in intercostals
Needs chest x-ray
Positioned lying on unaffected side
Thoracostomy
to return to negative pressure
Abdominal Paracentesis
Aspiration of peritoneal fluid in ascites
Semi-sitting/sitting position
Void before procedure
May be therapeutic or diagnostic
Watch out for hypovolemia
Lumbar Puncture/ Tap
L3, L4, L5, subarachnoid space
Paralysis risk low
Fetal position – widens the angle of the lumbar spine
50-200mm – normal CSF pressure
Prepare 4 test tubes since every test requires a different
test tube
Label test tubes and seal with appropriate cover; not with
cotton
Xanthochromic – hemolyzed blood; yellowish discoloration
Flat on bed after procedure (6-8 hours) to prevent spinal
headache
Diagnostic Exams
Visualization procedures
Endoscopy
o
direct visualization; lighted instrument
X-Ray – graphy
o
Contraindicated in pregnant women due to
terratogenic effect
Transformed
o
Ultrasound/ Sonogram
Electroencephalography (EEG)
Shampoo hair before and after procedure
Sedative must be withheld
Determining seizure disorders
Electrocardiography (ECG)
Electromyogram (EMG)
Invasive
Phase 2 – insertion of needle into muscle
CBC needs a heparinized syringe
Magnetic Resonance Imaging
CI: steel implant and pace maker
Some ortho implants/prosthesis are allowed
Assess for claustrophobia
Needs consent since it’s expensive
With contrast in special procedures
NPO – to avoid aspiration in case of untoward reaction
Computed Tomography Scan
Lesion must be bigger
Dye and NPO
Fundamentals of Nursing
Positron Emission Tomography
Radioactive glucose (Fluorine)
Cancer cells have strong affinity for glucose; detect
cancer sites of metastasis
Nuclear Medicine Thyroid Scan
Nodule/tumor on thyroid
For abdominal scans laxative, (castor oil/ Dulcolax) and NPO may
be necessary
Opthalmoscopy
Opthalmoscope
Used in determining cataract
Dim the light and focus light of opthalmoscope in the eye
Fundoscopy may be determined
Otoscopy
Otoscope
A cannula is inserted in the external auditory canal
No need for written consent
3 y/o above – up & back
3 y/o below – down & back
Rhinoscopy
Rhinoscope
Hyperextend the neck
Endoscope
Can be used for surgery, biopsy
Pharyngoscopy
Bronchoscopy
Langyngoscopy
Esophagogastroduedenoscopy
Anoscopy
Proctoscopy – rectum
Sigmoidoscopy
Coloscopy – anus to ileum
o
Cleansing enema until clear
Remove dentures
Remove gag reflex by local anesthetic agent and check
gag reflex
Resume food only when gag reflex is present
Consent and NPO
Urethroscopy
Cystoscopy – bladder, written consent, cystoclysis set up
(continuous flow of sterile water which also exits)
Colposcopy – vaginal examination, needs vaginal
speculum
o
Shirodkar – tying the cervix so that miscarriage is
avoided; incompetent cervix
Roentgenography
Electromagnetic radation photography
Xray but without contrast medium
Chest X-Ray
o
Not definitve of TB
Mammography
o
Examination of breast
Scout Film of Abdomen
KUB
Upper GI Series
Esophagus, stomach, duodenum
Barium swallow (dye) – outline the GI system, flavored, has
constipating effect – inc. fluid
Uses laxative, NPO
University of Santo Tomas – College of Nursing / JSV
Enema to evacuate barium to prevent fecal impaction
Lower GI Series
Barium enema
Outline of colon
Laxative and cleansing enema until it is clean
Pink phosposoda (oral cleansing enema)
Evacuate barium through enema to prevent fecal
impaction
Excretory Urography
Intravenous Pyelography
o
Hypaque- - made from iodine substance; check
for allergy for seafoods
o
Laxative + NPO
o
Given through IV port and the xray series is made
o
Assesses kidney’s ability to filter
o
Assesses presence of stones
o
If reverse, retrograde pyelography
Oral Cholecystography
o
Iapanoic acid (Telepaque) – taken every 5-10
minute interval; 6 tablets
o
Low fat meal the day before the exam
o
Laxative + NPO
Ultrasound/ Sonogram
US Brain
US Heart (2D ECHO, Echocardiography)
o
Regurgitation
o
Stenosis
US Lungs
US Breast/ Sonomamogram
o
Needs tranducer
US Abdomen
o
Colon – laxative, NPO
o
Kidney – KUB
o
Pelvic ultrasound – drink 6-8 glasses to have a full
bladder; do not allow to void
o
Gallbladder ultrasound
Transvaginal Ultrasound
o
Will outline fallopian tube, uterus and ovaries
o
consent
Transrectal Ultrasound
o
Consent
o
Empty the bladder for comfort and good
visualization
o
Visualization of uterus/ prostate
ADMITTING A CLIENT
Types of Bed
Closed – in anticipation for an admission
Open
Post-Op/ Surgical/ Anesthetic/ Heater bed
Occupied
Principle of Bed-making
Body Mechanics: Bed from knees, wide base of support
Obtain help
Asepsis, do not let linen touch uniform
Do not let the linen fall into ground
Finish one side of bed first
Remove wrinkles to have aesthetic value
o
Top sheet – excess linen in foot part
o
Bottom sheet – excess linen in head part
CHANGING GOWN
Remove with free arm first in changing gown
If both with contraption, any arms
ORIENTING THE CLIENT
Fundamentals of Nursing
ASSESSMENT
HISTORY TAKING
PHYSICAL EXAM
VITAL SIGNS
DOCUMENT
chief complaint only found on admission sheet
DISCHARGE OF PATIENT
may be against medical advice (DAMA) but it needs
doctor’s order
health instruction
Illegal detention (false imprisonment)
VITAL SIGNS
Children – Respiratory Rate, Pulse Rate, Temperature
* Blood Pressure can also be obtained in children


Course / Plateau phase: absence of chills, feels warm, up
HR, RR, thirtst
Abatement phase: flushed skin, sweating, reduced
shivering
Average: 36˚ - 38˚ degrees
Hypothermia: 36˚ degrees below
Death: 34˚ degrees
Types of Fever
Intermittent – fluctuates from febrile to afebrile
Remittent – febrile, temperature fluctuation is minimal
Relapsing – fluctuates in days
Constant / Continuous – febrile, temperature fluctuation is wide (+2)
Heat Stroke – depletion of fluid, hypothalamus does not regulate
Hypothermia – induced (surgery), extreme temperature
TEMPERATURE
Types of Temperature
Core temp. – more important; can’t be affected by environment
Surface temp. – more important in children since hypothalamus not
yet developed
Poikilothermia – temp is same with environment; newborn
Homeothermia – different with the environment
Factors that affect Body Temperature
1. Age
2. Ovulation – temp is higher; progesterone
3. Activity – inc. BMR
4. Environment
Temperature conversion
C-F multiply 1.8 + 32
F-C subtract 32/ 1.8
Methods of taking body temperature
Oral – contraindicated in brain damage, mental illness,
retarded, problem with nose and mouth, tooth extraction,
contraption in nose and mouth, altered LOC, dyspnea,
seizures, 7 y/o below
o
2 mins under the tongue
Rectal – contraindicated in imperforate anus, rectal
polyps, hirschprung’s disease, diarrhea, increase ICP,
cardiac disease (may cause vagal stimulation)
o
Not safe since it can cause rectal trauma
o
1 min
Axillary – 3mins
Tympanic – external ear. contraindicated in otitis, ear
surgery; most
accurate
Temporal Scanner - done in temporal; most convenient
Temperature can be checked every 30 mins since hypothalamus
can only fluctuate the temperature every 30 mins
Spot Vital Signs – HR, RR, BP
Thermopacifier – for crying babies
Plastic strip Thermometer – Amitemp
Alterations in body temperature
Hyperpyrexia: 41˚ degrees +
Pyrexia: 37.5˚ - 38˚ degrees +

Onset / Chill phase: up HR, up RR, shivering, cold skin,
cessation of sweating
University of Santo Tomas – College of Nursing / JSV
Nursing interventions
Feels chilled – provide extra blankets
Feels warm – remove excess blankets; loosen clothing
Adequate nutrition and fluids
Reduce physical activity
Oral hygiene
Tepid Sponge Bath – increase heat loss (conduction, convection,
evaporation)
Unexpected Situation and Associated Interventions
During rectal temperature assessment, the patient reports feeling
lightheaded or passes out  Remove the thermometer
immediately. Quickly assess the patient’s BP and HR. Notify
physician. Do not attempt to take another rectal temperature on
this patient.
PULSE
-
Temporal
Carotid – cardiac arrest
Apical
Brachial
Radial – thumb site
Femoral
Popliteal
Affected by the following:
1. Age – the younger, the faster
2. Activity
3. Stres
4. Drugs
 Increase – anticholinergic, sympathomimetic
 Decrease – cardiac glycoside
Palpation
Pattern of Beat (Rhythm)
Regular (60 – 100 bmp)
Irregular (arrhythmia)
o
Bigeminal pulse – 1, 2, disappear
o
Trigeminal pulse – 1, 2, 3, disappear
Pulse Strength = pulse volume
+1 – collapsible. thready
+2 – normal
+3 – full
+4 – full, bounding
Corrigan pulse/ Waterhammer pulse – thready and with full
expansion followed
by sudden collapse.
Fundamentals of Nursing
Auscultation
Apical (PMI)

3rd – 4th ICS MCL (below 7 years old)

4th - 5th ICS MCL (7 years old and aboe)
Unexpected Situations and Associated Interventions
The pulse is irregular  Monitor the pulse for a full minute. If the pulse
is difficult to assess, validate pulse measurement by taking the
apical pulse for 1 minute. If this is a change for the patient, notify the
physician.
You cannot palpate a pulse  Use a portable ultrasound Doppler to
assess the pulse. If this is a change in assessment or if you cannot
find the pulse sing an ultrasound Doppler, notify the physician.
RESPIRATION Normal: 16-20 bpm
Three processes
Ventilation – the breathing in and breathing out

Intact CNS

Clear airway

Intact thoracic cavity

Compliance and recoil
Diffusion – movement of gases from higher to lower concentration

Adequate concentration of gases

Normal lung tissue
Perfusion – circulation of the oxygenated blood to the different
tissues of the body
Inhalation / Inspiration – 1 to 1.5 seconds
Exhalation / Expiration – 2 to 3 seconds
Alterations in Breathing Patterns
Rate
Tachypnea – fast breathing
Bradypnea – slowed breathing
Apnea – absence of breathing
Eupnea – normal breathing
Rhythm
Biot’s – shallow breathing with periods of apnea
Cheyne-Strokes – deep breathing with apnea
Kussmaul’s – deep, rapid breathing (If with respiratory acidosis – to
blow off excess carbon dioxides)
Volume
Hyperventilation – leads to respiratory alkalosis
Hypoventilation – leads to respiratory acidosis
Ease of effort
Dyspnea – difficulty of breathing
Orthopnea – difficulty of breathing within supine position
(best position for this is orthopneic position)
Katupnea - Difficulty of breathing while in sitting position
Trepopnea - ease when in side-lying position
Hyperpnea – inc. rate and depth of respiration
BLOOD PRESSURE
Factor’s Affecting Blood pressure
Age, Gender
Activity, exercise, stress
Time of the day
Korotkoff sounds
Phase 1 – sharp tapping (systolic)
Phase 2 – swishing or wooshing sound
Phase 3 – thump softer than the tapping in phase 1
Phase 4 – softer blowing muffled sound that fades (end = diastolic)
Phase 5 – silence
University of Santo Tomas – College of Nursing / JSV
Kinds
-
Direct – venous pressue, CVP, invasive, cutdown (512mmHg)
Indirect
o
Palpatory
o
Ausultatory
Pulse pressure – 40 mmHg
Pulse deficit (systolic - diastolic)
Mean Arterial Pressure ([2D+S]/D)
Classification
SBP
mmHg
DBP
mmHg
Lifestyle
Modification
Optimal
<120
And <80
Encouraged
Prehypertension
Stage 1 HPN
Stage 2 HPN
Stage 3 HPN
120-139
Or 80-89
YES
140-159
>160
> 180
Or 90-99
Or > 100
Or > 110
YES
YES
YES
Choose the higher BP
Sources of error is BP Assessment
High BP reading
 Bladder cuff too narrow
 Arms unsupported
 Insufficient rest before the assessment
 Repeating reassessment too quickly
 Deflating cuff too slowly
 Assessing immediately after a meal or while client smokes
or has pain
Low BP reading
 Bladder cuff too wide
 Deflating cuff too quickly
 Arm above the level of the heart
 Failure to identify auscultatory gap
OXYGENATION
Respiratory Modalities
Abdominal (diaphragmatic) and purse-lip breathing

Semi / high fowlers position

Slow deep breath, hold for a count of 3 then slowly exhale
through mouth and pursed lip

5 – 10 slow deep breaths every 2 hours on waking hours
Coughing exercise

Upright position

Contraindicated: post brain, spinal or eye surgery

Take two slow deep breaths; on the third breath, hold for
dew seconds, cough twice without inhaling in between

May splint surgical incisions

Every 2 hours while awake
Incentive spirometry

A breathing device that provides visual feedback that
encourages patient to sustain deep voluntary breathing
and maximum inspiration.

10 times every 1 to 2 hours
Chest Physiotherapy

Postural drainage

Percussion

Vibration
Fundamentals of Nursing

Positioning > percussion > vibration > removal of secretions
by coughing or suction
o
Contraindications:

ICP more than 20mmHg, head and neck injury,
active hemorrhage, recent spinal surgery, active
hemoptysis, pulmonary edema, confused or
anxious patients, rib fracture
Postural Drainage

When = morning, at bedtime, 30 minutes – 1 hour before or
1-2 hours after meal

Each position = assumed for 10 – 15 minutes

Entire treatment should last only for 30 minutes
Percussion

Rhythmical force provided by clapping the nurse’s
cupped hands against the client’s thorax

Over affected segment for 1-2 minutes
Vibration

Perform by contracting all the muscles in the nurse’s upper
extremities to cause vibration while applying pressure to
the client’s chest wall

One hand over the other
Suctioning
Purposes

Maintain patent airway

Promote adequate exchange of O2 and CO2

Substitute for effective coughing
Size

Adult: Fr 12-18

Child: Fr 8-10

Infant: Fr 5-8
Length

From tip of nose to earlobe (5 in.)

Nasopharyngeal = 5-6 inches

Oropharyngeal = 3-4 inches

Nasotracheal = 8-9 inches

ET = lenth of ET + 1 inch

Tracheostomy = length of trachea + 1 cm
Suctioning

Duration of suction: 5-10 seconds

Intermittent suctioning upon withdrawal using rotating
motion

If to repeat: 1-2 mins interval

Limit suctioning in a total of 5 minutes
Unexpected Situations and Associated Interventions
Patient vomits during suctioning  If patient gags or becomes
nauseated, remove the catheter; it has probably entered the
esophagus inadvertently. If the patient needs to be suctioned
again, suction catheter because it is probably contaminated.
Secretion appear to be stomach content  Ask the patient to
extend the neck slightly. This helps to prevent the tube from passing
into the esophagus.
Epistaxis noted with continued suctioning  Notify the physician and
anticipate the need for a nasal trumpet.
Oxygen Therapy
Special consideration:
 Given with a doctor’s order
 Careful and continuous assessment to evaluate the need
for and its effect on the patient
University of Santo Tomas – College of Nursing / JSV

Safety precuations: “NO SMOKNG” and “O2 IN USE” signs
at the door
Nasal Cannula (approx. 20-40% of oxygen)

1L/min = 24%

2L/min = 28%

3L/min = 32%

4L/min = 36%

5L/min = 40%

6L/min = 40%
Priority nursing interventions:
o
Check frequently that both prongs are in the patient’s
nares.
o
Encourage the patient to breathe through the nose,
with mouth closed.
o
May be limited to no more than 2-3L/min to patient
with chronic lung disease.
Face mask
Simple face mask (approx. 40-60%)

5-6L/min = 40%

7-8L/min = 50%

10L/min = 60%
Priority nursing interventions:
o
Monitor patient frequently to check the placement of the
mask.
o
Support patient if claustrophobia is a concern.
o
Secure physician’s order to replace mask with nasal
cannula during meal time
Partial rebreather mask (approx. 60-80%)

6-10L/min = up to 80%
Priority nursing interventions:
o
Set flow rate so that mask remains two-thirds full during
inspiration
o
Keep reservoir bag free of twists or kinks.
Nonrebeather mask

10L/min = 80-100%
Priority nursing interventions:
o
Maintain flow rate so reservoir bag collapses only slightly
during inspiration.
o
Check that valved and rubber flaps are functioning
properly (open during expiration and closed during
inhalation)
o
Monitor SaO2 with pulse oximeter.
Venturi mask (most accurate and precise oxygen concentration
delivery)

4L/min = 24%

4L/mins = 28%

6L/min = 31%

8L/min = 35%

8L/min = 40%

10L/min = 50%
Oxygen Tent
Unexpected Situations and Associated Interventions
Child refuses to stay in the tent  Parent may play games in the tent
with child. Alternative methods of O2 delivery may need to be
considered if child still refuses to stay in tent.
It is difficult to maintain an O2 level above 40% in the tent  Ensure
that the flap is closed and edges of tent are tucked under blanket.
Check O2 delivery unit to ensure that rate has not been changed.
Patient was confined on O2 delivered by nasal canula but now is
cyanotic, and the pulse oximeter reading is less than 05%  Check
to see that O2 tubing is still connected to the flow meter.
Fundamentals of Nursing
becomes cyanotic or patient becomes
bradycardic  Stop suctioning. Auscultate lung
sounds. Consider hyperventilating patient with
manual resuscitation device. Remain with
patient.
When dozing, patient begins to breathe through the mouth 
Temporarily place the nasal cannula near the mouth. If this does not
raise the pulse oximetry reading, you may need to obtain an order
to switch the patient to a mask while sleeping.
Inhalation Therapy
Moist inhalation – Steam inhalation = 12- 18 inches; 15 – 20 mins.
Dry inhalation – Metered dose inhaler = use of spacer; hold breath
for 10 seconds with 5 minutes interval
o
Patient is accidentally extubated during tape
change.  Remain with the patient. Instruct
assistant to notify physician. Assess patient’s vital
signs, ability to breathe without assistance and O2
saturation. Be ready to administer assisted breaths
with a bag-valve mask or administer O2.
Anticipate need for reintubation.
o
Patient is biting on ET  Obtain a bite block. With
the help of an assistant, place the bite block
around the ET or in patient’s mouth.
o
Lung sounds are greater on one side  Check
the depth of the ET. If the tube has been
advanced, the lung sounds will appear greater
on one side on which the tube is further down.
Remove the tape and move tube so that it is
placed properly.
**Water
Child – has 70- 90 percent water
Adult – has 50-70 percent water
Males have more water than females since they have more adipose
tissue
Artificial Airways
Oropharyngeal airway

Prevents tongue from falling back against the posterior
pharynx

Measurement: from opening of the mouth to the ear (back
angle of the jaw)

Check for loose teeth, food and dentures
Unexpected Situations and Associated Interventions
o
The patient awakens  Remove the oral airway
o
The tongue is sliding back into the posterior pharynx,
causing respiratory difficulties  Put on disposable gloves
and remove airway. Make sure airway is the most
appropriate size for the patient.
o
Patient vomits as oropharyngeal airway is inserted 
Quickly position patient onto his side to prevent aspiration
Nasopharyngeal Airway / Nasal Trumpets

Indications Clenched teeth, enlarged tongue, need for
frequent nasal suctioning

Measurement: from the tragus of the ear to the nostrils plus
one inch

Proper lubrication for easy insertion
Endotracheal

Indications: route for mechanical ventilation, easy access
for secretion removal, artificial airway to relieve
mechanical airway obstruction.

Care for patients with ET:
o
Repositioned at least every 24-48 hours
o
Depth and length during insertion should be
maintained
o
Level of tube: gumline / biteline
o
Maintain cuff pressure of 20-25 mmHg
o
Check lips for cracks and irritation
Unexpected Situations and Associated Interventions
o
Patient is accidentally extubated during
suctioning  Remain with the patient. Instruct
assistant to notify physician. Assess patient’s vital
signs, ability to breathe without assistance and O2
saturation. Be ready to administer assisted breaths
with a bag-valve mask or administer O2.
Anticipate need for reintubation.
o
Oxygen saturation decreases after suctioning 
Hyperoxygenate patient.
o
Patient develops signs of intolerance to
suctioning; O2 saturation level decreases and
remains low after hyperoxygenating, patient
University of Santo Tomas – College of Nursing / JSV
Tracheostomy

To maintain patent airway and prevent infection of
respiratory tract.

Care of patient with tracheostomy:
o
Sterile technique: acute phase
o
Clean technique: home care
o
1st 24 hours: tracheostomy care every 4 hours
o
Prevent aspiration
Unexpected Situations and Associated Interventions
o
Patient coughs hard enough to dislodge
tracheostomy  Keep a spare tracheostomy and
obturator at the bedside. Insert obturator into
tracheostomy tube and insert tracheostomy into
stoma. Remove obturator. Secure ties and
auscultate lung sounds.
Pulse Oxymetry

Purpose: measure arterial blood O2 by external sensor
(non-invasive)

Placement
o
Adult: usually on the finger
o
Pedia: usually on the big toe
o
Other sites: earlobes, nose, hand and feet
NUTRITION
Principles in the Promotion of Good Nutrition

The body requires food to:
o
Provide energy for organ function, movement,
and work.
o
Provide raw materials for enzyme function,
growth, replacement of cells and repair.

The process of digestion, absorption, and metabolism work
together to provide all body cells with energy and
nutrients.

Man’s energy requirement vary and is influenced by many
factors: Age, body size, activity, occupation, climate,
sleep, physiological stress, pathological disorders, lifestyle,
and gender.
Fundamentals of Nursing
Foods are described according to the density of their nutrients.
Nutrient density – the proportion of essential nutrients to the number
of kilocalories.
Macronutrients – Give off calories for energy

Fat soluble viramins: Vit. A, D, E, and K
Micronutrients – No calories, vitamins and nutrients

Water soluble vitamins: Vit. C, B1, B2, B3, B6, B9, and B12
Calorie (kcal) – unit of energy measurement; amount of heat
required to raise the temperature of 1kg of water to 1°C
Sources:
CHO – 4 calories/gm; first to be burned
FATS – 9 colories/gm; stored as adipose tissue
CHON – 4 calories/gm; meat
Alcohol – 7 calories/gm
Vitamins
Fat soluble - ADEK
Water soluble – B complex , C
Macrominerals – 100 mg or more
Microminerals – Less than 100 mg; Zinc, iron, iodine
**Kaesselbach’s plexus – prone to epistaxis
B Vitamins – Metabolism since these have enzymatic activity
Vit B1 (Thiamin)
Deficiency: Beri-beri; Wernicke-Korsakoff Syndrome
Edema in wet Beri-beri
Vit B2 (Riboflavin)
Deficiencies: Ariboflavinosis, cheilosis
o
Angular stomatitis - mouth fissures
Vit B3 (Niacin)
Deficiency: Pellagra – butterfly sign, cassel’s collar
Vit B5 (Pantothenic Acid)
Keeps integrity of hair
Deficiency: alopecia
Vit B6 (Pyridoxin)
Deficiency: Neuritis
**Potato – highest in potassium
**The tip of the banana has the highest amount of potassium
Vit B12 (Cyanocobalamin)
Definition: pernicious anemia, neuritis
Iodine – prevent cretinism
Zinc – to improve appetite
Iron - correct anemia
Hypervitaminosis – increase in vitamins intake; occurs commonly in
fat soluble
Vit C (Ascorbic)
Inc. absorbtion of iron
Deficiency : scurvy – easy bruising, gums, perifollicular
lesion, hemorrhage
Types of Diet
Regular
–
Has all essentials, no restrictions
–
No special diet needed
Clear liquid
–
“see-through foods” like broth, tea, strained juices, gelatin
–
Recovery from surgery or very ill
Full liquid
–
Clear liquids plus milk products, eggs
–
Transition from clear to regular diet
Soft diet
–
Soft consistency and mild spice
–
Difficulty swallowing
Mechanically soft
–
Regular diet but chopped or ground
–
Difficulty chewing
Bland
–
Chemically and mechanically non stimulating, no spicy
food
–
Ulcers or colitis
Low residue
–
No bulky foods, apples or nuts, fiber, foods having skins and
seeds
–
Rectal disease
High calorie
–
High protein, vitamin and fat
–
Malnourished
Low calorie
–
Decreased fat, no whole milk, cream, eggs, complex CHO
–
Obese
Diabetic
–
Balance of protein, CHO and fat
–
Insulin-food imbalance
High protein
–
Meat, fish, milk, cheese, poultry, eggs
–
Tissue repair and underweight
Low fat
–
Little butter, cream, whole milk or eggs
–
Gallbladder, liver or heart disease
No hypervitaminosis in water soluble since it is easily eliminated in
urine
Overweight – increase in macronutrients; may progress to obese
Marasmus
calorie malnutrition
Old man facie, intercostals and subcostal retractions
Kwashiorkor
moon face, Globular abdomen, edema
protein malnutrition
VITAMIN DEFICIENCIES
Vit A (Retinol)
Healthy eyes, skin, and gums
Deficiency: Xeropthalmia (night blindedness) – Bitot’s spot
Severe: Keratomalacia (irreversible)
Vit D (Calciferol)
Not coming from the sun; but sunlight activates it
Enhances calcium and phosphorus absorption
Deficiency: Ricketts
Severe: Osteomalacia
o
Bow legged – genu varum
o
Knock knee – genu valgum
o
Pectus carinatum (Harrison’s groove)
o
Spinal deformity
o
Stunted growth
You can store calcium up to 31 years
Vit E (Tocopherol)
Antioxidant: remove free radicals
Amount should not go 400 units because if it exceeds. It
becomes prooxidant
En hances RBC maturation
Deficiency: anemia
Vit K (Menadione)
Anti-hemorragic
Deficiency: hemorrhagic, bleeding
University of Santo Tomas – College of Nursing / JSV
Fundamentals of Nursing
Low cholesterol
–
Little meat or cheese
–
Need to decrease fat intake
Low sodium
–
No salt added during cooking
–
Heart or renal disease
Nutritional Problems
1. Antropometric Measurement
a. BMI – kg/m2
i. Underweight – below 18
ii. Normal – 18-24
iii. Overweight – 24 above
2. Biochemical Assay – laboratory exams
3. Clinical signs – sx/s
4. Dietary History
a. Food habits
Anorexia – no eating
Bulimia – binge-purge syndrome
Management:
Hygiene
Small frequent feeding
Serve attractively
Enteral and Parenteral Nutrition
Parenteral Nutrition
 Nonfunctional GIT
 Extended bowel rest
 Preoperative TPN
Enteral Nutrition
 Cancer
 Neurological and Muscular disorder
 Gastrointestinal disorder
 Respiratory failure with prolonged intubation
Nasogastric Tube Feeding/ Levine’s Tube

Position: sitting

Head: hyperextend and slightly flexed

Insertion: NEX (Tip of the nose – Earlobe – Xyphoid Process)

pH gastric content: 4 – 6

Confirmation: By X-ray
Gavage

Position: sitting

Gastric aspirate: >1000mL – withhold feeding; put back the
residue

If with medication and is not gastric irritant: 20-30cc
flushing > meds > feeding > 20-30cc flushing
Lavage

To irrigate the stomach in case of gastric bleeding, food
poisoning or ingestion; if corrosive substance: do not
irrigate

Position: sitting

Gastric aspirate: discard

Amount of irrigating solution: 750mL – 1L
Unexpected Situations and Associated Interventions
o
Tube found not to be in the stomach or intestine  Replace
the tube
o
Patient complains of nausea after tube feeding  Ensure
that the head of the bed remains elevated and that
suction equipment is at bedside; Check medication record
to see if any antiemetics is ordered.
o
When attempting to aspirate contents, the nurse notes that
tube is clogged  Try using warm water and gentle
University of Santo Tomas – College of Nursing / JSV
pressure to remove the clog; Never use a stylet to unclog
the tubes; Tube may have to be replaced.
Gastrostomy / Jejunostomy Feeding

Long term nutritional support, more than 6 – 8 weeks

Place in high fowler’s position

Check the patency of the tube: Pour 15-30 cc of water

Check the patency of the tube: Pour 15-30 cc of water

Check for residual feeding

Hold asepto-syringe 3-6 inches above ostomy feeding

Frequently assess for skin breakdown
Unexpected Situations and Associated Interventions
o
Gastrostomy tube is leaking large amount of drainage 
Check tension of the tube; Apply gentle pressure to tube
while pressing the external bumper closer to the skin; If
tube has an internal balloon holding it in place, check to
make sure that the balloon is inflated properly.
o
Skin irritation around the insertion site  Stop the leakage,
as prescribed previously and apply a skin barrier.
o
Site appears erythematous and patient complains of pain
at the site  Notify physician, patient could be developing
cellulitis at the site.
French is directly proportional to size
Gauge is inversely proportional to size
**Intravenous Hyperalimentation/ TPN
Kabiven
Watch out for gylcosuria and blood sugar
May necessitate insulin
Large needle since it is central route
Monitor for complications
ELIMINATION
URINE ELIMINATION
1200 – 1500cc/day
Normal output: 30ml/hour
Urge to urinate: 300-500ml
Poliacuria – frequent, scanty urine
Urgency – urge but unproductive of urinate
Retention – stimulate urination, running water, warm water over
perineum, warm compress, and straight catheterization
Catheterization
Indication:
 Decompression
 Instillation
 Irrigation
 Specimen collection
 Urine measurement: Residual urine; Hourly urine output
 Promotion of healing of GUT
Catheter size

Children: Fr 8-10

Female adult: Fr 14-16; Fr 12 for young girls

Male adult: Fr 16-18
Position

Female: dorsal recumbent

Male: supine with thighs slightly abducted
Length of insertion

Female: 2-3 inches (5 – 7.5 cm)

Male: 7-9 inches (17 – 22.5 cm)
Anchor

Female: inner thigh

Male: Top of thigh or lower abdomen
Unexpected Situations and Associated Interventions
Fundamentals of Nursing
o
o
No urine flow is obtained and you note that catheter is in
vaginal office  Leave catheter in place as a marker;
Obtain new sterile gloves and catheter set; Once new
catheter is correctly in place, remove the catheter in
vaginal orifice.
Patient complains of extreme pain when you are inflating
the balloon  Stop inflation of balloon; Withdraw solution
from the balloon.
Bladder Irrigation
Open system (intermittent)
– For installation of medications or irrigation of catheter
Closed system (Intermittent or Continuous)
– For those who had genitourinary surgery
– For instillation of medications, promoting homeostasis,
flushing of
clots or debris
**NEVER INFLATE THE BALLOON UNLESS URINE FLOWS
**If inserted in vagina, keep in place but insert another one
Catheter can be placed in one month as long as no signs of
infection
Condom Catheter – must be secured through a belt
Fides’ Maneuver – application of pressure in the bladder to stimulate
urine
BOWEL ELIMINATION
Assessment

Inspection – Auscultation – Percussion – Palpation
approach

Bowel sound (4 quadrants)
o
Active – every 5-20 seconds
o
Hypoactive – 1 per minute
o
Hyperactive – every 3 seconds
o
Absent – None heard in 3-5 minutes

Fecalysis – an inch of formed stool, 15-30 mL of liquid stool

Fecal occult blood testing / Guiac test
Fecal Elimination Problems
Diarrhea – watery stools; ORESOL; banana rice apple
Constipation – hard stools; laxative; Psilium (bulk-formers), Castor oil
(GI irritant)
Tenesmus – urge to but unproductive of stool
Fecal impaction
constipation and seepage of watery stools
No enema
Digital/Manual extraction with doctor’s order
Monitor for vagal stimulation; stop if signs are noted
Eructation/ Belching
Expulsion of gases through mouth
Flatulence/Typanism
Avoid gas forming foods: cauliflower, cola
Carminative enema – expel flatus
Rectal tube insertion – inserted in anus then placed in
water for 20 mins; if need to be repeated wait for 2-3 mins.
to prevent anal sphincter damage
Types of Laxatives
Bulk forming – Increases fluid, gaseous or solid bulk (Metamucil,
Citrucel)
Emolient / Stool Softener – Softens and delays drying of feces
(Colace)
University of Santo Tomas – College of Nursing / JSV
Stimulant / Irritant – Irritates / stimulates (Dulcolax, Senokot, Castor
Oil)
Lubricant – Lubricates (Mineral Oil)
Saline / Osmotic – Draws water into intestine (Epsom salts, Milk of
Magnesia)
Enema
Types
Cleansing Enema

Prior to diagnostic test, surgery

In cases of constipation and impaction

Either be: High enema (12-18 in.) or Low enema (12 in.)
Carminative Enema

To expel flatus

60 – 80 mL of fluid
Retention Enema

Solution retained for 1-3 hours

Oil enema, antibiotic enema, anti-helminthic enema,
nutritive enema
Return-flow Enema

To expel flatus

Alternating flow of 100-200 mL of fluid in and out of the
rectum
Enema Administration
Appropriate Size

Adult: Fr 22-30

Child: Fr 12-18
Correct Volume

Adult: 750 – 1,000 mL

Adolescent: 500 – 750 mL

School-aged: 300 – 500 mL

Toddler: 250 – 350 mL

Infant: 150 – 250 mL
Length of Insertion

Adult: 3-4 inches

Child: 2-3 inches

Infant: 1 – 1 ½ inches
Commonly Used Enema Solutions
Hypertonic – Draws water into colon (Sodium phosphate solution)
Hypotonic – Distends colon, stimulates, softens (Tap water)
Isotonic – Distends colon, stimulates, softens (Normal saline)
Soap suds – Irritates mucosa, distends colon (3-5 mL soap to 1L of
water)
Oil – Lubricates feces (Mineral, olive, cottonseed)
Unexpected Situations and Associated Interventions
o
Solution does not flow into the rectum  Reposition
rectal tube, if solution will still not flow, remove tube
and check for any fecal contents.
o
Patient cannot retain enema solution for adequate
amount of time  Patient needs to be placed on
bedpan in the supine position
o
Patient cannot tolerate large amounts of enema
solution  Amount and length of administration may
have to be modified if the patient begins to complain
of pain
o
Patient complains of severe cramping with
introduction of enema solution  Lower solution
container and check temperature and flow rate; If
the solution is too cold, or too fast, severe cramping
may occur.
Colostomy
 Size of stoma will be stabilized within 6-8 weeks
 Effluent; Foul-smelling and irritating to the skin = ileostomy
Guidelines for Ostomy Care
Fundamentals of Nursing






Keep patients as free of odors as possible. Empty ostomy
appliance frequently.
Inspect stoma frequently
Normal color of stoma, pinkish-red, moist. Pale or bluish
indicates cyanosis or decreased circulation in the tissue
Note the side of the stoma
Keep skin around the peristomal area clean and dry
Intake and output
Unexpected Situations and Associated Interventions
o
Peristomal skin is excoriated or irritated  Make sure
appliance is not cut too large; Assess for presence of
fungal skin infection; Thoroughly cleanse skin and
apply skin barrier; Allow to dry completely; Reapply
pouch
o
Patient continues to notice odor  Check system for
any leaks or poor adhesion; Thoroughly empty pouch
MEDICATIONS
Parenteral
Intradermal
Gauge 25 -25
Insert only the bevel; zero to 15 degree angle
Epidermal
Sensitivity test
Subcutaneous
Stretch if fat, pinch if thin
Adipose layer of the buttocks, arms
Best site is abdomen, below the umbilicus!
Gauge 23-25, 5/8 inch inserted
If long needle, insert 5/8; if short 90 degree
Intramuscular
Must be strictly 90 percent
1-1.5 inch
Gauge 22-23
Z-track technique
Deep IM
Prevent leakage of solution to tissue
**NO INSERTION IN GLUTEUS MAXIMUS, BUT ON MINIMUS AND MEDIUS
Intravenous
IV Push – check backflow, if none do not insert
IV infusion pump – for more accurate drip
Soluset – chamber up to 100cc; microset calibration
Opthalmic solution – lower conjunctival site; 1-2 drops at maximum
Rectal Suppository – go beyond the anal sphincter
Inhaler – may use spacer


Decrease inflammation
Local anesthetic effect
Inflammation – first 24 hours = cold; then heat
Pain – cold; to block nerve
Dry heat
Hot water bags temperature: 110-125 degrees F
Disposable hot packs
Floor lamp / gooseneck lamp / heat cradle
o
Bulb = 25 watts
o
Distance = 12-24 inches
Dry cold application
Ice cap
Compress
After 15 mins
Tepid Sponge Bath
Do anterior first
Use 1 washcloths
Sitz Bath
immersion of 110-115 degrees Fahrenheit
do not remove rectal pack, remove rectal dressing
may have cerebral hypoxia – put ice cap on forehead
WOUND MANAGEMENT
No gauze cause it can stick to skin
Center to outer when cleaning
Jackson Pratt
keep in negative pressure; remove drainage
in head injury, can have JP but not on negative pressure
since it can interfere with ICP
HYGIENIC MEASURES
Perineal care
Female: Dorsal recumbent; front to back
Male: Supine; circular
one stroke, one direction
Oral Care
Brushing – sulcular technique
Lemon-glycerine swab, mineral oil
Oral hygiene for unconscious
supine, head turned to one side
antiseptic solution
Bed Bath
Water temperature: 43-46C or 110-115F
Arms: Long, firm strokes, distal to proximal
Breasts: Female – circular; Male – Longitudinal
DO NOT USE INHALER IN STEROIDS TO PREVENT MOUTH SORES!
HEAT AND COLD APPLICATION
 Do not prolong more than 20 mins. because of rebound
Heat





Cold



Vasodilation
Increase capillary permeability
Increase cellular metabolism
Increase inflammation
Sedative effect
Vasoconstriction
Decrease capillary permeability
Decrease cellular metabolism
University of Santo Tomas – College of Nursing / JSV
EXERCISE AND ACTIVITY
Active-assitive – one side help the affected side
Isotonic – jogging; change in length
Isometric – mucle tension no change in length
Isokinetic – weights
Aerobic – exceed oxygen needs
Anerobic – does not exceed oxygen needs
Massages
Effleurage – smooth, long gliding stroke
Petrissage – large pinch of skin; “kneading”
Tapotement – side of each hand, sharp hacking movement
Fundamentals of Nursing
Immobility
Thrombus formation
Edema
Constipation
Urinary stasis – stones- calculi
Atrophy
Disuse syndrome
Trochanter roll to prevent external rotation of femur
Pressure Ulcer
Decubitus ulcer/ bed sore
Prone in bony surfaces
1 – non blanchable erythema
2 – open lesion
3- with fat exposed
4 – exposed mucles and bones
Dressing
-
Transparent barrier
Gauze not used
To absorb exudates
Hydrocolloid
SLEEP
Rest – State of calmness; relaxation without emotional stress or
freedom from anxiety.
Sleep – State of consciousness in which the individual’s perception
and reaction to the environment are decreased.
Physiology of Sleep
Reticular Activating System (RAS) – responsible in keeping you
awake and alert
Bulbar Synchronizing Region (BSR) – causes sleep
Types of Sleep
NREM (Non-Rapid Eye Movement/ deep, restful sleep / slow-wave
sleep)
Stage I: very light; drowsy; relaxed, eyes roll from side-to-side; lasting
a few mins.
Stage II: light sleep; body processes slow further (decrease PR/RR),
eyes are still; lasts about 10-20 mins.
Stage III: domination of the PNS; difficult to arouse; not disturbed by
sensory stimuli; snoring; muscles totally relaxed.
Stage IV: delta sleep; deep slow-wave sleep
REM (Rapid Eye Movement)
 Where most dreams take place.
 Brain is highly active, hence, paradoxical sleep
Common Sleep Disorders
Insomnia – warm bath, massage, milk (tryptophan), medication
Parasomnia – periods of waking up while asleep
Somabulism – sleep walking; lock the door
Soliloquy – sleep talk
Notcurnal enuresis (night)/Diurnal enuresis (morning) – Bed wet,
place diaper
Bruxism – anxiety; grinding of teeth
Hypersomnia – excessive sleep; may have hypothyroid, DKA
Narcolepsy – uncontrolled desire to sleep; ampethamine - taken
after breakfast, anorexiant
University of Santo Tomas – College of Nursing / JSV
PAIN
-
Subjective
May have psychogenic pain as well
Acute – less than 6 months
Chronic – more than 6 months
Intractable – not relieved
Wong and Baker Scale – 1-10 rating
Phantom pain – pain from amputated limb
Gate Theory of Pain - Substantia gelatinosa
Pain threshold
May be psychological/ physiological
o
Heat and cold
o
Imagery and distraction
DEATH
Thanantology – study of death
Stages of Grieving by Kubler Rosss
Post-mortem care
Must be pronounced dead by physician
Rigor Mortis - stiffening
Algor Mortis – change in temperature
Livor Mortis – color change