FUNDAMENTALS OF NURSING DAY 1

THEORIES OF NURSING
NURSING PROCESS
PHYSICAL ASSESSMENT

Historical and Contemporary Nursing Practice

Theodore Fliedner- opened a small hospital and training school at Kaiserswerth Germany
- No economic gain
- Devotion to duty and hard work
- Self-denial, spiritual calling
- Led to exploitation and few monetary rewards
Harrieth Tubman- the Moses of her people
- Abolitionist, provided care and safety to slaves
- Used Spiritual as coded messages warning fellow travelers of danger or to signal a clear
path
Sojourner Truth- “The Truth calls me”
- Abolitionist and a women’s right activist, religious tolerance
- Spirit calls me and I must go
Dorothea Dix- Defender of Mentally ill and Prisoner
- Set guidelines for nurse candidates
- Early US nursing pioneer--predecessor and contemporary of Florence Nightingale
- Strong advocate for the mentally ill and for prisoners
- Civil War Superintendent of Union Army Nurses
Florence Nightingale- Called by God to help
- L-ady with the Lamp
- A-dvocate for the improvement of care and condition in the military hospital
-dvocate for sanitary living condition
- M-odern Nursing sets as an example of commitment, compassion and diligent hospital
administration
- P- olitical Nurse reformed hospital and produced public health policies
Clara Barton- Established American Red Cross
- Established the main agency to obtain and distribute supplies to wounded soldiers
Linda Richard- First trained Nurse
- Initiated wearing of uniforms
- Introduced Nurse’s notes and Doctors order
Mary Mahoney- First African American Professional Nurse
- Worked for the acceptance of African American Nursing
Lilian Wald- Founder of American Community Nursing/ Public Health Nursing
- Activist for peace, women’s, children’s and civil rights
Lavinia L. Dock- pioneer in nursing education and social activist
Margaret Sanger- Founder of Planned parenthood
- Imprisoned for opening the first birth control information clinic
Mary Breckinridge- provided health care to the people of rural America
 - Started one of the midwifery training schools in the US

Theories of Nursing
Metaparadigm for Nursing
1. Person/Client- recipient of care (Individual, family, group and community)
2. Environment- internal or external surroundings that affect the client
3. Health- degree of wellness or well-being the client experiences
4. Nursing- attributes characteristics and actions of the nurse providing care

Nightingale’s Environmental Theory

- The act of utilizing the environment of the patient to assist him in his recovery.
- Five environmental factors – pure/ fresh air, pure water, efficient drainage, cleanliness
and light especially direct sunlight

Peplau’s Interpersonal Relations Model

-Hildegard Peplau Identified four sequential phases in the interpersonal relationship:
1. Orientation
2. Identification
3. Exploitation
4. Resolution
Orientation phase
- Problem defining phase
- Starts when client meets nurse as stranger
- Defining problem and deciding type of service needed
- Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and
expectations of past experiences
- Nurse responds, explains roles to client, helps to identify problems and to use available
resources and services
Identification phase
- Selection of appropriate professional assistance
- Patient begins to have a feeling of belonging and a capability of dealing with the problem
which decreases the feeling of helplessness and hopelessness
Exploitation phase
- Use of professional assistance for problem solving alternatives
- Advantages of services are used is based on the needs and interests of the patients
- Individual feels as an integral part of the helping environment
- They may make minor requests or attention getting techniques
- The principles of interview techniques must be used in order to explore, understand and
adequately deal with the underlying problem
- Patient may fluctuates on independence
- Nurse must be aware about the various phases of communication
- Nurse aids the patient in exploiting all avenues of help and progress is made towards the
final step
Resolution phase
- Termination of professional relationship
 - The patients’ needs have already been met by the collaborative effect of patient and nurse
- Now they need to terminate their therapeutic relationship and dissolve the links between
them.
- Sometimes may be difficult for both as psychological dependence persists
- Patient drifts away and breaks bond with nurse and healthier emotional balance is
demonstrated and both becomes mature individuals

Henderson’s Definition of Nursing

- She emphasized the importance of increasing the patient’s independence so that progress after
hospitalization would not be delayed
- She described the nurse's role as substitutive (doing for the person), supplementary (helping the
person), complementary (working with the person), with the goal of helping the person become
as independent as possible.

The 14 components
1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes-dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and modifying
environment
8. Keep the body clean and well groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others.
10. Communicate with others in expressing emotions, needs, fears, or opinions.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and
use the available health facilities.

The first 9 components are physiological. The tenth and fourteenth are psychological aspects of
communicating and learning The eleventh component is spiritual and moral The twelfth and
thirteenth components are sociologically oriented to occupation and recreation

Roger’s Science of Unitary Human Beings

- Humans are dynamic energy in continuous exchange with environmental fields.
- Nurses’ use of noncontact therapeutic touch is based on the concept of human energy
fields.

OREM’S GENERAL THEORY OF NURSING

Orem’s general theory of nursing in three related parts:-
1. Theory of self-care
2. Theory of self-care deficit
3. Theory of nursing system
A. Theory of Self Care
This theory Includes:
Self-care – practice of activities that individual initiates and performs on their own behalf in
maintaining life,health and well being
Self-care agency – is a human ability which is "the ability for engaging in self-care" -conditioned
by age developmental state, life experience sociocultural orientation health and available
resources
Therapeutic self-care demand – "totality of self care actions to be performed for some duration in
order to meet self care requisites by using valid methods and related sets of operations and
actions"
Self care requisites-action directed towards provision of self care.

B. Theory of self-care deficit

Specifies when nursing is needed
Nursing is required when an adult (or in the case of a dependent, the parent) is incapable or
limited in the provision of continuous effective self-care. Orem identifies 5 methods of helping:
- Acting for and doing for others
- Guiding others
- Supporting another
- Providing an environment promoting personal development in relation to meet future
demands
- Teaching another

C. Theory of Nursing Systems

Describes how the patient’s self care needs will be met by the nurse , the patient, or both
Identifies 3 classifications of nursing system to meet the self care requisites of the patient:-
- Wholly compensatory system
- Partly compensatory system
- Supportive – educative system
Design and elements of nursing system define
Scope of nursing responsibility in health care situations
General and specific roles of nurses and patients
Reasons for nurses’ relationship with patients and
The kinds of actions to be performed and the performance patterns and nurses’ and patients’
actions in regulating patients’ self care agency and in meeting their self care demand
Orem recognized that specialized technologies are usually developed by members of the health
profession

King’s Goal Attainment Theory

- Theory describes a dynamic, interpersonal relationship in which a person grows and
develops to attain certain life goals.
- Shows the relationship of operational system (individual), interpersonal system (nurse-
patient), and social system (educational and health care system.
 If perceptual interaction accuracy is present in nurse-client interactions, transaction will
occur
  If nurse and client make transaction, goal will be attained

 If goal are attained, satisfaction will occur

 If transactions are made in nurse-client interactions, growth & development will be

enhanced

 If role expectations and role performance as perceived by nurse & client are congruent,
transaction will occur

 If role conflict is experienced by nurse or client or both, stress in nurse-client interaction

will occur

Neuman’s Systems Model

The lines of resistance represent the internal factors that help the patient defend against a
stressor, the normal line of defense represents the person's state of equilibrium, and the flexible
line of defense depicts the dynamic nature that can rapidly alter over a short period of time.

The purpose of the nurse is to retain this system's stability through the three levels of prevention:

1. Primary prevention to protect the normal line and strengthen the flexible line of defense.
2. Secondary prevention to strengthen internal lines of resistance, reducing the reaction, and
increasing resistance factors.
3. Tertiary prevention to readapt and stabilize and protect reconstitution or return to
wellness following treatment.

Roy’s Adaptation Model

- Person Is a biopsychosocial adaptive system
- Input (stimuli)- throughput (control processes)- output (behaviours or adaptive response)
- Response needs- Physiologic Mode fluid and electrolyte , fluid and elimination, oxygen,
circulation
- Interdependence- relation with significant others
- Role function- need for social integrity, performance of duties
- Self concept- physical and personal self

Leininger’s Cultural Diversity

Human caring varies among cultures in its expressions, processes and patterns.

Watson’s Human Caring Theory

- Caring promotes health more than does curing

NURSING PROCESS
- Is a systematic, rational method of planning and providing nursing care. Its purpose is to
identify a client’s health care status and actual or potential health problems, to establish
 plans to meet the identified needs, and to deliver specific nursing interventions to address
those needs.

Assessment is the systematic and continuous collection, organization, validation and

documentation of data. In effect assessing is a continuous process carried out during all phases of
the nursing process.

Subjective data- refers to a symptoms or covert data. Only apparent to the person affected and
can be described or verified only by that person.

Objective data- refers to a sign or over data, detectable by an observer or can be measured or
tested against an accepted standard.

Sources of data
Primary- Client
Secondary- Family members, other support persons, health professionals, records and reports,
laboratory and diagnostic analyses, and relevant literature.

Components of a Nursing Health History

Biographic data- Clients name, address, age, sex, marital status, occupation, religion preference,
health care financing

Chief Complaint

Medical History- Childhood illness, immunizations, allergies to drug, accidents and injuries,
Hospitalizations and medications

Family History of Illness- to ascertain risk factors for certain diseases, the ages of siblings,
parents, and grandparents and their current state of health.

Psychosocial data- Family relationships/ friendships, ethnic affiliation, occupational history,

major stressors and usual coping pattern

Activities of Daily Living

Diagnosing- nurses use critical thinking skills to interpret assessment data and identify client
strengths and problems.

Types of Nursing Diagnoses

Actual Diagnosis- is a client problem that is present at the time of nursing assessment.
Risk Nursing Diagnosis- clinical judgement that a problem does not exist, but the presence of
risk factors indicates that a problem is likely to develop unless nurse intervenes.
Wellness Diagnosis- Describes human response to levels of wellness in an individual, family or
community that have a readiness for enhancement.
Possible Nursing Diagnosis- one in which evidence about a health problem is incomplete or
unclear.
Syndrome diagnosis- is associated with a cluster of other diagnoses.

Components of a NANDA Nursing Diagnosis

Problem and Definition- the problem statement or diagnostic label, describes the client’s health
problem or response for which nursing therapy is given.
Etiology- (Related factors and Risk factors) identifies one or more probable causes of the health
problem
Defining Characteristics- are cluster of signs and symptoms that indicate the presence of
particular diagnostic label.

The Diagnostic Process

- Analyzing data
- Identifying Health problems, risks and strengths
- Formulating diagnostic statements

Planning- is a deliberative, systematic phase of the nursing process that involves decision
making and problem solving.

Types of Planning
Initial Planning- this should be initiated as soon as possible after the initial assessment.
Ongoing Planning- done by all nurses who work with the client. Ongoing Planning also occurs at
the beginning of a shift as the nurse plans the care to be given that day.
Discharge Planning- the process of anticipating and planning for needs after discharge, is a
crucial part of comprehensive health care and should be addressed in each client’s care plan.

The Planning Process

- Setting Priorities
- Establishing client goals/ desired outcomes
- Selecting Nursing Intervention
- Writing Individualized nursing intervention on care plans

Types of Nursing Interventions

Independent Intervention- are those activities that nurse are licensed to initiate on the basis of
their knowledge and skills
Dependent Interventions are activities carried out under the physician’s order or supervision or
according to specified routines.
Collaborative Interventions are actions the nurse carries out in collaboration with other health
team members.

Implementing is the action phase in which the nurse performs the nursing interventions

Implementing Skills
Cognitive skills include problem solving, decision making, critical thinking and creativity.
Interpersonal Skills are all activities, verbal and non-verbal, people use when interacting directly
with one another.
Technical Skills are purposeful “hands-on skills” such as manipulating equipment, giving
injections and repositioning client.

The Process of Implementing

- Reassessing the client
- Determining clients need for assistance
- Implementing the Nursing Intervention
- Supervising the delegated care
- Documenting nursing activities

Evaluation- collects data related to outcome

- Compare data with outcomes
- Relate nursing actions
- Draw conclusions about problem status
- Continue, modify or terminate the client’s care plan

PHYSICAL ASSESSMENT
Method of Examination
Inspection is the visual examination that is assessing by using the sense of sight.
Palpation is the examination of the body by using the sense of touch. The pads of the fingers are
used because their concentration of nerve endings makes them highly sensitive to tactile
discrimination.
Percussion is the act of striking the body surface to elicit sounds that can be heard or vibrations
that can be felt
Auscultation is the process of listening to sounds produced within the body.

The Integument
Skin
Pallor – conjunctiva, oral mucous membranes, nail beds, palms of the hand and soles of the feet.
Dark skin- absence of underlying red tones in the skin in the buccal mucosa
Brown skinned- yellowish brown tinge
Black skinned- ashen gray
Cyanosis- nail beds, lips, buccal mucosa
Dark skinned- palpebral conjunctiva, palms and soles
Jaundice- evident in the sclera of the eyes, mucous membranes and the skin
Dark skinned- normal yellow pigmentation in the sclera, if suspected the posterior part of
the hard palate should also be inspected for a yellowish color tone.

Nails- colorless and has a convex curve (160 degrees)

Blanch test- test the capillary refill, peripheral circulation
Spoon shape/ Koilonychia- nail curves upward from the nail bed
Clubbing- angle between nail and nail bed is 180 degrees or greater
Beau’s line- horizontal depressions in the nail that can result from injury or severe illness
Onychomycosis- nail fungus (brittleness, discoloration, thickening, distortion of nail shape)
Paronychia- inflammation of the tissues (ingrown nail)
Hair- resilient and evenly distributed
Kwashiorkor- faded appears reddish or bleached, coarse and dry
Hypothyroidism- very thin and brittle hair
Alopecia- hair loss

The Head
Normocephalic- normal head size
Exopthalmos- protrusion of the eyeballs with elevation of the upper eyelid, resulting in a startled
or staring expression
Moon face- round face with reddened cheeks

Eyes and Vision

Mydriasis- enlarged pupils/ dilated, insicate injury of glaucoma or result from such drugs like
atropine
Miosis- constricted pupils, indicate an inflammation of pupils or result from such drugs like
morphine or pilocarpine
Anisocria- unequal pupils, may result from a central nervous system disorder

Rosenbaum eye chart- test near vision

Snellen or character chart- test distance vision

Functional Vision Testing

Light perception- shine a penlight into the client’s eye from a lateral position and turn the light
off.
Hand movements- hold your hand 30 cm from the clients face and move it slowly back and forth
Counting Fingers- Hold up some of your fingers 30 cm from the clients face and ask client to
count your fingers.

Ears and Hearing

Low set ears- associated with a congenital abnormality such as Down syndrome
Straighten the Ear Canal
- Adult- straighten the ear by pulling the pinna up and back
- Children (less than 3 years)- down and back
Gross Hearing Acuity Test
- Normal Voice Tones
- Watch tick test
- Tuning Fork Test
Weber’s test
Rinne test
Tympanic membrane- pearly gray color, semitransparent

Nose and Sinuses

A speculum is not necessary to examine the septum, turbinates, and vestibule. It may cause the
child to be apprehensive, instead push the tip of the nose upward with the thumb and shine a
light into the nares.
Central Vessels
Carotid artery- Palpate one carotid artery at a time, avoid exerting too much pressure and
massaging the area.
Listen for presence of a bruit if positive gently palpate the artery to determine the
presence of a thrill (suggest occlusive artery disease).

Jugular veins- assess for distention while the client is placed in a semi fowler’s position with the
head supported in a small pillow (30-45 degrees angle). Veins not visible indicates that the right
side of the heart is functioning normally.

Peripheral Vascular System

Homans’ test- firmly dorsiflex the clients’ foot while supporting the entire leg in the extension, or
have the person stand or walk
Pain in calf muscles with forceful dorsiflexion of the foot (positive Homans’sign) a sign
of phlebitis
Buerger’s test- assist client to a supine position, ask client to raise one leg or one arm about 30
cm above heart level, move the foot or arm briskly up and down for about 1 minute and then sit
up and dangle the leg or arm.
Original color returns in 10 seconds, veins in feet or hands fills in about 15 seconds
Capillary refill test- Squeeze client’s fingernail and toenail between your fingers sufficiently to
cause blanching (about 5 seconds)
Normally refills immediately less than 2 seconds.

Breast and Axillae

The majority of breast tumors are located in the upper outer breast quadrant including the Tail of
Spence

Abdomen
Assist client to supine position with the arms placed comfortably at the sides. Place small pillows
beneath the knees and the head to reduce tension in the abdominal muscles. Expose the client’s
abdomen only from the chest line to the pubic area to avoid chilling and shivering.

Method of Examination
Inspection- inspect for skin integrity, observe abdominal movements associated with respiration,
peristalsis or aortic pulsations

Auscultation-
For bowel sounds- ask when client last ate
Normoactive- irregular gurgling noises occurring about every 5-20 seconds
Hypoactive- extremely soft and infrequent occurring about one per minute
Hyperactive- high pitched, loud rushing sound occurring about every 3 seconds
Percussion- begin in the RLQ- RUQ-LUQ-LLQ

Palpation- Light palpation first to detect areas of tenderness and muscle guarding
 - If client is excessively ticklish begin by pressing your hand on top of the client’s hand
while pressing lightly. Then slide your hand off the client’s and onto the abdomen to
continue the examination
-
Neurologic System
Romberg Test- Ask the client to stand with feet together and arms resting at the sides, first with
eyes open then closed
- Negative Romberg may sway slightly but able to maintain upright posture
Finger to Nose and to the Nurse’s Finger- ask the client to touch the nose and then your index
finger.
- Normal findings: performs with coordination and rapidly.
Heel down Opposite Shin- Ask the client to place the heel of one foot just below the opposite
knee and run the heel down the shin to the foot
- Demonstrates bilateral equal coordination.
Stereognosis- Place familiar objects, such as a key, paper clip, or coin, in the clients hand, and
ask client to identify them.
Graphesthesia- Write a number or letter on the client’s palm, using a blunt instrument, and ask
the client to identify it.
Extinction Phenomenon- Simultaneously stimulates two symmetric areas of the body, such as the
thighs, the cheeks or the hand.

CRANIAL NERVE FUNCTIONS AND ASSESSMENTS METHOD

Cranial Nerve Function Assessment Method
Olfactory Smell Ask client to close eyes and
identify different mild aromas
Optic Vision and Visual Field Snellen chart
Opthalmoscopic examination
Oculomotor Extraocular eye movement Six ocular movements and
pupil reaction
Trochlear EOM Six ocular movements
Trigeminal
- Opthalmic Sensation of cornea, skin of Assess skin sensation
- face and nasal mucosa
- Maxillary Sensation of skin of face and
- anterior oral cavity
- Mandibular Sensation of skin of face,
muscles of mastication
Abducens EOM Assess direction of gaze
Facial Facial expression, taste Ask client to smile, raise the
eyebrows, frown, and puff out
cheeks, close eyes tightly. Ask
client to identify various tastes
Acoustic
- Vestibular Equilibrium Romberg Test
- Cochlear Hearing Hear spoken words, vibrations
of tuning fork
Glossopharyngeal Swallowing ability,
tongue Apply taste on posterior
movement tongue. Move tongue side to
side
Vagus Sensation of pharynx and Assess speech for hoarseness,
larynx, swallowing gag reflex (ah)
Accessory Head movement and Ask client to shrug shoulders
shrugging of shoulders against resistance from your
hands and turn head to side
against resistance
Hypoglossal Protrusion of tongue moves Ask client to protrude tongue
tongue up and down and side at midline then move tongue
to side up and down and side to side

Superficial Cutaneous Reflex

Cremasteric- stroke the inner surface of the thigh. Observe for prompt elevations of the testis on
the ipsilateral side.
Plantar/ Babinski- stroke the lateral aspect of the sole from the heel to the ball of the foot curving
medially across the ball.
Negative- five toes bend downward
Positive- the toes spread outward and the big toe moves upward
Pathologic Reflexes
Brudzinski’s sign- flex patient’s neck forward while in recumbent position. Observe voluntary
flexion of the knee and pain
Kernig’s sign- flex patient’s legs at hip and knee. Observe neck flexion and pain.

PREPARED BY:
MISCHELL Q. TIONGSON RN, MAN