CONCEPTUAL FOUNDATIONS OF NURSING

CHAPTER I
NURSING

Topic Description:
This topic focuses on the practice of nursing. The history of nursing will be
discussed as well as its evolution. And also, the many facets of the modern day nurse
will be explained. The history of TCQC-SLMC will also be brought to light in this chapter.

Competencies:
1. Define Nursing.
2. Knowledge on the History of Nursing locally and globally.
3. Determine the different roles of the modern day nurse.
4. Insight on how St. Luke’s College of Nursing was established.

OBJECTIVES TOPIC TIME STUDENT EVALUATIO

FRAME ACTIVITIES N
Determine how Nursing: Definition 1 Day Lecture Pre- Test
nursing came to
be. History of Nursing Discussion Post- Test

Determine the Evolution of Nursing Role Play on any Recitation

development of Education of the topics
Nursing education
in the Philippines Roles of
and the world. Professional Nurses

Elaborate the History of TCQC-

different roles the SLMC
professional nurse
perform.

Trace the roots of

St. Luke’s College
of Nursing.

Name the founders

of St. Luke’s
College of Nursing.

CONCEPTUAL FOUNDATIONS OF NURSING

1
 Chapter I
NURSING

DEFINITION:
 The term nurse originated from the Latin word NUTRIX- which means “to
nourish.
 The art and science of care.

Nightingale
The act of utilizing the environment of the patient to assist him in his recovery

Henderson
The unique function of the nurse is to assist the individual sick or well. In the
performance of the activities contributing to health or its recovery that he would
perform unaided if he head necessary strength, will or knowledge, and to do this
in such a way as to help him gain independence rapidly as possible.

Rogers
A Humanistic science dedicated to compassionate concern with maintaining and
promoting health, preventing illness and caring for rehabilitating the sick and the
disabled.

Roy
A theoretical system of knowledge that prescribes a process of analysis and
action related to the care of the ill or potentially ill persons.

Orem
A helping or assisting service to person who are wholly or partially dependent-
(infants, children and adults) where their parents, guardians, or other adult
responsible for their care are no longer able to give or supervise their care.

King
A helping profession that assists individuals or groups in society to attain,
maintain and restore health. If this is not possible, nurses help individual die with
dignity.

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 HISTORY OF NURSING

Ancient History
During this time beliefs about the cause of disease was embedded in superstition
and magic. Treatment often involved magical cues.

Contributions of the Greeks

Hippocrates – the father of Medicine Made a major advance in medicine by rejecting

the belief that diseases had supernatural causes. He also is credited with developing
assessment standards for clients, establishing overall medical standards, and
recognizing a need for nurses.

Early Christian Era

 Religion has a great role in the development of nursing during this time. Many of
the world’s religion encourage benevolence “Love thy neighbor as thyself”.
 Deacons and Deaconess were designated to perform services for the sick.
 Phoebe – is the most noted deaconess in nursing history. Fabiola – established
the first general hospital in Rome about 380 AD

The Middle Ages

 Poverty was a critical problem during the Middle Ages.
 During this time, society faced epidemics of leprosy, typhus and bubonic plague.
 The Crusaders resulted in the establishment of military nursing and the
recruitment of men into nursing.
 The church dictates the scope of nursing practice and viewed the spiritual needs
of clients as the priority of care.

The Renaissance
 “ The revival of learning spurred the advance of Medicine”
 This revival had contributed to recognition of the need for sound education
preparation in nursing and to the profession’s further advancement.
 Lack of effective sanitation and increasing poverty resulted in serious healthcare
problems, further delayed the move towards improving the nursing education.

The Reformation
 The dispersion of religious orders, which had been the primary source of
healthcare, resulted in a serious deterioration in hospital conditions and nursing
care.
 Women were viewed as subordinate to men and were expected to remain at
home caring for children; this decreased the number of women practicing
nursing.

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Nursing in the 18th Century
 Revolutions and epidemics resulted in the expansion of Nursing roles. Continuing
problems related to healthcare needs (poor sanitation and low standards of
living).
 By the end of the century, nursing was present in hospitals but working
conditions were poor, resulting in a loss of social status for members of the
profession.

Nursing in the 19th Century

 The Industrial Revolution initiated political, economic, and social expansion
throughout North America and Europe.
 Poverty, long work days for men, prevalence of disease increased the need for
nurses to addressed community health problems.
 Religion once again was influential; the Caring image of the nurse was believed
to be based on Spiritual calling to the profession.

Florence Nightingale
 Founder of Modern Nursing
 Improved health laws, reformed hospitals, reorganized military medical services.
 Nightingale viewed “Sick Nursing”- as helping clients use their own reparative
process to get well and “Health Nursing” – as preventing illness.
 Was born May 12, 1820 in Florence Italy
 She was educated in languages, philosophy and the liberal arts.
 Her hope was to replace “Sarah Gamp” image with one of education, intelligence
and kindness.
 “Trained” for 3 mos. in Kaiserswerth Germany
 Studied in Paris Sisters of Charity for further nursing Training
 Then returned to England and became the nurse superintendent at King’s
College Hospital
 During the British war- she took cared of the injured and sick soldiers. Her efforts
were credited with decreasing the mortality rate by half, and soon became known
as the “Lady with the lamp”.
 Because of her hard work and dedication she was awarded with $4500. And she
used this money to start the Nightingale Training School.
 Her efforts has changed the status of Nursing profession to a respectable
occupation.

Nursing During the American Civil War

 More hospitals and better prepared nurses were needed.
 Dorothea Dix - established the Nurse Corps of the US Army.
 Clara Barton - Founded the American Red Cross

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Nursing Education in the 19th Century
 1869 – the American Medical Association developed the Committee on the
Training of Nurses; as a result of this committee’s recommendations, hospital
based School of Nursing under medical supervision emerged.
 Lillian Wald (1867-1940)- founded the Henry Street Settlement and Visiting
Nurses Service (circa 1893) which provided nursing and social services and
organized educational and cultural activities. She was considered the founder of
public health nursing.
 Lillian Wald and Mary Brewster - established the first public Health nursing
service for the sick and the poor.

Nursing in the 20th Century

 Spanish American War - Volunteer Nurse Corps (1898)
 Nurses were transported to war areas in Europe and the Far East to care for the
sick and wounded.
 Esther Lucille Brown - wrote that nursing education belonged in colleges and
universities. And the need for university based education programs.
 **Black Nurses were admitted to the nursing Service.

National Commission on Nursing and Nursing Education

Addressed several issues including supply and demand for nurses, clarification
of nursing roles and functions, nursing education, and available career opportunities.
The report was called “Lysaught report, it helped clarify the role of professional nursing
practice.

PROFESSIONAL DEVELOPMENT OF NURSING IN THE 20TH CENTURY

Professional organizations were created:

 American Nurses Association(ANA)
 National League of Nursing ( NLN)
 American Association of Colleges of Nursing( AACN)
 American Journal of Nursing(AJN)
 Professional organizations were created:
 American Nurses Association(ANA)
 National League of Nursing ( NLN)
 American Association of Colleges of Nursing( AACN)
 American Journal of Nursing(AJN)

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 EVOLUTION OF NURSING EDUCATION IN THE UNITED STATES

1. Practical/ Vocational Nursing Programs

- a 1 year program that prepares nurses to perform technical skills under the
provision of registered nurses.
Differs than RN in two areas:
a. Educational preparation
b. Scope of practice

2. Diploma Nursing Program

 Used to be hospital sponsored, were at one time the primary source of nurses.
 First type of educational preparation for RNs, usually require 3 years of study.
 Can work as beginning practitioner in acute, intermediate, long term, and
ambulatory care.
 Must demonstrate competency in the Nursing process.

3. Associate Degree Nursing Program

 Initially developed in response to nursing shortage.
 Students pursuing this degree attend junior college for 2 years, receiving college
credit for all courses and clinical experience.
 Goal of the program is to prepare technical nurses who are capable of
functioning as quality practitioners under the supervision of professional nurses.

4. Three – Year Graduate Nurse Course

5. Baccalaureate Degree Nursing Program

 Offers students a full college or university education with background on liberal
arts.
 The programs provide students with credits for nursing courses and clinical
experience in all areas of nursing practice.
 Emphasizes community, health, leadership, and management.

ADVANCE NURSING EDUCATION OPPORTUNITIES

Master’s Degree Nursing Program

- Graduate education prepares nurses for advanced, independent practice with
continued emphasis on research.

Doctoral Degree Program

 Must have finished their master’s Degree.
 Advanced preparation for clinical research is a major component.

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 ROLES OF THE PROFESSIONAL NURSE

a. Care Provider
The nurse supports the clients by attitudes and actions that show concern for client
welfare and acceptance of the client as a person.

b. Communication/Helper
The nurse communicates with clients, supports persons and colleagues to facilitate all
nursing actions.

c. Teacher
The nurse provides health teaching to effect behavior change, which focus on acquiring
new knowledge or technical skills. This role give emphasis on health promotion and
health maintenance

d. Counselor
The nurse helps the client to recognize and cope with stressful psychologic or social
problems to develop improved personal relationships and to promote personal growth.
This role includes providing emotional, intellectual and psychologic support.

e. Client Advocate
The nurse promotes what is best for the client, ensures that the client’s needs are met,
and protects the client’s rights.

f. Leader
The nurse through the process of interpersonal influence, helps the client make
decisions in establishing and achieving goals to improve his well being.

g. Change Agent
The nurse initiates changes and assists the client make modifications in the lifestyle to
promote health. This roles involves identifying the problem, assessing the client’s
motivations and capacities for change, determining alternatives, assessing resources,
determining appropriate helping roles, establishing and maintaining a helping
relationship, recognizing phases of the change process and guiding the client make
decision through this phases.

HISTORY OF TCQC-SLCN

1903 - St. Luke’s hospital opened its doors for service as a small dispensary.

October 1907 - The school of Nursing opened at the same time St. Luke’s Hospital
known then as University Hospital.

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The first 3 Students of St. Luke’s were:
1. Quintana Beley
2. Veneranda Sulit
3. Caridad Goco

MISS. ELLEN T. HICKS

- was the Superintendent of nurses when the school of nursing opened in October
1907.

1911 - the first graduates of the St. Luke’s Hospital School of Nursing had their
commencement exercises in the Columbia Club in Ermita
The first graduates were sent to the United States and took a post graduate course in
the Protestant Episcopal Hospital in Philadelphia, Pennsylvania. This was made
possible by their benefactor Mrs. Elizabeth Whitelaw Reid.

June 1912 – The three graduates returned to the Philippines armed with the degree
that they have earned. They were assigned as members of the school faculty.
Degrees Earned:
1. Quintana Beley- General care of medical cases
2. Veneranda Sulit- OR and Surgical technique
3. Candida Goco- Children’s Disease

September 1917- Miss Hicks left for the US. There were 22 student nurses and 5
filipina head nurses at St. Luke’s Hospital.

DEACONESS CHARLOTTE MASSEY

 Took charge as school superintendent in 1918- 1921.
 Through her effort one of the graduates was sent to America to take her post
graduate course in dietetics.
 She was sponsored by the scholarship of the Daughters of the American
Revolution in 1921. And was sent to St. Luke’s Hospital in San Fransisco.

MISS. FELIZA DAVIS

 Was assigned as superintendent when Deaconess Massey was assigned to a
mission in the mountain province.
 But due to ill health she stayed at St. Luke’s Hospital for a brief time only.

8
MISS. LILIAN J. WEISER
 Superintendent of nurses in the early part of 1923
 Always concerned with nurses welfare and raising the standards of instruction
 Training was shortened to 3 years
.

MRS. VITALIANA G. BELTRAN

 In 1926, she was given a full time teaching job and was later assigned to assist in
the management of the school of Nursing which position she held until 1941.
 Later appointed superintendent of nurses when Mrs. Weiser resigned.

World War II
 Accommodated hundreds of sick American, British Interns who were allowed to
leave the concentration camp.
 Doctors and nurses stayed to render services to the sick, including Filipino and
Chinese patients.
 After the Liberation, The school of Nursing faculty focused attention to the
improvement of the school facilities and the standard of instruction.

MISS. MARY VITA BELTRAN

 She was given a scholarship grant in 1946 by the women's auxiliary of New York
and Pittsburg.
 Obtained an M.A Degree at Teachers’ College Columbia University.
 Appointed Principal of the School of Nursing.

Important Dates in the History of

St. Luke’s Hospital School of Nursing
 1911 Graduated its 1st batch of nurses
 1941 (December) World War II broke out and schools were closed.
 1943 Schools were resumed after the Japanese doctors and nurses took over.
 1907 St. Luke’s Hospital then called University Hospital opened training
school for nurses.
 1945 Japanese team left the country, Filipino staff continue the work
 1946 Graduation of the post War class
 1954 Incorporation of the St. Luke’s Hospital School of Nursing. It
began to have a separate Board of trustees and operated its own
budget. It was during this year when Mrs. Ester A. Santos
( Principal of the School at that time proposed that the school look into the
possibility of offering a BSN Program for its nurses.
 1956 BSN proposal was shelved by the Board of Trustees because of
requirements for a collegiate program.
 1963 Purchase of Capitol City College by the Episcopal Church thru
Prime Bishop Ret. Rev. Lyman C. Ogilby. It was renamed Trinity
College of Quezon City

9
  1965 The 1st class was admitted to take courses under the BSN program
of TCQC SLCN.
 1970 The 1st BSN class who graduated under a 5 Yr. Curriculum.
 1975 School granted special permission to offer a 2 year program.
Graduated later on took a 3 year Diploma Program. Took
licensure examination and became Registered Nurses.
 1975 Accredited by the Philippine Accrediting Association For
Schools, Colleges, and Universities.(PAASCU)
 1980 Graduated the last batch of the 5 year curriculum and started the
1st batch of the 4 year curriculum
 1984 New Curriculum with RLE implemented
 1988 1st graduates of the New BSN curriculum with RLE.

History of Nursing in the Philippines

Earliest Hospitals in the Philippines

- Hospital Real De Manila ( 1577 )
– San Lazaro Hospital ( 1578 )
– Hospital de Indios (1586 )
– Hospital de Aguas Santas ( 1590 )
– San Juan de Dios Hospital ( 1596 )

1st Hospitals with School of Nursing

1. Iloilo School of Nursing ( 1906 )
2. St. Paul’s Hospital School of Nursing ( 1907 )
3. Philippine General Hospital School of Nursing ( 1907 )
4. St. Luke’s Hospital School of Nursing ( 1907 )
5. Mary Johnston Hospital and School of Nursing ( 1907 )

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 CHAPTER II
THEORIES OF NURSING

Topic Description:
This topic focuses on the theories of nursing. In this chapter the different
theorist’s view on nursing will be examined.

Competencies:
1. Determine the theories of Nursing.
2. Identify the different theorist and their work.

OBJECTIVES TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Discuss the Theories of Nursing: 2 Days Lecture Pre- Test
different
theories of Florence Nightingale Discussion Post- Test
Nursing.
Dorothy Johnson Recitation
Differentiate
one theory Myra Estrin Levine
from the other.
Imogene King
Determine the
application of Faye Glenn Abdellah
each theory in
the day to day Betty Neuman
life of our
patients and to Sister Callista Roy
us as nurses.
Ida jean Orlando

Virginia Henderson

Hildegard Peplau

Martha Rogers

Dorothea Orem

Jean Watson

Dunn’s Concept of Health

Travis’ Concept of Health

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 Chapter II
THEORIES OF NURSING

Florence Nightingale (1960/1969)

 Often considered the first nurse theorist
 Defined nursing as “the act of utilizing the environment of the patient to assist
him in his recovery”.
 Nightingale’s theory remains an integral part of nursing and healthcare today.

5 Environmental Factors:
1. Pure or fresh air
2. Pure water
3. Efficient drainage
4. Cleanliness
5. Light, especially direct sunlight

Nightingale’s general concepts are:

1. Ventilation 4. Warmth
2. Cleanliness 5. Diet
3. Quiet

Dorothy E. Johnson (1980)

The Behavioral System Model for Nursing
 Focuses on how the client adapt to illness; the goal of nursing is to reduce stress
so that the client can move easily through recovery.
 Viewed the patient’s behavior as a system that is a whole with interacting parts.
The nursing process is viewed as a major tool.

Purpose: To reduce stress so the client can recover as quickly as possible.

View of components
Person: A system of interdependent parts with patterned, repetitive, and purposeful
ways of behaving.

Environment: All forces that affect the person and that influence the behavioral system.

Health: Focus on person, not illness. Health is a dynamic state influenced by biologic,
psychological, and social factors.

Nursing: Promotion of behavioral system, balance, and stability. An art and science
providing external assistance before and during system balance disturbances.

12
Myra Estrin Levin(1973)
Conservation Model

Described the Four Conservation Principles. She advocated that nursing is

a human interaction and proposed four conservation principles of nursing which
are concerned with the unity and integrity of the individual. The four principles are as
follows:
1. Conservation of Energy – The human
body functions by utilizing energy. The human body needs energy producing input
(food, oxygen, fluids) to allow energy utilization as output.
2. Conservation of Structural Integrity- the human body has physical boundaries
(skin, and mucous membranes) that must be maintained to facilitate health and
prevent harmful agents from entering the body.
3. Conservation of Personal Integrity- the nursing interventions are based on the
conservation of the individuals personality. Every individual has a sense of identity,
self-worth and self-esteem, which must be preserved and enhanced by the nurses.
4. Conservation of Social Integrity- the social integrity of the clients reflects the family
and the community in which the clients functions. Health care institutions may
separate individuals form their family. It is important for nurses to consider the
individual in the context of a family.

Imogene King (1971)

Goal Attainment Theory

 Highlights the importance of the participation of all the individuals in decision

making & deals with the choices, alternatives, & outcomes of nursing care
 This theory offers insights into nurses’ interactions with individuals & groups
within the environment
 Defines Health as a dynamic state in the life cycle; illness is an interference in
the life cycle. Health implies a continuous adaptation to stress
 Described nursing as a helping profession that assists individuals and groups in
society to attain, maintain and restore health. If this is not possible, nurses help
individuals to die with dignity.
 Viewed nursing as an interaction between the client and the nurse whereby
perceiving, setting goals and acting on them, transaction occurs and goals are
achieved.

13
 Imogene King’s
Goal Attainment Model

Social Systems (Society)

Interpersonal System
(Groups)

Personal
Systems Imogene King
(Individuals) A conceptual framework for nursing:
Dynamic interacting systems.
Nursing process is defined as
dynamic interpersonal process
between nurse, client and health care
system.

14
Faye Glenn Abdellah (1960)
Patient-Centered Approaches to Nursing

Purpose: To deliver nursing care for the whole individual.

 Abdellah described nursing as a service to people, families and society. The

nurse helps people, sick or well, to cope with their health needs. In Abdellah’s
model, nursing care means providing information to the client or doing something
to the client with the goal of meeting needs or alleviating an impairment.

View of components
Person: The recipient of nursing care having physical, emotional, and sociologic
needs that may be overt or covert.

Environment: Not clearly defined. Some discussion indicates that client interact
with their environment, of which the nurse is a part.

Health: Implicitly defined as a state when the individual has no unmet needs and
no anticipated or actual impairments.

Nursing: Broadly grouped in “21 nursing problems.”

1. To maintain good hygiene.
2. To promote optimal activity: exercise, rest, and sleep.
3. To promote safety.
4. To maintain good body mechanics.
5. To facilitate the maintenance of supply of oxygen.
6. To facilitate maintenance of nutrition.
7. To facilitate maintenance of elimination.
8. To facilitate the maintenance of fluid and electrolytes balance.
9. To recognize the physiologic response of the body to disease conditions.
10. To facilitate the maintenance of regulatory mechanisms and functions.
11. To facilitate the maintenance of sensory function.
12. To identify and accept positive and negative expressions, feelings and reactions.
13. To identify and accept the interrelatedness of emotions and illness.
14. To facilitate the maintenance of effective verbal and non-verbal communication.
15. To promote the development of productive interpersonal relationship.
16. To facilitate progress toward achievement of personal spiritual goals.
17. To create and maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with varying needs.
19. To accept the optimum possible goals.
20. To use community resources as an aid in resolving problems arising from illness.
21. To understand the role of social problems as influencing factors.

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Betty Neuman (1972)
Health Care Systems Model

Views client as an open system consisting of a basic structure or central core of

energy resources (physiologic, psychologic, sociocultural, developmental, &
spiritual) surrounded by lines of resistance that defends client against stressors

 She asserted that nursing is a unique profession in that it is concerned with all
the variables affecting an individual’s response to stresses which are intra
(within), inter (between one or more people) and extra-personal ( outside the
individual) in nature.
 The concern of nursing is to prevent stress invasion, to protect the client’s basic
structure and obtain or maintain maximum level of wellness.
 The nurse helps the client, through primary, secondary, and tertiary prevention
modes, to adjust to environmental stressors and maintain client system stability.

Betty Neuman’s
Health Care Systems Model

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Sister Callista Roy (1979)
Adaptation Model
 Focuses on the individual as a biopsychosocial adaptive system. Both the individual
& the environment are sources of stimuli that require modification to promote
adaptation, an on-going purposive response
 The individual receives inputs or stimuli from both the self & the environment
 She contended that the person is an adaptive system, function as a whole through
interdependence of its parts.
 The system consists of input, control process, output and feedback.
 In addition, she advocated that all people have certain needs which they endeavor to
meet in order to maintain integrity

These needs are divided into four different modes, the physiological, self concept, role
function, and interdependence.

Accordingly Roy believed that adaptive human behavior is directed toward an

attempt to maintain homeostasis or integrity of the individual by conserving energy
and promoting the survival, growth, reproduction and mastery of the human
system.

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 Sister Callista Roy’s
Adaptation Theory

Views the client as an adaptive system. The goal of nursing is to help the person adapt to changes in psychological
needs, self-concept, role function and interdependent relations during health and illness. The physical, psychological
and social environment in the care of clients is a nursing consideration.

Input Control Process Effectors Output

Physiological function Adaptive
Coping Self-concept And
Stimuli Mechanisms Role function Ineffective responses
Adapatation Regulator Interdependence
Level Cognator

The person as an adaptive system

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Ida Jean Orlando (1961)
The Dynamic Nurse-Patient Relationship

 Three elements – Client behavior, nurse reaction and nurse actions – compose
the nursing situation.
Purpose: To interact with clients to meet immediate needs by identifying client
behaviors, nurse’s reactions, and nursing actions to take.
Views of Components
Person: Unique individual behaving verbally and nonverbally. Assumption is that
individuals are at times able to meet their own needs and at other times unable to
do so.
Health: Not defined. Assumption is that being without emotional or physical
discomfort and having a sense of well-being contribute to a healthy state.
Nursing: Professional nursing is conceptualized as finding out and meeting the
client’s immediate need for help. Medicine and nursing are viewed as distinctly
different.
The concept of need is central to Orlando’s theory, which focuses on clients and their
unmet needs. Orlando believed that the purpose of nursing is to provide the assistance
that a client requires to meet his or her needs.

Ida Jean Orlando’s

Dynamic Nurse – Patient Relationship Model

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Virginia Henderson
Definition of Nursing

 Nursing as a discipline separate from medicine.

 Described nursing in relation to the client and the client’s environment
 Concerned with both healthy and ill individuals even when recovery may
not be feasible
 Teaching and advocacy roles of the nurse

The 14 Fundamental Needs

1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body waste
4. Moving and maintaining a desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature within normal range by adjusting clothing and
modifying the environment
8. Keeping the body clean and well groomed to protect the integument.
9. Avoiding dangers in the environment and avoiding injuring others.
10. Communicating with others in expressing emotions, needs, fears, or opinions
11. Worshipping according to one’s faith
12. Working in a such way that one feels a sense of accomplishment
13. Playing or participating in various forms of recreation
14. Learning, discovering, or satisfying the curiosity that leads to normal
development and health, and using available health facilities

Hildegard Peplau (1952)

Interpersonal Relations Model

 The use of a therapeutic relationship between the nurse and the client.

The nurse-client relationship evolves four phases:

1. Orientation
 The client seeks help
 The nurse assist the client to understand the problem and the extent of the need
for help.

2. Identification
 The client assumes a posture of dependence, interdependence, or independence
in relation to the nurse.
 The nurse’s focus is to assure the person that the nurse understands the
interpersonal meaning of the client’s situation.

20
3. Exploitation
 The client derives full value from what the nurse offers through the relationship.
 The client uses available services based on self-interest and needs.
 Power shifts from the nurse to the client.

4. Resolution
 Old needs and goals are put aside and new ones adopted. Once older needs are
resolved, newer and more mature ones emerge.

Nurses’ Roles:
 Stranger
 Teacher
 Resource Person
 Surrogate
 Leader
 Counselor

21
 Hildegard Peplau’s
Interpersonal Relationship Model

Person: Person:
Nurse Patient/Client

Learning
Further Nurse uses
all concepts &
Self-
Other
processes Nurse-Patient Developing Learning
Relationship Competencies
Understanding Relationship Other
(including phases) Health
Thinking Relationship
Communication Self-
Preconcepti Thinking Understanding
Health ons Employs Integration
Roles Self –
Understanding Preconcepti
Anxiety Self-understanding ons
Compentencies
Anxiety

22
Martha Rogers
Science of Unitary Human Beings

 Views person as an irreducible whole, the whole being greater than the sum of its
parts. Whole is differentiated from holistic.
 States that the humans are dynamic energy fields in continuous exchange with
environmental fields, both of which are infinite.
 Both human and environmental fields are characterized by pattern, a
universe of open systems, and four dimensionality.

What is a unitary man? Unitary man :

 Is an irreducible, four-dimensional energy field identified by pattern
 Manifests characteristics different from the sum of parts
 Interacts continuously and creatively with the environment
 Behaves as a totality
 As a sentient being, participates creatively in change.

Nurses applying Roger’s theory in practice:

a. focus on the person’s wholeness
b. seek to promote symphonic interaction between the two energy fields to
strengthen the coherence and integrity of the person
c. coordinate the human field with the rhythmicities of the environment field
d. direct and redirect patterns of interaction between the two energy fields to
promote maximum health potential.

Non-therapeutic touch:
 based on human energy fields
 affected by pain and illness
 can assess and feel the energy field and manipulate it to enhance the healing
process of people who are ill or injured.

Dorothea Orem
General Theory of Nursing
 Three related concepts
1. Self-care
2. Self-care deficit
3. Nursing systems

Self-care theory is based on four concepts:

2. Self-care – activities an individual performs independently to promote and
maintain personal well-being.
3. Self-care agency – individual’s ability to perform self-care activities. Consists of
two agents
a. A self care agent – an individual who performs self-care independently

23
 b. A dependent care agent – a person other than the individual who provides
the care
c. Self – care requisites (self-care needs) – actions or measures taken to
provide care. There are three categories:
i. Universal requisites – includes: Intake and elimination of air, water
and food; balancing rest, solitude, and social interaction; preventing
hazards to life and well-being; and promoting normal human
functioning.
ii. Developmental requisites – results from maturation or are
associated with conditions and events.
iii. Health deviation requisites – result from illness, injury or disease or
its treatment. (eg. Seeking health care assistance, carrying out
prescribed therapies, and learning to live with the effects of illness
or treatment)
d. Therapeutic self- care demand – all self-care activities required to meet
existing self-care requisites. ( Actions to maintain health and well-being

R R
Self-care

Contributing Contributing
Factors R Factors
Self-care
agency Self-care
< demands
Deficit

R
R
Nursing
Contributing Agency
Factors

Self-care deficit
 results when self-care agency is not adequate to meet the known self-care
demand.

5 Methods in helping:
a. Acting or doing for d. Supporting
b. Guiding e. Providing an environment that promotes the individual’s
c. Teaching abilities to meet current and future demands

24
 3 Types of Nursing Systems:
1. Wholly compensatory systems are required for individuals who are
unable to control and monitor their environment and process
information.
2. Partly compensatory systems are designed for individuals who are
unable to perform some, but not all, self-care activities
3. Supportive-educative (developmental) systems are designed for
persons who need to learn to perform self-care measures and need
assistance to do so.

Basic Conditioning Factors for Self-care Agency and Therapeutic Self Care
Demand:
 Age
 Gender
 Developmental state
 Sociocultural orientation
 Health State
 Family system factors
 Health care system factors
 Patterns of living
 Environmental factors
 Resource availability and adequacy

Basic Conditioning Factors for Nursing Agency

 Age
 Gender, race
 Physical and constitutional characteristics
 Health state
 Family/Community roles
 Nursing educational preparation
 Nursing experience
 Maturity/Status as a person

Jean Watson
Human Caring Theory

 Believes the practice of caring is central to nursing: it is the unifying focus

for practice
 Carative factors – nursing intervention related to human care.
 Redefining nursing as a caring-healing health model

25
10 Factors
1. Forming a humanistic-altruistic system of values
2. Instilling faith and hope
3. Cultivating sensitivity to one’s self and others
4. Developing a helping-trust (human care) relationship
5. Promoting and accepting the expression of positive and negative feelings
6. Systematically using the scientific problem-solving method for decision
making.
7. Promoting interpersonal teaching-learning
8. Providing a supportive, protective, or corrective mental, physical, socio-
cultural, and spiritual environment
9. Assisting with the gratification of human needs
10. Allowing for existential-phenomenologic forces

Watson’s Assumptions of Caring

Human caring is not just an emotion, concern, attitude or benevolent
desire. Caring connotes a personal response.
Caring is an intersubjective human process and is the moral ideal of
nursing.
Caring can be effectively demonstrated only interpersonally.
Effective caring promotes health and individual or family growth.
Caring promotes health more than does curing.
Caring responses accept a person not only as they are now, but also for
what the person may become.
A caring environment offers the development of potential while allowing
the person to choose the best action for the self at a given point in time.
Caring occasions involve action and choice by nurse and client. If the
caring occasion is transpersonal, the limits of openness expand, as do
human capacities.
The most abstract characteristic of a caring person is that the person is
somehow responsive to another person as a unique individual, perceives
the other’s feelings, and sets one person apart from another.
Human caring involves values, a will and a commitment to care,
knowledge, caring actions, and consequences.
The ideal and value of caring is a starting point, a stance, and an attitude
that has to become a will, an intention, a commitment, and a conscious
judgment that manifests itself in concrete acts.

26
 CONCEPT OF HOLISTIC HEALTH

Holistic Health Care

Holism
The concept of holism is based on the idea that it is more fruitful to study the human
being as a whole than to study its separate parts. It is also based on the concept
that a whole is greater than the sum of its parts.

Holistic Health Care

Refers to health care that takes into consideration the whole person in his
environment. Each state of health, as well as illness requires consideration for
physical, psychological, environmental and spiritual factors. Health involves an
approach that recognizes every aspect of a person who is interacting with his
environment.

Dunn’s Concept of Health

In 1959, Halbert L. Dunn describes his concept of high-level wellness as functioning
to maximal possible level of one’s ability within ones environment. Dunn’s
approach recognizes humans as holistic beings that both influence and are being
influenced by the environment.

5 Basic Components to Dunn’s Theory of High-Level Wellness

1. Totalitarity- involves the integration of the biopsychosocial components in

humans.

2. Uniqueness- the manner in which biopsychosocial components are integrated

constitutes the uniqueness of each individual.

3. Energy- required by every living thing. Humans obtain physical energy from
food, water and air. Psychosocial energy is obtained from contacts and
interactions with every living things, including other humans, animals and such
environmental elements sun, wind earth and plants.

27
4. Inner and outer world- refers to reflections of a humans experiences with his
past and present inner self and outer world. This reflections become the basis of
behavior.

5. Self-integration- uses reflection of the past and present as a basis for behavior.
Energy is used whenever a person must integrate biopsychosocial components
in the first place, and then again, when a change in behavior occurs to require
reintegration of biopsychosocial components. If a person cannot reintegrate,
illness or death may result.

Dunn also proposed a health-illness continuum. A continuum is a continuous whole.

When a person copes and functions effectively in daily living, he can be considered
to be within the health spectrum. Failure to cope or poor reintegration, results in
illness, and when the body fails completely and irreversible damage results, death
follows.

DUNN’S HIGH-LEVEL WELLNESS GRID

28
Travis’ Concept of Health

John W. Travis is a wellness oriented physician who focused his approach on a

concept of wellness education. In 1977, he published a model that explained his view of
wellness education and the relationship of traditional and alternative health-care models
to wellness care. Travis further illustrated his illness wellness continuum to indicate that
holistic wellness care is client oriented, As opposed to biomedical (atomistic) care which
is healer oriented.

The Travis illness-wellness continuum; moving from the center to the left shows
progressively worsening state of health. Moving to the right of center indicates
increasing levels of health well-being. The treatment model can bring you to the
neutral point, where the symptom of the disease have been alleviated. The
wellness model, which can be utilized at any point, directs you beyond neutral and
encourages you to move as far to the right as possible. It is not meant to replace
the treatment model on the left side of the continuum, but to work in harmony with
it. If you are ill treatment is important but don’t stop there.

TRAVIS’ ILLNESS-WELLNESS CONTINUUM

29
 NEUTRAL POINT
(no discernable illness or wellness)

CHAPTER III
ETHICS AND LEGAL CONSIDERATIONS IN NURSING

30
Topic Description:
This topic focuses on the ethics and legal considerations in the practice of the
nursing profession. In this chapter the proper conduct of a nurse in the work place will
be discussed, giving emphasis on the legalities of the professional nurse’s actions.

Competencies:
1. Concept on Ethics and Legality.
2. Insight on the principles of health care ethics
3. Determine the laws governing the practice of nursing.
4. Insight on the legally sensitive areas on the nursing practice.

OBJECTIVES TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Develop a concept Ethics and Legal 1 Day Lecture Pre- Test
of Nursing Ethics. Considerations in
Nursing: Discussion Post- Test
Determine the
principles behind Definition Case Analysis Recitation
healthcare ethics.
Principles in
Gain knowledge on Healthcare Ethics
the laws governing
the nursing The Law and
profession and the Nursing
repercussions of
breaking these Legally Sensitive
laws. Areas of the
Nursing Practice
Perform a case
analysis on legally
sensitive areas on
the nursing
practice.

31
 Chapter III
ETHICS AND LEGAL CONSIDERATIONS IN NURSING

Definition
 Originates from the Greek word ETHOS
 Concerned with judgments about what is right or wrong conduct in relation to moral
conflicts.
 One ought to do when society does not have a law or a rule to describe what one
should do.
 Healthcare ethics pertain to how professionals fulfill their responsibilities and provide
care to clients. While no set of absolute guidelines provides answers for all
problems, the fundamental principles of ethics serve as a basis for interpreting and
analyzing clinical situations in decision making.

Definition of Terms
 Personal morality – set of beliefs about the standards of right or wrong that help
a person determine the correct or permissible action in a given situation.
 Personal values – ideals or beliefs a person considers important and feels
strongly about.
 Institutional policies – guidelines developed by healthcare institutions to direct
professional practice.
 Legal guidelines – drawn from state and federal laws pertinent to healthcare.
 Professional ethics – involve principles and values with universal application
and standards of conduct to be upheld in all situations. Nurses must avoid
allowing personal judgments to bias their treatment of clients.

PRINCIPLES OF HEALTHCARE ETHICS

1. BENIFICENCE & NONMALEFICENCE

Beneficence – doing or promoting good
E.g. administer pain meds, perform dressing changes, feeding through NGT
etc….
Nonmaleficence – avoid doing harm or removing harm or prevent harm.
E.g. Reporting suspected child abuse, keeping side rails up at all times,
providing privacy

2. Respect for Autonomy – independence and ability to be self-directed. It is the

client’s right to self-determination.
 Verbal – Integrating client’s wishes into the treatment plan – food
preference, treatment preference
 Written – advance directives
 Advance directives – specifies what interventions the client would or would
not if he or she become terminally ill or sustained an injury or illness that
impeded the ability to make or communicate decisions.

32
  Living will – specifies type of medical treatment a client does or does
not want to receive should they be mentally/physically incapacitated.
 Proxy derivative – or durable power of attorney for healthcare
decisions wherein it allows an individual to designate another person to
make decisions if the client becomes incapacitated. Also called
surrogate decision maker.

3. Justice – principle of fairness, obligation to treat all clients equally and fairly.

Professional-Patient Relationships
 Veracity – telling the truth.
 Informing a cancer pt about his illness
 Fidelity – being faithful to one’s commitment and promises.
 Nurse making an agreement with psychiatric pt.
 Privacy – Ensuring proper draping during perineal care.
 Confidentiality – keeping private information
 Refusing to give information to co-worker about his pt who happens to be a
politician.

THE LAW AND NURSING

Laws are rules or standards of human conduct established by government through
legislative bodies and interpreted by courts to protect the rights of the citizens.

Sources of Laws
Civil Law – governs action by one individual or corporation against another
 E.g. malpractice – claim of client injury caused by nursing care
Criminal Law – involves actions by the state against an individual for violation of
criminal statutes
 E.g. Failure to report child abuse; mercy killing
Administrative Law – involves actions by state administrative agencies against
individuals or org.
 E.g. Licensing law

Licensure – defines nursing, address the scope and expectations of practice, describes
how profession will be governed and provide criteria for nursing education.
 Standards of Care – expected level of performance or practice as
established by guidelines, authority or custom.

INFORMED CONSENT
 Healthcare providers are legally required to involve clients in healthcare
decisions.
 The healthcare provider who performs a procedure is charged with obtaining
informed consent. Generally, however, nurses are responsible for obtaining the
client’s signature and verifying that the client was informed about the proposed
procedure.

33
CRIMES and TORTS
Crime – any wrong punishable by the state.
-prosecuted in the criminal judicial system
Tort – a wrong committed by a person against another person or his property.
-subject to action in civil court

CRIME: Results in prison term or short jail sentence to punish offender.

TYPES:
 Felony – Pre-meditated killing (1st degree murder)
- Impulsive/unintentional killing (2nd degree)
 Misdemeanor – less serious crimes than felonies.
Offense punishable by imprisonment of less that 1 year or a fine
of less than P50,000

TORT - Results in civil trial to assess compensation for plaintiff

TYPES:
1. Intentional Torts
- Assault and Battery
- Defamation of character
- Fraud
- Invasion of Privacy
- False imprisonment

2. Unintentional torts
Negligence – mistake or failure to be prudent
 Act of omission – neglecting to do something that a reasonably prudent person
would do
 Act of Commission – doing something that a reasonably prudent person would
not do.

Malpractice – negligence in the practice of nursing (e.g med error, failure in

assessing significant change, causing burn )
To prove malpractice, 4 elements are necessary:
a. Duty – at the time of injury, a duty existed between the plaintiff and
the defendant
b. Breach of duty – failure to meet standard of care
c. Causation – the breach of duty was the legal cause of injury to the
client
d. Damage or injury – the plaintiff experienced injury or damages or
both and can be compensated by law.

34
 Legally Sensitive Areas of Nursing Practice

1. Controlled Substance – adhere to facility policies and procedures concerning

administration of controlled substances which are governed by state and federal
laws.
- controlled substance must be kept securely locked and only authorized
personnel should have access to them

2. Death and Dying

Euthanasia:
 Active – deliberately hastening a person’s death
 Passive – measures that withhold treatment to allow death to occur
naturally over time.

Advance directives:
 Resuscitation – DNR
 Organ Donation
 Autopsy

3. Good Samaritan Law

- Offers legal immunity for people helping in an emergency situation providing they
give reasonable care.
- Encourage healthcare professionals to assist in emergency situations without fear of
being sued for the care provided.

Protecting Yourself Legally

1. Professional Practice
2. Professional Liability Insurance
3. Documentation

35
 CHAPTER IV
THE NURSING PROCESS

Topic Description:
This topic focuses on the Nursing Process. The phases of the nursing process
and its importance to the nurse as well to the client will be brought to light. And also the
characteristics of a well prepared NCP will be discussed.

Competencies:
1. Proper assessment techniques and tools.
2. Formulation of Nursing Diagnosis.
3. Formulation of plan of care for a client and its implementation.
4. Proper evaluation of the formulated NCP.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Develop proper The Nursing Process: 2 Days Lecture Pre- Test
assessment skills,
and utilize proper Assessment Discussion Post- Test
assessment tools.
Nursing Diagnosis Case analysis Recitation
Differentiate
Nursing diagnosis Planning Workshop on Submitted NCP
from medical Formulation of
diagnosis. Implementation an NCP

Determine the Evaluation

components of a
good plan. Characteristics of an
NCP
Formulate an
NCP based on
the case
presented.

Learn to evaluate
the effects of the
nursing care
rendered.

36
 Chapter IV
THE NURSING PROCESS

Systematic problem - solving approach toward giving individualized nursing care.

STEPS:
Assessment
Nursing Diagnosis
Planning
Intervention
Evaluation

ASSESSING PATIENT’S HEALTH STATUS

Assessment
 A systematic collection of subjective and objective data with the goal of making a
clinical nursing judgment about an individual, family or community.
 1st phase of nursing process which involves data collection , organization and
validation.

Purpose of Nursing Assessment

 To establish the client-nurse relationship.
 To obtain information about the client’s health, including physiologic, socio-cultural,
cognitive, developmental & spiritual aspects.
 To identify the client’s strength.
 To identify actual & potential problems.
 To establish a data base from w/c the subsequent phases of the nursing process
evolve.

Methods used in Nursing Assessment

Observation
Interview
Physical Examination

1. OBSERVATION
 To gather data by using the 5 senses
 Is a conscious deliberate skill that is developed only through effort and with
organized approach

37
Observational Skills
 Vision
 Overall appearance(body size, weight, posture); signs of distress or discomfort;
facial & body gestures; skin color & lesions; abnormalities of movement; non-
verbal demeanor
 Smell - Body or breath odors
 Hearing - Breath & heart sounds, bowel sounds, ability to communicate,
language spoken, orientation to time person & place
 Touch - Skin temp, pulse rate, rhythm; muscle strength; palpatory lesions

2. INTERVIEW
 Planned communication or conversation wherein its primary purpose is to gather
data.
 This will give information, identify problems of mutual concern, evaluate change,
teach, provide support, counseling & therapy

A. APPROACHES FOR INTERVIEW

 Directive Interview
 Nondirective Interview

a.1. Directive Interview

- Is a highly structured and elicits specific information.
- The nurse establishes the purpose of the interview & controls the interview by asking
closed type of questions
a.2. Nondirective Interview
- This is a rapport-building interview w/c allows the client to control the purpose,
subject matter, and pacing of the interview.
- The nurse usually used an open-ended questions

B. KINDS OF INTERVIEW QUESTIONS

Closed questions
 Used in directive interview, usually restrictive & generally require only short
answers giving specific information. Thus, the amount of the information gained
is limited.
 Often begins with 4WH.

Open-ended questions
 Associated in nondirective interview.
 Allow the clients to elaborate, clarify & illustrate their thoughts & feelings. (e.g.
Why did you come to the hospital tonight?; How did you feel in that situation?

38
Neutral question
It is a question the client can answer without direction or pressure from the nurse.
(e.g., How do you feel about that?;
Why do you think you had an operation?)
Leading question
Directs the client’s answer. The phrasing of the question suggests what answer is
expected.
e. g. You are stressed about the surgery tomorrow, aren’t you?;
You will take your medicine, won’t you?

C. POINTS TO REMENBER IN AN INTERVIEW

 Select a quiet private setting (time, place, seating arrangement, distance).
 Choose terms carefully and avoid using jargon.
 Use appropriate body language.
 Confirm patient statements to avoid misunderstanding.
 Use open-ended question.

D. COMMUNICATION STRATEGIES

a. Silence
- Moments of silence during the interview encourage the pt. to continue talking & give a
nurse a chance to assess the clients ability to organize thoughts.

b. Facilitation
-Facilitation encourages the pt. to continue with his story. (e.g. “please continue”, “go
on” and “uh-huh)

c. Confirmation
- Ensures that both the nurses & the pt. are on the same track.
(e.g. If I understand you correctly, you said…..)

d. Reflection
- Repeating something the pt. has just said can help you obtain more specific
information.

e. Clarification
- is used when an information given is vague.
e.g. client: I can’t stand this!
Nurse : What do you mean by I cant stand this?

f. Summarization
-restating the information that the pt. gave you. It ensures that the data collected is
accurate & complete.

39
g. Conclusion
- Signals the pt. that the nurse is ready to conclude the interview. It provides the pt.
the opportunity to gather his thoughts and make any pertinent final statements.
e.g. nurse: I think I have all the information I need now. Is there anything you would like
to add.

E. NURSING HEALTH HISTORY

 One example of an interview.
 1st part of the assessment of the client’s health status.
 Used to gather subjective data about the pt. & explore the past & the present
health problems.

F. COMPONENTS OF THE NURSING HISTORY

f.1. Biographic data

- Includes the client’s name, address, age, sex, telephone no., race, marital status,
b-day, occupation, religion, nationality, H.I.

f.2. Chief complaint or reason for visit

- The c/c should be recorded in the client’s own words. (‘What is troubling you?”)

f.3. History of present illness

P-rovocative/Palliative
- ask the patient: what triggers & relieves the symptom?

Q-uality or Quantity
- What the symptom feels like, look like?
- Are you having the symptom right now? If so , is it more or less
severe than usual?

R-egion or Radiation
- Where in the body does the symptom occur?
- Does the symptom appear in other regions? If so, where?

S-everity
 How severe is the symptom? How would you rate it on a scale of 1-
10, with 10 being the most severe.
 Does the symptom seem to diminishing, intensifying, or staying
about the same?

40
 T-iming
- When did the symptom begin?
- Was the onset sudden or gradual?
- How often does the symptom occur?
- How long does the symptom last?

f.4. Medical History

 Past and current medical problems such as hypertension, diabetes, and back
pain.
 Typical question:
 Have you ever been hospitalized? When & Why?
 What childhood illnesses did you have?
 Have you ever had a surgery? When & Why?

f.5. Family History

 The family nursing history reveals risk factors for certain diseases
 This information should include the ages of siblings, parents & grandparents &
their current state of health or cause of death.
 Particular attention should be given to disorders such as heart disease, cancer,
diabetes, hypertension, obesity, allergies, arthritis , TB, jaundice, bleeding, ulcers,
migraine & alcoholism.

f.6. Review of systems (ROS)

 It’s a review of all health problems by body system to prevent omission of data
related to the present illness and to discover any other problems that might have been
blessed.
 Head to Toe approach is used and often an agency checklist is available.

f.7. Lifestyle
 Personal Habits – the frequency of substance used such as, alcohol, coffee,
cola, tobacco, illicit or recreational drugs.
 Diet & elimination– food allergies, special food preparation, prescribed diet.
Frequency of bowel movement.
 Sleep/rest & exercise pattern
 Work & leisure – what he does for a living & leisure time; hobbies.
 Religious observances

f.8. Psychosocial
 Find out how the pt. feels about himself, his place in society & his relationship to
others, occupation, educational status & responsibilities.
 e.g. how have you coped w/ medical or emotional crises in the past?
 how adequate is the emotional support?
 do you have a health insurance?
 do you have a fixed income, extra money for health care?

41
Types of data

Subjective data
 These can be gathered solely from the patient’s own account. Includes the pt.
sensation, feelings, values, beliefs, attitudes & perception towards health status & life
situation.
 Referred to as symptoms or covert data
e.g. “I feel weak all over when I exert myself”
- “ I have a sharp pain on my chest”

Objective data
 Can be obtained through observation and verifiable
 Referred as signs or overt data, these can be seen , heard, felt or smelled
 Validates the subjective data
e.g. B.P. 90/50
Apical pulse 104, abdomen is distended, skin is pale & diaphoretic.

3. PHYSICAL EXAMINATION
 It is a systematic data-collection method that uses observational skills to detect
health problems. (cephalocaudal or body system approach)
 Uses the following techniques:
Inspection, Palpation, Percussion, Auscultation (IPPA)

A. PURPOSE OF PHYSICAL ASSESMENT

 To obtain baseline data about the client’s functional abilities.
 To supplement, confirm or refute the data obtained in nursing history.
 To obtain data that will help the nurse establish nursing dx. & plan the client’s
care.
 To evaluate the physiologic outcomes of healthcare & the progress of the client’s
health problem.

B. ASSESSMENT TOOLS
Sphygmomanometer Cotton balls
Gloves Visual acuity charts
Ophthalmoscope Otoscope
Penlight Percussion Hammer
Safety pins Scale with height measurement
Skin calipers Speculum
Stethoscope Tape measure
Thermometer Tuning fork
Tongue depressor

42
C. VITAL SIGNS AND STATISTICS
 Height & weight
 Body Temperature
 Pulse Rate
 Respiratory Rate
 Blood Pressure

c. 1. HEIGHT AND WEIGHT

 Important parameters for evaluating nutritional status of the client, calculating
medication dosages, and assessing fluid loss and gain.

c. 2. BODY TEMPERATURE
 It is the balance of between the heat produced by the body & the heat lost from
the body
 It is measured by degrees

Heat Production
 Basal metabolism
 Muscular activity
(shivering)
 Thyroxine & epinephrine
 Fever

Heat Loss
 Radiation- transfer of heat from one surface to another w/o contact
 Conduction- transfer of heat from one molecule to another, heat transfer to a
molecule of lower temp. (w/contact)
 Convection- dispersion of heat by air currents.
 Vaporization- continuous evaporation of moisture from respiratory tract, oral
mucosa & skin.

c. 2.1. 2 Kinds of body Temperature

Core Temperature – is the temp. of the deep tissues of the body, such as the cranium,
thorax, abdominal cavity, and pelvic cavity. (37 C, 98.6 F)

Surface Temperature – is the temp of the skin, subcutaneous tissue, & fats. It is by
contrast rise & fall in response to the environment.

43
c. 2. 2. Variations in Body temp.
 Newborn : axillary : 36.1-37.7 C : 7-10 min
 1 yr : Oral : 37.7 C : 3-5 min
 3 yrs : Oral : 37.2 C
 5 yrs : Oral : 37.0 C
 Adult : Oral : 37.0
Axillary : 36.4
Rectal : 37.6 : 2 min
Forehead : 34.4
Tympanic : 37.7
 Elderly Oral : 36.0
(over 70 yr)

c. 2. 3. Factors affecting body Temperature

 Age
 Diurnal variations (circadian rhythm)
 Exercise
 Hormones
 Stress, Environment

c. 2. 4. Alterations in Body Temp.

 Pyrexia – A body temp above the usual range. (hyperthermia or fever)
 Hyperpyrexia – High fever with a temp. of 41 c (105.8 F)
 Hypothermia – is a core body temp below the lower limit of normal.
34 C - death
35 C - hypothermia
36 – 37 C - normal
38 – 40 C - pyrexia
41 C - Hyper pyrexia
42 C & above - death

c. 2. 5. 4 Common types of fever

 Intermittent fever – The body temp. alternates regularly between a period of
fever & a period of normal or subnormal temp.
 Remittent fever – The body temp fluctuates several degrees, more than 2 C,
above normal but does not reach normal between fluctuations.
 Constant fever – The body temp remains consistently elevated & fluctuates very
little, less than 2 C.
 Relapsing fever – The body temp returns to normal for at least a day, but then
fever recurs.

44
c. 2. 6. Types of thermometers
 Mercury – in - glass thermometer
 Electronic thermometer
 Temperature-sensitive patch or tape
 Chemical disposable thermometer
 Infrared thermometers

Illustrations of Thermometers

c. 2. 7. Temperature scales

 Converting Celsius to Fahrenheit :

F = ( Celsius X 9/5) + 32 or F = (C x 1.8) + 32

 Converting Fahrenheit to Celsius

C = (Fahrenheit – 32) X 5/9 or C = (F – 32) / 1.8

c. 3. PULSE
 The pulse is a wave of blood created by contraction of the left ventricle of the heart.
 The heart pumps and the blood enters the arteries w/ each heartbeat, causing
pressure pulses or pulse wave.

c. 3. 1. Definition of terms
 Stroke volume output (SVO) – is the amount of blood that enters the
arteries w/ each ventricular contraction. (70 ml of blood in a healthy
adult/contraction)
 Compliance – is the ability of the arteries to contract & expand.
 Cardiac output (CO) – is the result of the stroke volume times the heart
rate per minute.
- 4-6 L of blood that pumps by an adult heart during rest.
- CO = SV x HR

45
c. 3. 2. Factors Affecting Pulse rate
 Age - as the age increases the pulse decreases.
 Sex – average male pulse rate is slightly lower than the female.
 Exercise – PR normally increases with activity.
 Fever – the pulse rate increases (a) in response to the lowered blood
pressure that results from the peripheral vasodilation (b) because of the increased
metabolic rate.
 Medications – Some medications decrease the CR (digitalis) others
increase it (epinephrine).
 Hemorrhage – Loss of blood from the vascular system normally increases
the PR.
 Stress – In response to stress, sympathetic nervous stimulation increases
the overall activity of the heart. (fear, anxiety, pain)
 Position changes –sitting or standing position usually pools the blood in
dependent vessels of the venous system. Thus venous blood return to the heart
decrease resulting to subsequent reduction in BP & increase in HR.

c. 3. 3. Pulse Sites
Temporal Carotid
Apical Brachial
Radial Femoral
Popliteal Posterior tibial
Pedal

c. 3. 4.
4. Pulse assessment

 Pulse rhythm – is the pattern of the beats & the intervals between the beats.
Equal time elapses between beats of a normal pulse.
- dysrhythmia or arrythmia – a pulse with an irregular rhythm. It may consist of
random, irregular beats or predictable pattern or predictable pattern of irregular
beat.

 Pulse volume – also called a pulse strength or amplitude, refers to the force of
blood with each beat.
- 0 Absent, not discernible
- 1 Thready or weak, difficult to feel
- 2 Normal, detected readily, obliterated by strong pressure
- 3 Bounding, difficult to obliterate

c. 3. 5. Elasticity of the arterial wall

 Reflects its expansiblity or its deformities.
 Normal artery feels straight, smooth, soft and pliable.

46
 c.3.6. Apical-Radial pulse assessment
 apical and radial rates are identical
 need to be assessed for client with cardiovascular disease.
 Pulse deficit – the difference between the apical pulse rate & radial pulse rate.
Measuring the PD allows the nurse to evaluate indirectly the ability of each
cardiac contraction to eject sufficient blood to peripheral circulation.

c. 4. RESPIRATION
It is the act of breathing; it includes the intake of oxygen and the output of carbon
dioxide.

 External Respiration – refers to the interchange of oxygen & carbon dioxide

between the alveoli of the lungs & the pulmonary blood.
 Internal respiration – interchange of the same gases between the circulating blood
and the cells of the body tissues.
 Ventilation – refer to the movement of air in & out of the lungs

c. 4. 1. 2 Types of breathing
 Costal/thoracic breathing – chiefly involves the external intercostal muscles &
other accessory muscles such as the sternocleidomastoid. (chest)
 Diaphragmatic breathing – involves the contraction & relaxation of the diaphragm
and usually observe by the movement of the abdomen.

c. 4. 2. Assessing respiration

Rate – normally described in breaths per minute.

Ave. Range
Newborn 35 30 – 80
1 yr 30 20 – 40
2 yrs 25 20 – 30
8 yrs 20 15 – 25
16 yrs 18 15 – 20
Adult 16 12 – 20

Depth – can be established by watching the movement of the chest.

 Deep respirations – large volume of air is inhaled & exhaled, inflating most of
the lungs.
 Shallow respirations – involve the exchange of small volume of air.

47
 Rhythm – refers to the regularity of the expirations & inspirations,
 normally respirations are evenly spaced
 can be described as regular or irregular

Quality or character – refers to those aspects of breathing that are different from
normal, effortless breathing. (effort exert & sound)

c. 4. 3. Breathing Patterns & Sound

Rate
 eupnea – normal respiration that is quiet, rhythmic, & effortless
 tachypnea – rapid respiration marked by quick, shallow breaths
 bradypnea – abnormally slow breathing
 apnea – absence of breathing

Volume
 Hyperventilation – an increase in the amount of air in the lungs, characterized by
prolonged & deep breaths.
 Hypoventilation – a reduction in the amount of air in the lungs; characterized by
shallow respirations.

Rhythm
 Cheyne – Stokes breathing – a gradual increase followed by a gradual decrease in
the depth of respirations & then a period of apnea; often associated with cardiac
failure, increased ICP, or brain damage.
 Biot’s - Respiration of the same depth followed by a period of apnea.

Ease or effort
 Dyspnea – difficult & labored breathing during w/c the individual has a persistent ,
unsatisfied need for air & feels distressed.
 Orthopnea – ability to breath only in upright sitting or standing positions.

Breath sounds
 Audible without amplification
 Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction
 Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the
upper airway
 Wheeze – continuous, high – pitched musical squeak or whistling sound occurring
on expiration & sometimes on inspiration when air moves through a narrowed or
partially obstructed airway
 Bubbling – gurgling sounds heard as air passes through moist secretions in the
respiratory tract

48
 Illustration of a Stethoscope

Audible by stethoscope
 Crackles (rales) – dry or wet crackling sounds simulated by rolling a lock of hair
near the ear. (Pneumonia, HF)

 heard on inspiration as air moves through accumulated moist secretions; reflects

underlying inflammation.
 fine – medium crackles occur when air passes through moisture in small air
passages & alveoli
 medium – coarse crackles occur when air passes through moisture in
bronchioles, bronchi, & the trachea.

 Gurgles (rhonchi) – coarse, dry, wheezy or whistling sound more audible during
expiration as the air moves through tenacious mucus or narrowed bronchi

 Pleural friction rub – coarse , leathery, or grating sound produced by the

rubbing together of inflamed pleura
- can be imitated by rubbing the thumb & index finger

c. 5. BLOOD PRESSURE
 Arterial blood pressure is a measure of the pressure exerted by the blood as it flows
through the arteries.
 To the force of the blood against the arterial walls.

Illustrations of Blood Pressure Apparatus

Aneroid Mercurial

49
c. 5.1. Blood Pressure Measure
 Systolic pressure – is the pressure of the blood as a result of contraction of the
ventricles.
 Diastolic – is the pressure when the ventricles are at rest

c. 5. 2. Physiology of Blood Pressure

 Pumping action of the heart – cardiac output is the volume of blood pumped into
the arteries by the heart.
 when the pumping action of the heart is weak, less blood is pumped into arteries,
and the blood pressure decreases.
 Peripheral Vascular Resistance

Factors that create resistance in AS

 Size of arterioles & capillaries – the smaller the lumen of the vessel the greater
the resistance.
 Compliance of the arteries – ability of the vessel walls to contract & relax.
 Blood volume – when the blood volume decreases the BP decreases,
conversely, when the BV increases the BP increases.
 Blood viscosity – BP is higher if the blood is highly viscous.

c. 5. 3. Factors affecting BP
Age Exercise
Stress Race
Obesity Sex
Medications Diurnal variations
Disease process

D. PHYSICAL ASSESSMENT TECHNIQUES

 Inspection
 Palpation
 Percussion
 Auscultation

d. 1. INSPECTION
-Is a visual examination or assessing by using the sense of sight.
- Use to assess color, rashes, scars, body shape facial expressions, body structures.

50
Pointers in performing a General Survey
 Symmetry – Are face & body symmetrical?
 Old – Does he look his age?
 Mental acuity – Is he alert, confused, agitated?
 Expression – Does he appear ill, in pain or anxious?
 Trunk – Is he lean, stocky, obese, or barrel-chested ?
 Extremities – Are his fingers clubbed, joint abnormalities, edema?
 Appearance – Is he clean or appropriately dressed?
 Movement – Are his posture, gait & coordination normal?
 Speech – Is his speech relaxed, clear, strong, Understandable, appropriate.?
Does it sound stressed?

d. 2. PALPATION
- It is the examination of the body using the sense of touch.
- It is used to determine (a) texture, (b)temperature, (c) vibration, (d) position, size,
consistency, and mobility of organ or masses, (e) presence & rate of peripheral pulses.
(f) distention, (g) tenderness & pain.

2 Types of Palpation
 Light palpation - used to assess surface abnormalities; texture , tenderness,
temperature, moisture, elasticity , pulsations, superficial organs, & masses.
 Deep palpation – used to feel internal organs & masses for size, shape,
tenderness, symmetry & mobility.

d. 3. PERCUSSION
 is an assessment method in which the body surface is struck to elicit sounds that
can be heard or vibration that can be felt.
 this technique helps you locate organ borders, identify organ shape & position, &
determine if an organ is solid or filled with fluid or gas.

2 Types of Percussion
 Direct percussion – the nurse strikes the area to be percussed directly with the
pads of two, three or four fingers or with the pad of middle finger.
- usually used in percussing an adult’s sinuses
 Indirect percussion – is the striking of an object, usu. a finger held against the
body area to be examined.
- the middle finger of the non dominant hand is the pleximeter which is placed firmly on
the client’s skin; using the tip of the flexed middle finger of the other hand, called
the plexor , the nurse strikes the pleximeter.

51
Types of sound
 Flatness – is an extremely dull sound produced by very dense tissue, such as
muscle or bone.
 Dullness – is a thudlike sound produced by dense tissue such as liver , spleen,
or heart.
 Resonance – is a hollow sound with such as that produced by lungs filled with
air.
 Hyperresonance – not normal, a booming sound that is usually heard over an
emphysematous lungs.
 Tympany – is a musical or drum like sound produced from an air filled stomach.

d. 4. AUSCULTATION
 Is the process of listening to the sounds produced within the body.

4 Properties used to describe sound

 Pitch – is the frequency of the vibrations (the number of vibrations per second)
- e.g . Low pitched sounds such as heart sounds have fewer vibrations per second
than high pitched sound like the bronchial sounds.
 Intensity (amplitude) – refers to the loudness or softness of a sound.
e.g. trachea has a loud sound, heart sound is soft
 Duration – the length of the sound
 Quality – is a subjective description of sound.
e.g. whistling, gurgling, snapping, blowing, squeaking, humming.

52
 NURSING DIAGNOSIS

 A clinical judgment about an individual, family or community responses to actual

or potential health/life process.
 Provides the basis for selection of nursing intervention to achieve outcomes for
which the nurse is accountable.
 Diagnosing is a process which results to a diagnostic statement.

Nursing Diagnosis
– is a statement of a client’s potential or actual alteration of health status. It results
from analysis and synthesis.

Purpose: To identify the client’s health care needs and to prepare diagnostic statements.

Medical diagnosis
 describes a disease or pathology of specific organs or body system
 Provide convenient means for communicating treatment requirements
Nursing Diagnosis
 describes an actual, risk or wellness human response to a health problem that
nurses are responsible for treating independently.

EXAMPLE:
Medical Dx: Pneumonia
Nursing Dx: Ineffective airway clearance r/t tracheobronchial secretions

Medical Dx: Tonsillitis

Nursing Dx: Elevated body temperature related to presence of pyrogens.

NURSING DIAGNOSIS TAXONOMY

Taxonomy
 Method for ordering complex information
 Classification system to provide structure for nursing practice.
Purpose: to provide vocabulary for classifying phenomena in a discipline

COMPONENTS F NURSING DIAGNOSIS

Diagnostic Label/Problem - this describes the client’s health status clearly and
concisely in a few words. - name of the nursing diagnosis as listed in the
taxonomy
E.g. Impaired mobility; activity intolerance

53
Descriptors – words used to give additional meaning to a nursing diagnosis. They
describe changes in condition, state of the client or some qualification
E.g. altered, impaired, decreased, ineffective, acute, chronic, excessive, delayed

Related factors/Etiology – describes the conditions, circumstances that contribute to

the problem. Terms used: associated with, related to or contributing to.

Defining characteristics/Signs and symptoms – observable cues that cluster as

manifestation of an actual or wellness nursing diagnosis.

Risk factors – describe clinical cues in risk nursing diagnosis. They are environmental,
physiological, psychological, genetic, or chemical factors that increase the
vulnerability of pt. leading to unhealthful event.

STEPS IN NURSING DIAGNOSIS

1. Identify pattern – organizing, clustering, grouping data

E.g. 23 y/o female, ilokano, living in Tondo, wt – 110 lbs., ht – 5’2”, severe, dull,
pelvic pain, (+) vaginal bleeding, pallor, dyspnea, BP-100/80, weakness, uses 5
pads/day, T- 39.4 C, RR- 17 bpm, PR – 123 bpm, fatigue, rbc = 4m/cu.mm, hgb
= 10 g/dl, (+) chills, wbc = 7,000cu.mm, (+) furuncle at right gluteus 10 mm
elevation, warm flushed face.

2. Compare data against standards.

a. Standards or norms are generally accepted rule, measure or pattern that
can be used for comparing things in the same class or category.

Characteristics of standards:

 Relevant standard is of the same class as the data

 General standard is relevant for general data
 Specific type of data is relevant for specific types of data
 Reliable standard generally is based on data collected large number of
people.
 A reliable standard may be based on one person but it is relevant only
for that person.

3. Analyze data after comparing with standards

4. Analyze data after comparing with standards
5. Formulate the diagnostic statement

54
TYPES OF DIAGNOSTIC STATEMENTS

1. Actual Nsg. Dx. - Describes a human response to a health problem that is being
manifested.
A. Three-part statements: PES
Problem + Etiology + S/Sx
Ex: Elevated Body Temperature related to staphylococcal infection as
evidenced by flushed, warm skin and diaphoresis

B. Two-part statement: P + E
Ex: Impaired skin integrity related to presence of furuncle
Hyperthermia related to presence of staphylococcal infection

2. Risk Nursing Diagnosis – describes human responses to health conditions/life

processes that may develop in a vulnerable individual.
Two-part statement: P + E
Ex: Risk for Fluid Volume Deficit
Risk for activity intolerance

3. Possible Nursing Diagnosis

- made when not enough evidence supports the presence of the problem but the
nurse thinks that it is highly probable and wants to collect more information
Two-part statement : P + E
Ex: Possible disturbed thought process related to unknown etiology

4. Wellness Nursing diagnosis

- diagnostic statement that describes the human response to level of wellness
- One-part Statement: Diagnostic Label
Ex: Readiness for enhanced organized infant behavior
Readiness for enhanced spiritual well-being

PLANNING

 Involves determining beforehand the strategies or course of actions to be taken

before implementation of nursing care.
 To be effective, involve the client and his family in planning.

Purpose: To identify the client’s goal and appropriate nursing interventions.

55
STEPS IN PLANNING

• Set priorities in collaboration with the patient

E.g. Lessened pain scale from 9 – 5
Increase weight from 110 lbs – 115 lbs
• Set goals and objectives in collaboration with the client. Short-term goal (STG) or
Long-term goal (LTG)
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time-framed

Example: STG
At the end of 8 hrs of nursing interventions, the patient’s temperature will be
equal to or less than 37.8 C per axilla.
At the end of 4 hrs of nursing interventions, the patient’s pain will be relieved if
not lessened as manifested by decrease pain scale from 9 – 5 and presence of
unguarded behavior.

Example: LTG
After one week of nursing interventions, the
patient’s body temperature will remain under
normal range of =/> 37.8 C per axilla.
After 2 weeks of nursing intervention, the patient’s weight will increased
from 110 lbs – 115 lbs.

IMPLEMENTATION

 Putting the nursing care plan into action

Purpose: To carry out planned nursing interventions to help the client attain goals

Requirements:
1. Knowledge
2. Technical skills
3. Communication Skills

56
STEPS IN IMPLEMENTATION

1. Reassess the client

2. Set priorities
a. ABC
b. Maslow’s hierarchy of needs
3. Implement nursing interventions
4. Documentation

Implementing Nursing interventions

1. Assessment – for baseline data
ex: Assess breath sounds, assess wt
2. Independent nursing interventions
ex: Positioned pt to high-fowlers position
Encouraged slow but deep breathing
Instructed to small but frequent feeding
3. Dependent nursing interventions
ex: Administered pain reliever as ordered.
4. Interdependent nursing interventions
ex: Secured specimen for urinalysis as ordered
5. Psychosocial interventions (case-to-case basis)
ex: Encouraged verbalization of feelings

EVALUATION

Assessing the client’s response to nursing interventions and then comparing the
response to predetermined standards or outcome criteria.
Purpose: To determine the extent to which goals if nursing care have been achieved.

STEPS IN EVALUATION

1. Collect data about client’s response

2. Compare the client’s response to outcome criteria
3. Analyze the reasons for the outcomes
4. Modify care plan as needed.

Example:
After 8 hours of nursing intervention, the patient verbalized relief of pain with Pain
scale from 9 – 5. Patient manifests unguarded behavior.
After 8 hrs of nursing intervention, the pt’s body temperature was 37.8 C per
axilla.

57
Characteristics of Nursing Care Plan
1. Problem-oriented – it is comparable with scientific problem solving approach
2. Goal oriented
3. Orderly, planned, step by step
4. Open to accepting new information during its application
5. Interpersonal
6. Permits creativity among nurses and clients in devising ways to solve the health
problems
7. Cyclical
8. Universal

Benefits for clients

1. Quality of care
2. Continuity of care
3. Participation by the clients in their health care

Benefits for the Nurse

1. Consistent and systematic nursing education
2. Job satisfaction
3. Professional growth
4. Avoidance of legal action
5. Meeting professional nursing standards
6. Meeting standards of accredited hospitals

58
 CHAPTER V
SHARING INFORMATION
AMONG HEALTH PRACTITIONERS

Topic Description:
This topic focuses on sharing information among health practitioners. This
chapter will discuss how the professional nurse communicates with other health
practitioners and why communication is vital among health care workers.

Competencies:
1. Proper communication skills.
2. Proper conduct and ethics during communication process.
3. Familiarity with the tools used in communication with other health care
practitioner.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Apply previously Sharing 1 Day Lecture Pre- Test
learned information among
communication health care Discussion Post- Test
skills. practitioners:
Group activity Recitation
Determine the Common methods (fill up a clients
importance of of communication. record form) Submitted filled
proper up client record
communication The Patients forms.
among health Records
care practitioner
to the Nursing Entries on
management of a the Client
client’s condition. Records.

Learn proper
documentation
techniques.

Determine the
importance of
utilizing the
client’s record in
the management
of his care.

59
 Chapter V
SHARING INFORMATION
AMONG HEALTH PRACTITIONERS

Introduction
• Sharing information pertinent to a patient’s care is an important function of
communication among health practitioners.

Topics of Discussion
• Common Methods of Communicating among Health Practitioners
• The Patient’s Record
• Sharing Information among Nursing Personnel

Common Methods of Communicating Among Health Practitioners

• Face-to face meetings
• Telephone
• Messenger
• Written message
• Audio taped message
• Computers

Advantages of Various Methods for Communicating Messages

• A message can be delivered immediately when communicating in a face-to face
meeting or by telephone.
• Nonverbal messages are readily conveyed during face-to face meetings.
• Using a messenger is sometimes the most efficient way to relay information when
other methods are impractical or impossible.
• Written and audio taped messages can be exchanged at times convenient for the
people involved.
• A record is available when messages are written or audio taped .

Disadvantages
• The communicating person must be available at the same time to converse in
order to utilize face-to-face meetings and the telephone. The person must also be at
the same place when communicating face-to-face.
• Ordinarily there is no permanent record for later use when communicating face-to
face or by telephone.
• Only the tone of voice and voice inflections can be communicated nonverbally
when using a telephone or an audiotape.

60
• A message cannot usually be validated conveniently with the sender if questions
arise when using a written word, an audiotape or a messenger.
• A messenger may garble information he is conveying from one person to
another.

4 General Categories in Sharing Information among Health Practitioners

Reporting
 To report is to give an account of something that has been seen, heard, done, or
considered.
Directing
 To direct is to guide or order. The nurse uses nursing orders to guide nursing
care activities.
Conferring
 To confer is to consult with someone to exchange ideas or to seek information,
advice, or instructions from another. A nurse may consult with other members of
the health team.
Referring
 To refer is to send or direct someone for action or help.
 The process of guiding someone to another source for assistance is called
referral.
 Referrals are especially important in providing continuity of care for persons
needing a variety of services.
 The client must know and approve of a referral to another agency or health
personnel for care.

The Patient’s Record

• Is a compilation of a person’s health care information.
• May also be called patient chart, health record, or client record.
• The record contains personal information therefore confidentiality must always
be maintained.
• Should be organized for easy input and retrieval; forms the basis for
interdisciplinary communication.
• Each piece of data is crucial in forming the actual picture of the client’s health
care status and the care he or she received.
• Client’s record promotes a coherent plan of care, communication of common or
individual goals, and progress of client towards those goals.
• Nurses’ entries on the client record are important because they show medical
and nursing orders carried out, independent assessments and interventions
performed, the exact dates and times of care delivered, and evaluation of care
provided.

61
PURPOSE

Communication
• Clearly documented information on the client record communicates the plan of
care and the client’s progress to all the members of the health care team.
• Ensures continuity of care.
Assessment
 By reading about the client’s history and initial assessment and comparing these
data with additional subjective and objective information that has been obtained,
client’s health status and progress toward goals can be determined.

Care Planning
 Formulation of an individualized plan of care flows from assessment data.
 All data in the client's record are considered when nursing diagnosis, goals,
outcome criteria, intervention and evaluation criteria for that client are developed.

Quality Assurance
 Audit is a review of records.
 To determine if certain standards of care are met and documented.
 Results may lead to changes in that manner in which care is provided.
 The goal is to review continually and to improve the quality of nursing care
provided.

Reimbursement
 Documentation of client’s care often provides the basis for decisions regarding
care to be provided and criteria to be met to cover health related expenses.
 Nurses’ must be familiar with criteria for reimbursement and knowledgeable
about obtaining authorization for care.

Legal Documentation
 The client record may be used in court to prove or disprove juries a client
incurred unintentionally or to implicate or absolve a healthcare professional in
regard to improper care.
 The care may have been excellent, but the documentation must prove it.

Research
 Research based on documentation of nursing care provided allows the
professional to refine the definition of practice.

Education

62
  Members of the healthcare team and students of nursing and medicine use the
client’s record as an educational tool.

Principle of Data Entry and Management

Accuracy
 Nurses must write only what they have seen, heard, smelled, or felt.

Completeness
Note all relevant data to support an assessment or plan.
• Be sure to include the following essential information when charting:
• Any new or change information
• Signs and symptoms
• Client behavior
• Nursing interventions
• Medications given
• Physician’s orders carried out
• Client teachings
• Client’s responses

Conciseness
 Good charting is concise and brief (clear).
 Helpful in time management because nurses can spend less time charting and
more time with the patient.

Objectivity
 When charting subjective findings, make every effort to identify the source and
context of the finding.
 Directly quote statements made by the client.

Organization
 Each entry must clearly show a logical and systematic grouping of important
information by problem or occurrence.

Timeliness
 Documentation in a timely manner can help avoid errors.

Legibility
 Writing must be clear and easily read by others, specially numbers and medical
terms.

63
High-Risk Errors in Documentation
• Falsifying client’s record
• Failure to record changes in client’s condition
• Failure to document that physician was notified when client's condition changes
• Inadequate admission assessment
• Failure to document completely
• Failure to follow agency’s standards or policies
• Charting in advance

Nursing Entries on the Client Record

1. Nursing Care Plan

2. Kardex
• series of flip cards usually kept in a portable file.
• is a was to ensure continuity of care from one shift to another.
• is updated as the client’s condition changes or a new doctor’s orders are
obtained and entries are often in pencil.

3. Nursing Progress Notes

• Descriptive forms of documentation that summarize nursing assessments,
intervention and evaluation.

Formats in writing NPN

• Narrative
• SOAP
• PIE
• Focus DAR notes

Comparing Documentation Notes

PIE – Problem, Intervention, Evaluation
Advantage:
• Easily adapted
• Less redundancy noted
• Can be used

64
FOCUS – Data, Action, Response (DAR)
Advantage:
• Charting on any significant area can be done.
• Flexile and works well in long term care
Disadvantage:
• May not relate to NCP
CHAPTER VI
HEALTHCARE MILIEU

Topic Description:
This topic describes the environment in which patients receive care from
healthcare practitioners. Also discussed in this chapter is the nurse patient relationship.

Competencies:
1. Determine what a therapeutic healthcare milieu is.
2. Develop a therapeutic nurse patient relationship.
3. Gain knowledge on the standards of patient care.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Identify a Healthcare 1 Day Lecture Pre- Test
therapeutic Milieu:
healthcare milieu. Discussion Post- Test
3 Phases of
Determine the Nurse patient Recitation
three phases of relationship.
Nurse patient
relationship and Establishing a
the importance on safe and
accomplishing comfortable
them. healthcare
milieu.
Insight on how to
establish a safe Standards of
and comfortable Patient Care.
healthcare milieu
and how it affects Standards of
the client. Patient
Admission (ER
Determine the and Gen. Unit).
standards of
patient admission
in the ER and

65
differentiate it from
that of Gen. Unit.

Chapter VI
HEALTHCARE MILIEU

• Environment in which patients receive care from healthcare practitioners.

eg: Hospital milieu ( viewed as a necessity, a frightening environment, an
important industry and employer of persons.
• Nursing responsibility: maintain a milieu that is therapeutic for patients

RELATIONSHIP
- An interaction of persons over a period of time.
time.

Helping Relationship
 An interaction that sets the climate for movement of the participants toward
common goals.
 Also known as “ NURSE-CLIENT OR NURSE-PATIENT RELATIONSHIP/
THERAPEUTIC RELATIONSHIP/ INTER-PERSONAL RELATIONSHIP.

Goals of a Helping Relationship

1. Increase independence for patient.
2. Increase self-worth.
3. Improve physical well-being.

* The nurse selects nursing activities depending on the goal.

eg: GOAL- decrease body temperature
NURSING ACTIVITIES- giving tepid sponge bath, encourage increase
fluid intake, etc.

3 Basic Characteristics of a Nurse-Patient Relationship

1. It is dynamic
2. It is purposeful and time-limited.
3. The helper assumes the dominant role.

3 PHASES OF NURSE-PATIENT RELATIONSHIP

66
1. ORIENTATION PHASE- occurs when nurse starts gathering data.
a. Role of both person in the relationship are clarified.
b. Agreement or contract about the relationship is established ( goals,
location, frequency and duration)
c. Orientation to health care agency.

2. WORKING PHASE
 occurs when effort is exerted by both participant to achieve their common goal.

A. Functional Factor
- direct action that is taken to move people
toward the goal.
eg: SITUATION- elderly patient has a poor \
appetite
GOAL- to increase this food intake

ACTION- nurse discusses the idea of small, more frequent meals with the
patient. With the patient’s approval, the nurse makes necessary
arrangements.

B. Expressive Factor
- refers to an emotional state.
- when sentiments and feelings are satisfactory,
the persons can usually work together.

eg: the elderly relationship with the nurse

may have allowed him to respond
positively to the small, more frequent
meals without feeling as though he
was being treated as a child.

3. TERMINATION PHASE
 occurs when the conclusion of initial agreement is acknowledged.
a. change-of-shift time
b. when patient is discharged
c. nurses leaves on vacation
d. when she departs on agency/employment

SUMMARY OF TYPICAL PATIENT BEHAVIORS

DURING THE 3 PHASES OF AN EFFECTIVE NPR

67
1. ORIENTATION PHASE
1. the patient will call the nurse by name.
2. the patient will accurately describe the roles of the
participants in the relationship.
3. The patient and nurse will estanlish an agreement about goals,
location, frequency and duration.

2. Working Phase
1. The patient will actively participate in the relationship.
2. The patient will respond positively to both functional and expressive factors of the
nurse’s behavior.

3. Termination Phase
1. The patient will participate in identifying the goals accomplished, or the progress
made toward goals.
2. The patient will verbalize his feelings about the termination of the relationship.

THE PATIENT’S EXPECTATIONS

1. Professionally competent.
2. Serious at work.
3. Thoughtful, understanding and accepting of him.
4. Orient him to the healthcare agency.
5. Provide an explanation of his care.
6. Include him in the planning of care.
7. Help meets his needs when he is unable to do so himself

ESTABLISHING A SAFE AND COMFORTABLE HEALTH CARE MILIEU

68
A. FURNISHINGS
1. beds
2. pillows bedside stand
3. chairs
4. mattress
5. overbed table
6. lamps
7. call system
B. LIGHTING
1. natural
2. artificial
C. TEMPERATURE, HUMIDITY AND VENTILATION
D. PERSONAL-CARE ITEMS
E. PRIVACY AND QUIET
F. SAFETY MEASURES
1. restraining patients
2. preventing spread of microorganisms
3. preventing falls
4. preventing equipment-related accidents

STANDARD FOR PATIENT CARE

STANDARD
 descriptive statement of desired level of performance against which the quality of
structure, process or outcome can be judged.

NURSING CARE STANDARD

 descriptive statement of desired quality to evaluate nursing care given to a patient or
a group of patient.
 can be used as a:
a. gauge to measure performance ( CONTROL DEVICE)
b. mark or target to be aimed at ( PLANNING TOOL)

STANDARD NURSING CARE

 level of care agreed upon by the nursing staff as necessary to achieve desirable
care and treatment goals for a specific group of patients.

PURPOSE OF NURSING CARE STANDARDS

1. To improve quality nursing care by focusing nurse’s attention/effort toward goals.
2. To decrease the cost of nursing care, eliminating non-essential nursing activities
that serve no useful goal
3. To provide basis for determining nursing negligence and failure to meet the
prevailing standard causing harm to the patient.

69
 Standards on Patients Admission through the Emergency Room

Purposes
• To give immediate care to emergency cases.
• For proper evaluation of patient’s management and placement.

Equipments
• Examining table
• Thermometer tray
• BP apparatus
• Penlight
• Bandage scissors

PRN
• O2 tank
• Nasal Cannula
• Suction apparatus
• Dressing cart

Procedural Workflow
• Assist the patient to the examining table, if condition allows it.
• Assist the pt. in filling up ER sheet
• Take Vital signs
• Call the doctor immediately
• Secure pertinent information
• Prepare equipments necessary for examination
• Carry out “STAT” orders

Standards on Patients Admission in General unit

Purposes
• To ensure the patient and relative a courteous welcome into the hospital
• To orient the patient and family to the hospital set-up
• To provide for an immediate care of the patients upon arrival at the Nursing
units.

Equipments
• Checklist from Admission Office
• Doctor’s order sheet
• Consent properly signed
• Patient’s data and Pin Number
• Patient Name tag

70
 • Admission Kit
• Kardex
• Ready made chart
• Chart cover
• Pencil
• Ball pen – 3 colors
• Complete bedside amenities- bath basin, kidney basin, bedpan, urinal, drinking
pitcher.
• Open bed
• Weighing scale
• Bp apparatus and stethoscope
• Patient’s gown/ pajama

Procedural Workflow
1. Receive call from Admission Office or ED
• Receives preliminary telephone endorsement of the patient
» Name and Room number
» Condition and amenities needed
» Chief complaints
» Procedures done
»Attending doctors
2. Prepares room for admission – rechecks room for amenities . Turns
on aircon, light, TV, ref., etc.

3. Receives patient from Admission office or ED

• Welcomes the pt. with smile
• Takes pt’s ht and wt and ask for allergies
• Receives the following from the Admission or Ed staff- DOS, Consent signed,
data sheet, name tag, pin #, admission kit
• Checks on the ID wrist band being worn and completeness of admission kit
• Usher patient and relatives to the room
4. Renders preliminary nursing care
• Provide privacy when undressing the patient
• Help the pt. change clothes to gown and assist him to bed
• Explains hospital policy on safekeeping
• Orients to hospital policies and usage of amenities
• Takes v/s

71
 • Makes initial assessment of all pertinent observations
• Carries out admitting orders.
5. Retrieves old chart from the Medical records
6. Documents Nursing Care rendered.

Standards for transfer of Patients to other Units

Purpose:
• To transfer the patient to other unit with all possible safety considerations and
courtesy.

Procedural Workflow
1. Receives doctors’ order written transfer order.
• Identifies patients chart correctly
• Verifies the order for transfer
• Note: For request transfer, clarify with the patient or patients relative.
For patient to be transferred to Intensive care units, request relatives to
go to In House Collection Department or Admission Office for financial
assessment.

2. Prepares the client for transfer

• Carries out transfer order
• Accomplishes the transfer slip
• Instructs the relatives to bring the Slip to Admission office
• Receives blue copy of transfer slip from the relatives
• Notifies the receiving unit through telephone of the following:
• Room number reserved
• Patient’s condition
• Contraptions/ equipment needed
• Informs patient/ relatives of room readiness
• Informs AMD’s / ROD/ Fellow/ Interns of transfer
Note: All patients for transfer to PICU shall be accompanied by PROD

3. Documents the procedure

– Documents the following in the nurse’s notes:
– Condition of the patient prior to transfer
– Contraptions

72
 – Time patient was transferred
– Who accompanied the patient
• Checks the completeness of the following:
• Kardex, Patient’s chart & medicines / supplies
• NOTE: all unused medicines/ supplies should be returned in prior to transfer
• Counter checks the admission checklist for the completeness of room
amenities prior to transfer.

4. Transfer patient to other unit

• Wheels the patient in the room reserved for him/ her
• Endorse the patient of the following:
– Reason for transfer
– History and condition
– Contraptions
– Medicines/ supplies
– Special endorsement
– patient’s chart and kardex

Standards for Transfer of Patient to other Hospital

Purpose:
• To ensure that all arrangements with other hospital have been made prior to
transfer

Procedural Workflow
1. Receives transfer order to other hospital.
• Identifies patient’s chart
• Verifies order for transfer

2. Prepares patient for transfer

– Carries out transfer order
– Informs other referral doctors
– Informs the intern- in charge for the preparation of clinical summary
– Verifies the coordination of the concerned resident/ fellow to the receiving hospital

73
3. Arranges for the transport
• For SLMC ambulance conduction:
– Verifies the ED of the ambulance availability
– Ask the relatives to go down to ED for proper instructions and charges.
• On use of outside ambulance:
– Verifies relative for previous arrangement
– Unit to coordinate the use of other transport services
• Prepares and encodes discharge clearance

PRINCIPLES AND PRACTICE OF NURSING CARE

CHAPTER VII
HELPING TO CONTROL
SPREAD OF MICROORGANISM

Topic Description:
This topic discusses how nurses can control the spread of microorganisms in and
out of the work place. This chapter provides information on how the infection cycle takes
place and how to counter act it.

Competencies:
1. Knowledge on the infection cycle.
2. Knowledge on medical and surgical asepsis.
3. Develop an understanding of communicable disease control.
4. Insight on the development of nosocomial infection.

74
 OBJECTIVE TOPIC TIME STUDENT EVALUATION
FRAME ACTIVITIES
Determine the Helping Control of 2 Days Lecture Pre- Test
infection cycle and Spread of
how to prevent its Microorganisms: Discussion Post- Test
progress.
Infection Cycle Return Recitation
Differentiate Medical Demonstration
from surgical asepsis. Medical Asepsis of Hand Performance
washing, Checklist
Develop an Surgical Asepsis Hand
understanding of Scrubbing,
communicable Communicable Sterile
disease control. Disease Control gowning and
closed gloving
Gain insight in the Nosocomial Infection techniques
development of and Medical Asepsis
nosocomial infection
and how to prevent it. Standards of
Infection Control
Apply proper
technique in
performing Hand
washing, Hand
Scrubbing, Sterile
Gowning and Closed
gloving.

PRINCIPLES AND PRACTICE OF NURSING CARE

Chapter VII
HELPING TO CONTROL
SPREAD OF MICROORGANISM

Definition of Terms
 Infection - disease state resulting from the presence of pathogens in our body.
 Pathogens - disease- producing microorganism
 Infection Cycle - chain of Infection

75
Infection Cycle
1. Reservoir – natural habitat of the organism
a. Human – patients/ health care workers
e.g. Mycobacterium tuberculosis
b. Animals- rabies
c. Soil - tetanus

2. Exit – paths by which infectious agent leaves the reservoir

* Respiratory Tract
*Gastrointestinal Tract
*Genitourinary Tract
*Open Lesions
*From bloodstream or tissues by insect bites, hypodermic
needles or surgical equipments.

3. Vehicle – means for transmitting organisms from one

place to another

Contact Transmission
Direct Contact – person to person
Indirect Contact – usually inanimate object
Droplet Contact – large particles from coughing, sneezing or talking by
infected person.
Common Vehicle route
Food – Salmonellas
Water – Shingellosis
Drugs – Bacteremia resulting from infusion of a
contaminated infusion product.
Blood – Hepatitis B

Airborne Transmission
 Droplet Nuclei
- Residue of evaporated droplets that remain suspended in the air.
- Dust particles in the air containing the infectious agent.

4. Portal of Entry - Paths by which infectious agent enters the human body.
Respiratory Tract
GI Tract
GU Tract
Direct infection of mucous membrane
5. Susceptible Host
 One who lacks effective resistance to infectious agent.
 Factors influencing susceptibility:

76
  Intact skin and mucous membrane
 Normal pH levels of gastric secretion and GUT
 WBC count
 Age, sex
 Immunization
 Fatigue, climate, presence of pre existing disease
 Absent or abnormal immunoglobulins.

Medical Asepsis
 Practice designed to reduce the number and transfer microorganism
 Also called CLEAN TECHNIQUE
Common Medical Asepsis Practice
 Wash Hands frequency
 Before and after caring for any patient
 Before and after invasive procedure
 After touching contaminated objects
 After going to the bathroom
 After sneezing or coughing
Surgical Asepsis
 Practices that render and help objects and areas free of microorganism
 Also called STERILE TECHNIQUE
Common Surgical Asepsis Practices
 Open sterile package so that the first edge of wrapper is directed AWAY from the
worker
 Avoid getting any solution on a cloth or paper used as a field for sterile set – up
 Hold sterile objects above the level of the waist.
 Avoid talking, coughing, sneezing or reaching over a sterile field/ object
 Never walk away from or turn your back on a sterile field.

Communicable Disease Control

 Practices that prevent transmission of specific microorganisms
 Also called STRICT ISOLATION TECHNIQUE or ISOLATION TECHNIQUE
 Contagious Disease - Diseases that is spread relatively easily from one person to
another by direct contact.

77
Isolation Precautions
 Center for Disease Control and Prevention(CDC)
 1983 – made guidelines to health care facilities to choose systems:
 Category- specific Isolation
 Disease - Specific Isolation- for specific disease

Universal Precaution (UP)

 1987
 blood borne pathogens – Hepa B, HIV
 Proper handling of Body fluids ( vaginal secretions, semen, cerebrospinal fluid,
synovial, amniotic fluid etc.

CDC (HIPAC) Isolation

 Updated 1997

1. Standard Precaution
 used in the care of all hospitalized persons regardless of the diagnosis or possible
infection
 Apply to all blood, all body fluids, secretions
2. Transmission Based
 In addition to standard precaution
 Airborne, droplet, contact

TYPES

Reverse Isolation
Practices that prevent organism from being transmitted to susceptible host.
e.g. Leukemia
Immunocompromised patients
Patients receiving chemotherapy
Radiation Therapy
Immunosuppresive therapy

Strict Isolation
Prevent transmission of highly communicable disease spread by direct contact and
airborne
Infected burns
Diphtheria
Rabies
Rubella (German measles)
Respiratory Isolation
Prevent transmission from respiratory tract by direct contact or airborne

78
 Chicken pox
Herpes zoster
Rubeola (Measles)
Mumps
PTB
Enteric Isolation
Prevent transmission through fecal matter
Infectious hepatitis
Typhoid Fever
Cholera
Salmonellosis
Wound and Skin Isolation
Direct contact with wounds and wound drainage.
e.g. Burns and gas gangrene

Discharge Precaution
Direct contact with body secretions and excretions.

Blood Isolation
Contacted with blood
Malaria
Hepatitis
AIDS

Nosocomial Infections and Medical Asepsis

Nosocomial Infection
- infection acquired in the hospital.

TYPES:
Bacteremias (blood), GI, GU, Respiratory, Surgical sites.

**Infection occurs when a person’s resistance decreases.

Factors that contribute to decrease resistance:

 Trauma
 Pre existing disease
 Age
 Inactivity
 Poor nutrition
 Stress
 Fatigue

79
  Invasive therapy
 Frequent use of antibiotics
 Immunosuppressive therapy

Nurses Role
Minimize number and kind of microorganism
Control portals of exit and entry
Avoid actions that spread microorganism
Prevent bacteria from finding a site to grow
Medical Asepsis
 Practice of reducing the number of microorganism or prevent or reduce transmission
of microorganism from one person to another.
 Also referred as Clean technique
 Components
Reduce number of skin microorganism through hand washing
 Using barrier techniques (gloves and gowns)
 Keeping the environment clean and controlled to reduce disease transmission.
Protective Gears
 Gowns
 Masks
 Gloves
 Hair and shoe Cover
 Eye shield
Barrier Techniques
 Use personal protective equipment (PPE)- gloves, eye protection, masks, and gowns.
Principle
 to keep organisms from entering or leaving the respiratory tract, your eyes, or
break the skin.

STANDARDS ON INFECTION CONTROL

HANDWASHING: Single most important procedure for protecting yourself and your
clients against disease transmission.

Handwashing should be done in all of the following instances:

a. At he beginning of every work

80
 b. Before and after contact with a patient
c. Before and after an invasive procedure.
d. Before contact with especially susceptible patients
e. Before and after touching wounds
f. After contact with body substances even when gloves are worn.
g. Any time you are in doubt about the necessity for doing so
h. At the end of every shift before leaving the healthcare facility.

PURPOSE:
1. Reduce the number of resident and transient bacteria on hands.
2. Prevent transfer of microorganisms form the environment to
the client and from the client to health care personnel.

ASSESSMENT:
1. Inspect hands for cuts and abrasions
2. Inspect appropriate times for handwashing.
3. Identify the need to repeat handwashing.

EQUIPMENT:
1. Easy-to-reach sink with warm running water
2. Anti-microbial or regular soap.
3. Paper towel or air dryer.
4. Clean orangewood stick (optional)

STEPS KEY POINTS

1. Roll you sleeves above your elbows.
Remove jewelry and watch
2. Stand in front of the sink and avoid
leaning against it.
3. Turn on the water and regulate its flow
and temperature. Knee or foot pedals
maybe available on some sinks. In some
facilities, water automatically flows when you
placed your hands under the faucet.
4. Wet your hands and forearms with water,
keeping the hands lower than your elbow.
5. Apply an antibacterial liquid soap. If you
are using a bar soap, rinse the bar before
Rough places in jewelry cab
harbor microorganisms.
Avoid transferring contamination
from the sink to your uniform.
Controlling the force of flow limits
splashing,. Warm water makes
better soapsuds than cold water.
Hot water tends to dry and chap
skin by removing oils from the
skin.
Allows water to flow less
contaminated area towards your
hands which are most
contaminated.
Rinsing may reduce bacterial
contamination on the bar soap.

81
and after you lather with it and return it to
the soap dish,. Liquid soap with a foot
operated dispenser is the most sanitary. If
the bar is dropped accidentally, start the
washing procedure again.
6. Wash your hands, wrists and lower
forearms for a minimum of 10 – 15 seconds,
using a scrubbing motion. Interlace your
fingers and rub your hands back and forth.
7. Insert your fingernails from one hand
under those of your other hand using a
sweeping motion. Repeat with other hand.
8. Clean under the nails (subungual areas)
with an orange stick or a flat toothpick
carefully when hands are heavily
contaminated and at least once a day before
beginning work.
9. Rinse thoroughly, keeping your hands
lower than your forearms.
10. Repeat the procedure if your hands are
very soiled.
11. Dry hands thoroughly from fingers to
forearm using either paper towel or dryer (if
available).
12. Use a clean paper towel to turn off the
faucets
Illustrations on Hand Washing and Open Gloving
Contaminated soaps will
contaminate the hands.
Friction loosens dirt and bacteria
on all surfaces. Dirt and organism
lodge between fingers and in skin
crevices of knuckles as well as on
the palms and back of the hand.
Bacteria tend to accumulate under
the fingernails.
Organisms can lodge and remain
under the nails where they can
grow and be spread to others.
Prevent soap from re-
contaminating clean areas.
Ensure thorough cleaning.
Drying thoroughly prevents
chapping. Using paper towels
prevents spread of
microorganism.
Dry, clean towel prevents
recontamination of hands with
organism on faucets.
Step 1
82
Step 2

Step 3 Step 4

Step 7
Step 5

83
 Step 9 Step 10

Step 6

Step 8

84
 Step 11 Step 12

Step 13 Step 14

SURGICAL HAND SCRUB – also called surgical handwashing.

PURPOSE:
1. Remove as many as microorganisms from the hands as possible before a
sterile field.
2. Decrease the risk of infection

ASSESSMENT:

85
 a. Assess hospital policy regarding scrubbing.
b. Assess hands for cuts or abrasions.
c. Assess nails (remove nail polish)

EQUIPMENT:
Deep sink with knee or foot controls for soap and water
Anti-microbial soap
Surgical scrub
Sterile towel for drying
Plastic nail stick or sterile nail cleaner

FIVE-MINUTE SCRUB KEY POINTS

1. Wet hands and forearms. Initial handwashing removes
gross contamination.
2. Apply antiseptic agent from dispenser to
wash the hands.
3. Wash hands and arms several times Water runs from gravity from
thoroughly to 2-3 inches above the elbow. fingertips to elbows. Hands
Hands need to be above elbows at all times. become cleanest part of UE.
Keeping hands elevated allows
water to floe from least to most
contaminated areas.
4. Rinse thoroughly under running water. Removes transient bacteria.
With hands upward, allowing water to drip
from flexed elbows
5. Take sterile brush or sponge. Apply Remove dirt and organic material
antimicrobial agent if it is not impregnated in that harbor large numbers of
the brush. Scrub nails. microorganism.
6. Start timing. Scrub each side of each Scrubbing loosens resident
finger, between the fingers and the back and bacteria that adhere to skin
front of the hand for 2 minutes surface.
7. Proceed to scrub the arms, keeping the
hand higher than the arm at all times.
8. Wash each side of the arm to 2-3 inches
above the elbow for one minute.
9. Repeat the process on the other hand
and arm, keeping the hands above elbows
at all times. If the hand touches anything
except the brush at any time, the scrub must
be lengthened by 1 minute for the area that
has been contaminated.
10. Rinse hands and arms by passing them This manner avoids
through the water in one direction only – contamination.
from fingertips to elbow. Do not move the
arm back and forth through the water.
Proceed to the operating room suite holding

86
hands
DRYING HANDS AND ARMS
11. Reach down to the opened sterile This prevents accidental
package and pick up the towel. Be careful contamination.
not to drip water onto the pack. Be sure no
one is within arms’ reach.
12. Open full towel length, holding one end
away from non sterile scrub attire.
13. Dry both hands thoroughly but Oscillating motion ensures
independently. To dry one arm, hold the adequate drying of hands.
towel in the opposite hand and using Moisture is a possible source of
oscillating motion if the arm, draw the towel contamination.
up to the elbow.
14. Carefully reverse the towel, still holding
it away from the body. Dry the opposite end
of the towel.

Illustrations on Hand Scrubbing

STERILE GOWNING
1. Reach down to the sterile package and
lift the folded gown directly upward.
2. Step back away from the table, into an
unobstructed area.
3. Holding the folded gown. Carefully locate
the neckband.
4. Holding the inside front of the gown just
below the neckband with both hands. Let the
gown unfold keeping inside of the gown
toward the body. Do not touch the outside
of the gown with bare hands.
Gowns are considered sterile in
front from chest to level of the
sterile field.
To provide a wide margin safety
while gowning and prevent
contamination.
Clean hands may touch inside of
gown without contaminating the
outer surface.

87
5. Holding hands at the shoulder level, slip Gown covers hand to prepare for
both arms into armholes simultaneously. closed gloving.
6. The circulating nurse brings gown over
the shoulder by reaching inside to shoulder
and arm seams. The back of the gown is
securely tied or fastened at the head and
neck.

Illustrations on Sterile Gowning

Step 1 Step 2

Step 3 Step 4

88
 Step 5

GLOVING BY CLOSED GLOVE TECHNIQUE

- additional barrier to bacterial transfer.

1. Using the left hand and keeping it within Sterile gown touches sterile glove.
the cuff of the sleeve, pick up the right glove
from the inner wrap of the glove package by
grasping the folded cuff.
2. Extend the right forearm with palm Positions glove for application
upward. Place the palm of the glove against over cuffed hand, keeping glove
the palm of the right hand grasping in the sterile.
right hand the top edge of the cuff, above
the palm. In correct position, glove fingers
are pointing toward you and the thumb of
the glove is to the right. The thumb side of
the glove is down.
3. Grasp the back of the cuff in the left hand
and turn it over the end of the right sleeve
and hand. The cuff of the glove is now over
the stockinet cuff of the gown, with hand still
inside the sleeve.
4. Grasp the top of the right glove and Seal created by glove over gown
underlying gown sleeve with covered left prevents exit of microorganisms
hand. Pull glove on over extended right over operative sterile field.
fingers until it completely covers the
stockinet cuff.
5. Glove the left hand in the same manner, Sterile touches sterile.
reversing hands. Use gloved right hand to
pull on the left glove.

Illustration on Closed Gloving Technique

89
 Step 1 Step 2

Step 3

Gloves
 Gloves provide a protective barrier when you must touch blood or body fluids. You will
use gloves in all care for clients that involves potential exposure to body substances.
 Gloves provide protection from microorganism that clients carry.
 Help prevent the spread of pathogens from one client to another, from client to
healthcare staff or from healthcare to client.

Donning gloves
1. -To remove gloves, grasp the outside of one glove, near the cuff, with your thumb and
forefinger of your other hand.
-Pull the glove off, turning it inside out as you pull.
-Confine contamination to the gloves

2. -Hook your bare thumb inside the other glove and pull it off, turning it inside out.
-Roll the two gloves together with the side that was nearest your
hands on the outside.
-Confine contamination.

3. -Drop gloves into the appropriate waste receptacle

-Prevent the spread of infection.

4. -Wash your hands again

-Prevent the spread of infection

90
91
 TRINITY COLLEGE OF QUEZON CITY
ST. LUKE’S COLLEGE OF NURSING

Student’s Return Demonstration Checklist

STANDARDS ON INFECTION CONTROL

Name:__________________________________________Section:__________

Steps Done Needs Not Remarks

2 Improvement Done
1 0
1. Roll you sleeves above your elbows.
Remove jewelry and watch
2. Stand in front of the sink and avoid leaning
against it.
3. Turn on the water and regulate its flow and
temperature. Knee or foot pedals maybe
available on some sinks. In some facilities,
water automatically flows when you placed
your hands under the faucet.
4. Wet your hands and forearms with water,
keeping the hands lower than your elbow.
5. Apply an antibacterial liquid soap. If you are
using a bar soap, rinse the bar before and
after you lather with it and return it to the soap
dish,. Liquid soap with a foot operated
dispenser is the most sanitary. If the bar is
dropped accidentally, start the washing
procedure again.
6. Wash your hands, wrists and lower
forearms for a minimum of 10 – 15 seconds,
using a scrubbing motion. Interlace your
fingers and rub your hands back and forth.
7. Insert your fingernails from one hand under
those of your other hand using a sweeping
motion. Repeat with other hand.
8. Clean under the nails (subungual areas)
with an orange stick or a flat toothpick carefully
when hands are heavily contaminated and at
least once a day before beginning work.
9. Rinse thoroughly, keeping your hands lower
than your forearms.
10. Repeat the procedure if your hands are
very soiled.
11. Dry hands thoroughly from fingers to
forearm using either paper towel or dryer (if
available).
12. Use a clean paper towel to turn off the
faucets
FIVE-MINUTE SCRUB
1. Wet hands and forearms.
2. Apply antiseptic agent from dispenser to
wash the hands.
3. Wash hands and arms several times
thoroughly to 2-3 inches above the elbow.
Hands need to be above elbows at all times.
4. Rinse thoroughly under running water. With
hands upward, allowing water to drip from
flexed elbows
5. Take sterile brush or sponge. Apply
antimicrobial agent if it is not impregnated in
the brush. Scrub nails.
6. Start timing. Scrub each side of each
finger, between the fingers and the back and
front of the hand for 2 minutes
7. Proceed to scrub the arms, keeping the
hand higher than the arm at all times.
8. Wash each side of the arm to 2-3 inches
above the elbow for one minute.
9. Repeat the process on the other hand and
arm, keeping the hands above elbows at all
times. If the hand touches anything except the
brush at any time, the scrub must be
lengthened by 1 minute for the area that has
been contaminated.
10. Rinse hands and arms by passing them
through the water in one direction only – from
fingertips to elbow. Do not move the arm back
and forth through the water. Proceed to the
operating room suite holding hands
DRYING HANDS AND ARMS
11. Reach down to the opened sterile package
and pick up the towel. Be careful not to drip
water onto the pack. Be sure no one is within
arms’ reach.
12. Open full towel length, holding one end
away from non sterile scrub attire.
13. Dry both hands thoroughly but
independently. To dry one arm, hold the towel
in the opposite hand and using oscillating
motion if the arm, draw the towel up to the
elbow.
14. Carefully reverse the towel, still holding it
away from the body. Dry the opposite end of
the towel.
STERILE GOWNING
1. Reach down to the sterile package and lift
the folded gown directly upward.
2. Step back away from the table, into an
unobstructed area.
3. Holding the folded gown. Carefully locate
the neckband.
4. Holding the inside front of the gown just
below the neckband with both hands. Let the
gown unfold keeping inside of the gown toward
the body. Do not touch the outside of the
gown with bare hands.
5. Holding hands at the shoulder level, slip
both arms into armholes simultaneously.
6. The circulating nurse brings gown over the
shoulder by reaching inside to shoulder and
arm seams. The back of the gown is securely
tied or fastened at the head and neck.
GLOVING BY CLOSED GLOVE TECHNIQUE
1. Using the left hand and keeping it within the
cuff of the sleeve, pick up the right glove from
the inner wrap of the glove package by
grasping the folded cuff.
2. Extend the right forearm with palm upward.
Place the palm of the glove against the palm of
the right hand grasping in the right hand the
top edge of the cuff, above the palm. In
correct position, glove fingers are pointing
toward you and the thumb of the glove is to the
right. The thumb side of the glove is down.
3. Grasp the back of the cuff in the left hand
and turn it over the end of the right sleeve and
hand. The cuff of the glove is now over the
stockinet cuff of the gown, with hand still inside
the sleeve.
4. Grasp the top of the right glove and
underlying gown sleeve with covered left hand.
Pull glove on over extended right fingers until it
completely covers the stockinet cuff.
5. Glove the left hand in the same manner,
reversing hands. Use gloved right hand to pull
on the left glove.

Score:_______________
Evaluator’s Signature:_________________________
Date:_______________________________________
 CHAPTER VIII
PERSONAL HYGIENE

Topic Description:
This topic focuses on how to provide or assist clients with their personal hygiene.
In this chapter the anatomical system of interest is the skin, the discussion pertain to
common skin problems and how to manage it.

Competencies:
1. Knowledge on the anatomy and physiology of the skin.
2. Determine common Skin problems.
3. Develop understanding on common foot and nail problems.
4. Determine common hair and scalp problems.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Demonstrate Personal 1 Day Lecture Pre- Test
Knowledge of the Hygiene:
anatomy and physiology Discussion Post- Test
of the skin. The Skin: Review
of Anatomy and Recitation
Determine common skin Physiology
problems and its
treatment. Common Skin
Problems
Determine the common
foot and nail problems Common Foot
and its treatment. and Nail
Problems
Determine the common
hair and scalp problems Common Hair
and its management. and Scalp
Problems
Develop an
understanding of Decubitus Ulcer
decubitus ulcer: its
development and
prevention/management
 Chapter VIII
PERSONAL HYGIENE

THE SKIN

ANATOMY AND PHYSIOLOGY

 The integument refers to the skin
 The integumentary system is consists of:
skin & it’s appandages (hair, glands in the skin, & the nails)

2 layers of the Skin

Epidermis - superficial portion
> made up of layers of stratified epithelial cells
>Epithelial cells have no blood vessel of their own, they depend on
underlying tissues for nourishment & waste removal
>They form a protective, waterproof layer of keratin material
>When well nourished, epithelium regenerates relatively easily & quickly.

Dermis - deeper layer of the skin

> consists of smooth, muscular tissue, nerves, fat, hair follicles, certain glands &
their ducts, arteries, veins & capillaries & fibrous elastic tissue.

GLANDS IN THE SKIN

 Sebaceous gland secrete an oily substance called sebum
 Sweat glands secrete perspiration
 Ceruminous glands secrete cerumen in the external ear canals consisting of a
heavy oil & brown pigment

FUNCTIONS OF THE SKIN

 The skin protects the body
 It helps regulate body temperature
 It is a sense of organ
 It is an excretory organ
 Helps maintain water & electrolyte balance
 The skin produces & absorbs vitamin D

FACTORS INFLUENCING THE SKIN’S CONDITION

 Infant’s skin & mucous membranes are easily injured & subject to infection.
 A child’s skin becomes increasingly resistant to injury & infection.
 Adolescent’s skin ordinarily has enlarged sebaceous glands & increased glandular
secretion caused by hormonal changes in the body
 Secretions from the skin glands are at their maximum during adolescence and up to
50y/o
 The skin becomes thinner & less elastic & supple with aging
 Very thin & very obese people tend to be more subject to skin irritation and injury
 Dehydration predisposes to skin injury
 Diseases of the skin are usually characterized by various lesions that require special
care to promote personal hygiene & to carry out therapeutic regimens

Basic Principles
 Unbroken & healthy skin & mucous membranes serve as the first lines of defense
against harmful agents
 Resistance to injury of the skin and mucous membranes varies among people
 Body cells adequately nourished & hydrated are resistant to injury
 Adequate circulation is necessary to maintain cell life

COMMON SKIN PROBLEMS

I. Abrasion
Superficial layers of the skin are scraped or rubbed away. Area is reddened & may have
localized bleeding or serous weeping
Nursing Implication:
 Prone to infection; should be kept clean & dry at all times
 Do not wear rings or jewelry when providing care to avoid causing abrasions to
clients
 Lift, do not pull client across a bed

II. Excessive dryness

Skin can appear flaky & rough
Nursing Implications:
 Provide alcohol-free lotions to moisturize the skin to prevent cracking thus
preventing infection
 Bathe client less frequently; use no soap; or limit use of non-irritating soap;
rinse thoroughly
 Encourage increase fluid intake if health permits to prevent dehydration

III. Ammonia Dermatitis

 Caused by skin bacteria reacting with urea in the urine. The skin becomes
reddened & is sore
 Keep skin dry& clean by applying protective ointments containing zinc oxide
to areas at risk (buttocks, perineum)
 Boil an infant’s diapers or wash with antibacterial detergent to
prevent infection
IV. Acne
Inflammatory condition with papules & pustules
Nursing Implications
 Keep the skin clean to prevent secondary infection
 Treatment varies widely

V. Erythema
Redness associated with a variety of conditions, such as rashes, exposure to sun,
elevated body temperature
Nursing Implication
 Wash area carefully to remove excess microorganisms
 Apply antiseptic spray or lotion to prevent itching, promote healing and
prevent skin breakdown

VI. Hirsutism
Excessive hair on a person’s body & face, particularly in women
Nursing Implications
 Remove unwanted hair by using depilatories, shaving, electrolysis or tweezing
 Enhance client’s self-concept

Common foot & nail problems

1. Callus – thickened portion of epidermis

 Usually flat & painless
 Caused by pressure from shoes
 Can be softened by soaking the foot in warm water with Epson salts, &
they can be abraded by pumice stones
 Creams with lanolin help to keep the skin soft & prevent the formation of
calluses

2. Corn
 Keratosis caused by friction & pressure from a shoe
 Wear comfortable shoes
 Unpleasant odors
 Occurs as a result of perspiration & it’s interaction with microorganisms.
 Regular & frequent washing of the feet

3. Plantar warts
 Appear on the sole of the foot
 Caused by virus papovavirus hominis
 Moderately painful
 Frequently painful & make walking difficult
 Physician may curettage the warts, freeze them with solid carbon dioxide
several times, or apply salicylic acid
 4. Fissures
 Deep groves, frequently occur between the toes as a result of dryness &
cracking of the skin
 Treatment: good foot hygiene & application of an antiseptic to prevent
infection (a small piece of gauze is inserted between the toes in applying the
antiseptic & left in place to assist healing by allowing air to reach the area

5. Athlete’s foot or tinea pedis

 Ringworm of the foot caused by a fungus
 Scaling & cracking of the skin particularly the toes
 Treatment: Potassium permanganate 1:8000 solution; application of
commercial antifungal oinments or powder
 Preventive measures: keep feet well ventilated; dry feet well after bathing;
 Wear clean stockings or socks; not going barefooted in public showers

6. Ingrown toenail
 The growing inward of the nail into the soft tissues around the nails
 Most often results from improper nail trimming
 Treatment: frequent, hot antiseptic soaks & surgical removal of the portion of
the nail imbedded in the skin

Common Hair and Scalp Problems

1. Dandruff
 Diffuse scaling of the scalp often accompanied by itching
 In severe cases it involves the auditory canals and eyebrows
 Treatment: Mild – anti-dandruff shampoo
 Severe – seek physician’s

2. Hair Loss
 Occurs with aging, hereditary
 Treatment: no known remedy other that wearing of a hairpiece / costly
surgical hair transplant (hair is taken from the back or the sides of the
scalp and surgically moved to the hairless area)

3. Ticks
 Small parasites that bite into tissue & suck blood
 They can attach to human beings & are frequently found in the hair
 Transmits several diseases to people, in particular Rocky Mountain spotted
fever & Lyme’s disease
4. Pediculosis (Lice)
 Parasitic insects that infest mammals
 Infestation with lice is called pediculosis

3 common kinds:
a. Pediculosis Capitis (head louse)
b. Pediculosis Corposis (the body louse)
> tends to cling to clothing
> sucks blood from the person & lay their eggs on the clothing
> suspects presence when:
a. The person habitually scratches
b. There are scratches on the skin
c. There are hemorraghic spots on the
skin where lice have sucked blood
c. Pediculosis pubis (the crab louse)
> crab louse in the pubic area has red legs
> may contacted from infested clothes &
direct contact with an infested person

Treatment: Gamma benzene hexachloride (Kwell)

Preparation: shampoo, lotion, cream

4. Scabies - Contagious skin infestation by the itch mite

Characteristic lesion :
- burrow produced by the female mite (short, wavy, brown or black
threadlike lesions most commonly observed between the webs of the
fingers & the folds of the wrists & elbows)
- Intense itching mostly at night

Treatment: thorough cleansing with soap & water;

application of scabicide lotion.
*all bed linens and clothing should be washed in very hot or boiling water

DECUBITUS ULCER

A.K.A.: Pressure ulcers; Pressure sores; Bedsores; Distortion sores

Definition:
- Any lesion caused by unrelieved pressure that results in damage to Underlying
tissue
- Clients at risk in developing decubitus ulcer:
 Immobile patients
 Orthopedic clients with fractures
 Elderly with femoral fractures
 Clients in nursing home settings
Etiology
Unrelieved pressure
localized ischemia
Deprivation of oxygen & nutrients
Accumulation of waste products in the cell
Tissue dies
Prolonged unrelieved pressure
Damage to the blood vessels

2 contributing factors in the formation of pressure ulcer

 Friction - force acting parallel to the skin
 Shearing force - combination of friction & pressure
e.g. when the client in fowlers position slides down towards the foot
of the bed

RISK FACTORS
a. Immobility & Inactivity
 Immobility refers to an alteration in the amount & control of movement a
person has
 Inactivity refers to an alteration in a person’s ability to ambulate
independently
b. Inadequate nutrition
 Prolonged inadequate nutrition causes wt loss, muscle atrophy & loss of
subcutaneous tissue
c. Hypoproteinemia
 Abnormally low protein content in the blood
 Prone to dependent edema
 Edema makes skin more prone to injury by decreasing its elasticity, resilience
& vitality
 Vitamin C aids in the absorption of and use of iron and is essential for protein
collagen formation (lack of it could impede healing process)
d. Fecal & Urinary Incontinence
 Accumulation of excretions & secretions is irritating to the skin; harbors
microorganisms & makes individual prone to skin breakdown
 Promotes skin maceration (tissue softened by prolonged wetting or soaking)
making skin more susceptible to injury
e. Decreased Mental Status
f. Diminished Sensation
g. Excessive Body Heat
 It increases the body’s metabolic rate thus increasing the need of the cells for
oxygen
h. Advanced Age
 Loss of lean body mass
 Generalized thinning of the epidermis
 Reduced skin turgor
 Diminished pain perception
 Decreased dryness & scaliness
i. Other factors
 Poor lifting technique
 Incorrect positioning
 Repeated injections in the same area
 Hard support surfaces
 Incorrect application of pressure-relieving devices

Stages of Pressure Ulcer Formation

Stage I: Nonblanchable erythema of intact skin;

this is the heralding lesion of skin

Stage II: Partial-thickness skin loss involving epidermis &/or dermis.

Presents clinically as an abrasion, blister or shallow crater

Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous

tissue that may extend to, but not through, underlying fascia
- Presents clinically as a deep crater with or without undermining of adjacent
tissue

Stage IV: Full-thickness skin loss with extensive destruction, tissue

necrosis or damage to muscle, bone or supporting structures such
as a tendon or joint capsule

ASSESSMENT
- Location of lesion
- Size of lesion in centimeters
- Stage of the ulcer
- Color of the wound bed & location of necrosis
- Condition of the wound margins
- Integrity of surrounding skin
- Integrity of surrounding skin
- Clinical signs of infection
(redness, warmth, swelling, pain, odor & exudate)
- Amount of time the lesion has been known to exist
- Any previously used treatments
DIAGNOSIS
 High risk for impaired skin integrity
 Impaired skin integrity (stages I & II)
 Impaired tissue integrity (stages III & IV)

PREVENTION
 Providing nutrition
High in calories, vitamin C & zinc to maintain skin integrity
 Maintaining Skin Hygiene
 Avoiding Skin Trauma
- Provide smooth, firm and wrinkle free foundation
- Correct positioning, turning & transferring of the patient
- Use of trapeze in lifting a client to change position rather than dragging the client
- Positioning every two hours
- Providing supportive devices
- Overlay mattress: applied on top of the standard bed mattress
(e.g. egg crate mattress)
- Replacement mattress: replaces the standard mattress
- Specialty beds: replace hospital beds

Provides pressure relief, eliminate shearing & friction & decrease moisture (e.g.
High Air Loss beds (HAL); Low Air Loss beds (LAL); kinetic beds (RotoRest) –
provides continuous passive motion or oscillation therapy

Client teaching
a. Causes of pressure ulcers
b. Individual risk factors
c. Skin inspection for redness, temp, blistering & pulses
d. Skin care plan (clean, lubricated skin, protection from
secretions & excretions)
e. Keep pressure off the skin & bony prominences as much as possible
f. Selection of pressure-relieving devices
g. Schedule for repositioning & demonstration of desired position
h. Importance of maintaining or increasing correct activity level
i. Avoidance of massage, donuts & heat lamps
j. Need to contact the physician when there is skin redness, blister
formation, or breakdown

Treatment
 Minimize direct pressure on the sore; reposition every 2 hours
 Clean the pressure sore daily (whirlpool bath-Stage I; wound irrigation-Stage IV)
 Use surgical asepsis to clean & dress sore (Avoid the use of alcohol that are
vasoconstrictors & reduce blood flow to the area)
 Obtain sample of the drainage for culture for infected sore
 Reduce friction by applying a small amount of cornstarch on the bedsheet
  Keep head part of the bed flat or elevated to a maximum of 30 degrees to reduce
shearing force unless contraindicated
 Use pressure relieving devices such as egg crate mattress if the client can’t keep
weight off the pressure sore
 Encourage ambulation or sitting in a wheelchair as the client’s condition permits
 Provides range of motion (ROM) exercises as the client’s condition permits
 Dressings for Decubitus Ulcers

Evaluation
1. Has the client condition changed?
2. Were risk factors correctly identified?
3. Were appropriate lifting devices & techniques used?
4. Did the client fail to comply with instructions about moving & turning? Why?
5. Were appropriate pressure-relieving devices used, & were they applied
correctly?
6. Was the repositioning schedule adhere to?
7. Is the client’s diet & fluid intake adequate?
8. Were appropriate measures used to control incontinence & protect the client’s
skin?
9. If an ulcer is present, was the wound treated appropriately?
10. If the client is at home, were support services adequate? Did the support person
have the ability to perform required care?

Bath and Back Rub

TYPES OF BATHS
a. Cleansing bath - Keep the skin free of secretions, microorganisms,
perspiration & debris
b. Therapeutic bath - Soothe skin irritation or promote healing

Back Rub/Back Massage

- Given to enhance blood supply to skin & muscles, promote comfort & relaxation
- Position: Prone/Side lying
a. Provide privacy
b. Warm hands in warm water before massaging to prevent startle response &
muscle tension from cold lotion & hand
c. Begin massage in sacral area with circular motion. Use continuous firm pressure
to promote relaxation & stimulates circulation
d. Assess for broken skin areas while massaging. Avoid pressure over areas of
breakdown or redness to prevent damage or trauma to the tissues
e. If additional stimulation is desired, nurse can use petrissage (kneading) over the
shoulders & gluteal area & tapotement (tapping) up & down the spine
f. End massage with long, continuous, stroking movements (Most relaxing of the
massage movements)
g. Pat excess lubricant; dry with towel; assist to comfortable position
h. Wash hands
 CHAPTER IX
PROMOTING ACTIVITY AND EXCERSICE

Topic Description:
This topic focuses on the promotion of activity and exercise for the patient. This
chapter will discuss about the conditions that arises due to immobility.

Competencies:
1. Develop an understanding of body mechanics.
2. Determine factors that affect body alignment and mobility.
3. Knowledge on how to promote exercise and range of motion among
patients.
4. Determine the different mechanical aids for walking.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Develop an Promoting 1 Day Lecture Pre- Test
understanding about Activity and
body mechanics and Exercise: Discussion Post- Test
how it can help both
the nurse and client. Definition of Recitation
Terms
Determine ways to
promote a clients Principles of
ability to perform Body
activity and exercise. Mechanics

Gain knowledge on Factors

the factors affecting Affecting Body
body alignment and Alignment and
mobility and its mobility
effect to the client.
Effects of
Determine the Immobility
effects of immobility
to a client and how Exercise
to improve a clients
range of motion. Range of
motion
Determine the
different aids for Mechanical
walking and its Aids for
proper application. Walking
 Chapter IX
PROMOTING ACTIVITY AND EXCERSICE

Activity
 This can be described as energetic action or as being in a state of movement
 Mobility is vital to independence
 A fully immobilized person is as vulnerable and dependent as an infant

Body Mechanics
 It is the efficient coordinated and safe use of the body to produce motion and
maintain balance during activity
 Involves 3 basic elements: Body alignment (posture), Balance (stability),
Coordinated body movement

Body Alignment
 It is the geometric arrangement of body parts in relation to each other
 Promotes optimal balance and maximal body function
 Synonymous with posture
 Proper body alignment enhances lung expansion and promotes efficient circulatory,
renal and gastro intestinal functions

Balance
 A state of equipoise (equilibrium) in which opposing forces counteract each other
 It is the result of proper body alignment
 A person maintains balance as long as the line of gravity passes through the center
of gravity and the base of support

Coordinated Body Movement

 Muscle tone, the neuromuscular reflexes and the coordinated movements of
opposing voluntary muscle groups (antagonist, synergistic, antigravity muscles) play
important roles in producing balanced, smooth and purposeful movement
 Body mechanics involves the integrated functioning of the musculoskeletal, nervous
system and joint mobility

Synergistic Muscles
 Prevent undesirable movements
 They aid the action of a prime mover by affecting the same movement or by
stabilizing joints across which the prime mover acts

Antagonist Muscle
 Muscles on the other side of the joints that relaxes or lengthen to permit movement
 Example is the hamstring muscle when flexing to bend the knee and the quadriceps
femoris muscles extends the leg to straighten the knee
Antigravity Muscles
 Also referred to as the extensor muscles
 Continuous action of postural muscles sustains humans in an upright position
against the force of gravity

Synovial Joints
 Are freely movable joints, has spaces between the articulating bone surfaces, and
characteristically has a cavity enclosed by a capsule

Synovial Joint Movements

 Flexion- Decreasing the angle of the joint
 Extension- Increasing the angle of the joint
 Hyperextension- Further extension or straightening of a joint
 Abduction-Movement of the bone away from the midline of the body
 Adduction- Movement of the bone towards the midline of the body
 Rotation – Movement around its central axis
 Circumduction- Movement of the distal part of the bone in a circle whiloe the
proximal end remains fixed
 Eversion- Turning the sole of the foot outward by moving the ankle joint
 Inversion- Opposite of Eversion
 Pronation- Moving the bones of the forearm so that the palm of the hand faces
downward when held in front of the body
 Supination- Moving the bones of the forearm so that the palm of the hand faces
upward when held in front of the body
 Protraction- Moving a part of the body forward in the same plane parallel to the
ground
 Retraction- Moving a part of the body backward in the same plane parallel to the
ground

Range of Motion
 The ROM of a joint is the maximum movement that is possible for that joint
 This varies from individuals and is determined by genetic makeup, developmental
patterns, the presence or absence of disease and amount of physical activity one
engages in.

Principles of Body Mechanics

 Balance is maintained and muscle strain is avoided as long as the line of gravity
passes through the base of support
 The wider the base the lower the center of gravity the greater the stability
 Objects that are close to the center of gravity are moved with less effort
 Balance is maintained when the base of support is enlarged in the direction in which
the movement will occur
 The greater the preparatory of muscles before moving an object the less energy
required to move it and the less likelihood to injury
 The synchronized use of many large muscle groups increases the overall strength
and prevents fatigue and injury
 The closer the line of gravity to the center of the base of support the greater the
stability
 The greater the friction beneath an object the greater the force required to move the
object
 Pulling creates less friction than pushing
 The heavier the object the greater the force required to move the object
 Moving an object along a level surface requires less energy than moving it up an
inclined plane or lifting it against the force of gravity
 Continuous muscle exertion can result in muscle strain and injury

Factors Affecting Body Alignment and Mobility

 Growth and Development- Age, musculoskeletal, and nervous system
 Physical Health- Problems of the musculoskeletal and nervous system. Example:
Osteoporosis, Osteoarthritis, Parkinson’s disease, stroke
 Mental Health- can affect a person’s appearance and movement
 Nutrition- Poorly nourished people may have muscle weakness and fatigue
 Life-Style- Postures repeatedly assumed during work can result in permanent
postural defects
 Personal Values- Person’s who value their health and appearance are more likely to
practice good body mechanics and gait
 Fatigue and Stress- This can deplete a person’s energy
 External Factors- Example are temperature, money and availability of recreational
facilities

Effects of Immobility

Musculoskeletal System
• Disuse osteoporosis- without the weight bearing activity the bones demineralize
• Disuse atrophy- decrease in muscle size
• Contractures- muscle fibers no longer shortens or lengthens
• Stiffness and Pain- without movement, the collegen tissues at the joints become
ankylosed or permanently immobility

Cardiovascular System
• Diminished Cardiac Reserve- Person experiences tachycardia and angina with even
minimal exertion
• Increase use of Valsalva Manuever- refers to the holding of breath and straining
against a close glottis while moving
• Orthostatic Hypotension- During prolonged immobility the vasoconstriction reflex of
the lower extremities when standing becomes dormant
• Venous Vasoconstriction & Stasis- In an immobile person the skeletal muscle do not
contract sufficiently and the muscle atrophy
• Dependent Edema- Most common in the parts of the body positioned below the
heart level
• Thrombus Formation- A clot that is loosely attached to an inflamed vein wall due to
Virchow’s triad ( 3 factors that predisposes the formation of thrombophlebitis)

Respiratory System
• Decreased Respiratory movement- the rigid bed presses against the body and
curtails chest movement
• Pooling of Respiratory Secretions- Immobility allows secretions to pool by gravity
• Atelectasis- Collapse of a lobe or an entire lung due to increased secretions
• Hypostatic Pneumonia- due to static secretions

Metabolic System
• Decreased Metabolic Rate- Due to decrease energy requirements
• Negative Nitrogen Balance
• Anorexia
• Negative Calcium Balance

Urinary System
• Urinary Stasis
• Renal Calculi
• Urinary Retention
• Urinary Infection

Gastrointestinal System
• Constipation- due to increase adrenaline production resulting to decreased
peristalsis

Integumentary System
• Reduced skin turgor- Skin can atrophy due to prolonged immobility as a result of
fluid shifting
• Skin Breakdown- Immobility impedes circulation and diminishes the supply of
nutrients to specific areas

EXERCISE

 It is the active contraction and relaxation of muscles

 Three classifications according to type:
• Isotonic- those in which muscle tension is constant and the muscle shortens to
produce muscle contraction and movement
• Isometric- Are those in which there is a change in muscle tension but not in muscle
length
• Isokinetic- the person moves or tenses against resistance
Two types according to source of energy:
• Aerobic- activity in which the amount of oxygen taken into the body is greater than or
equal to the amount the body requires
• Anaerobic- activity in which the amount of oxygen taken into the body is insufficient
to meet the body’s need

Range of Motion (ROM)

 Active ROM- isotonic exercises in which the client moves each joint in the body
through its complete range of movement. These exercises maintain or increase
muscle strength and endurance and help to maintain cardiorespiratory function

 Passive ROM- Another person moves the client’s joints through their complete
range of movement, maximally stretching all muscle groups within each plane over
each joint

 Active Assistive ROM- The client uses a stronger opposite arm or leg to move each
of the joints or limb incapable of active motion

Mechanical Aids for Walking

 Canes - Canes should have rubber caps to improve traction and prevent slipping.
The length should permit the elbow to be slightly flexed
 Walkers - Given to clients who needs more support than what the cane can offer.
Has four legs and rubber tips and plastic hand grips
 Crutches - This device enables a person to move independently. Maybe a
temporary or permanent need.

Three type of crutches:

• Axillary crutch- most commonly used.
• Lofstrand crutch- use as a substitute for a cane
• Canadian/Elbow extensor- used by clients who require support for weak extensor
muscles of the arm
 CHAPTER X
PROMOTING COMFORT, REST AND SLEEP

Topic Description:
This topic focuses on promoting comfort, rest and sleep among patients. In this
Chapter the pain and its management will also be discussed, its understanding will
provide the reader with on how to further promote comfort, rest and sleep.

Competencies:
1. Determine the cause of pain.
2. Knowledge on how to properly assess pain.
3. Determine ways to promote comfort, rest and sleep for the patient.

OBJECTIVES TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Determine the Promoting Comfort, 1 Day Lecture Pre- Test
different causes Rest and Sleep:
of pain and its Discussion Post- Test
management. Pain
Recitation
Gain an insight Concepts Associated
on how to with Pain
properly assess
pain. Pain Assessment

Determine the Physical Examination

different pain
management Pain Management
methods
available to the Rest and Sleep
client.

Determine how
comfort rest and
sleep can
promote the
clients well
being.
 Chapter X
PROMOTING COMFORT, REST AND SLEEP

PAIN
 Pain is a highly unpleasant and very personal sensation that cannot be shared with
others.
 One of the most complex human experiences; an individual phenomenon influenced
by the interaction of affective, behavioral, cognitive and physiologic-sensory factors.

A. NOCICEPTORS
• Sensory pain receptors are free nerve endings in the tissue that respond to tissue-
injuring stimuli (noxious stimuli).
• Receptors that respond to noxious temperature
changes(thermoreceptors),chemicals(chemoreceptor), or pressure (mechanical
receptors) transmit the pain if the noxious stimuli are sufficiently strong.
• Found in the skin, blood vessels, subcutaneous tissue, muscle, fascia, periosteum,
viscera, joints and other structures.
• Nociceptors are located on two types of peripheral nerve cells that are responsible
for transmitting pain from the tissues to the central nervous system.

2 Types of peripheral nerve cells:

• A – delta fibers – give rise to the bright sharp localized pain that is immediately
associated with injury. (1st pain)
• C – fibers – cause a second pain sensation that is dull, poorly localized, and
persistent after injury.

B. ORIGINS & CAUSES OF PAIN

Cutaneous pain – Originates in the skin or subcutaneous tissue.

e.g. paper cut causing a sharp pain

Deep Somatic pain – arises from ligaments , tendons, bones, blood vessels, and
nerves. It is diffuse and tends to last longer than cutaneous pain
e.g. ankle sprain

Visceral pain – results form stimulation of pain receptors in the abdominal cavity,
cranium, and thorax. Tends to appear diffuse and often feels like deep somatic
pain, that is burning, aching or feeling of pressure.
e.g. ischemia, or muscle spasms.
C. TYPES of PAIN
Acute Pain
-may have a sudden or slow onset; it varies from mild to severe,
and may last up to 6 mos and subsides as healing takes place.
-it reflects potential and present tissue damage.

Chronic Pain
-6 months or longer and often limits normal functioning.
-usually increases at night.

D. CONCEPTS ASSOCIATED WITH PAIN

• Pain Threshold – is the amount of pain stimulation a person requires in order to feel
pain.
• Pain Reaction – ANS & behavioral response to pain; it protects the individual from
further harm. (automatic withdrawal of hand from hot stove)
• Pain tolerance – is the maximum amount & duration of pain that an individual is
willing to endure; influenced by psychologic and socio cultural factor; appears to
increase with age.

PAIN ASSESSMENT

An accurate assessment focusing on pain’s cause is essential for determining the

proper therapy. The nurse must obtains a pain history, physical examination that
focuses on the client’s physiologic & behavioral responses to pain.

Data that should be obtained on Pain History

1. Location -“Where is the pain located?”
-This can be measured objectively by using a drawing of a body outline
2. Intensity -“What is the magnitude or intensity (level) of the pain?”
-Pain intensity is measured with the use of scale
3. Quality – Descriptive adjectives help people to communicate the quality of pain.
e.g. Hammer like, piercing like a knife
4. Pattern – it includes time of onset, duration, and persistence of
or intervals without pain.
-“when the pain began (onset), how long the pain lasts, if
recurrent-the length of interval without pain; when the pain
last occurred.
5. Precipitating factors - activities that sometime precede pain.
6. Alleviating Factors – this will include the analgesics taken, rest,
and application of heat or cold.
PHYSICAL EXAMINATION

1. This will determine the client’s physiologic and behavioral responses to pain.
 The nurse needs to assess the client’s vital signs and observes the skin color, skin
dryness, diaphoresis, facial expression, and body gestures.
Physiologic Response
- this may vary according to whether the pain is acute or chronic.
- Acute pain stimulates the sympathetic nervous system, resulting in increased BP,
PR, RR, pallor, diaphoresis, and pupil dilation.
• Chronic pain or visceral pain – parasympathetic stimulation may be observed:
lowered BP, decreased PR, pupil constriction & warm dry skin.

2. Affective Responses
• Vary according to the situation, degree & duration of pain.
• The nurse needs to explore the clients feeling( anxiety, fear, exhaustion, depression)
• People with chronic pain become depressed & tends to be suicidal.

3. Behavior Responses
–The very young, aphasic and confused or disoriented persons often
communicate their experience of pain only non-verbally.
-Facial expression is often the first indication of pain.
(clenched teeth, tightly shut eye, open somber eyes, lip biting & other facial grimaces)
 Immobilization of the body part, muscle guarding.
 Rhythmic body movement – rubbing of affected body part.
 Speech & vocal pitch –Rapid speech & elevated pitch often reflect anxiety;slow
speech & monotonous tone can signal intense pain.

PAIN MANAGEMENT

 It is the alleviation of pain or reduction in pain to a level of comfort that is acceptable

to the client.
 It includes two types of NURSING interventions: Pharmacologic & Non
Pharmacologic.

1.Pharmacologic Pain Mgt.

• It involves the use of Opioids(narcotics), nonopiods/NSAID, adjuvants, or
coanalgesic drugs.
• Opiods Analgesics – include opium derivatives, such as morphine and codeine.
• Nonopoid – include NSAID such as aspirin , acetaminophen, and ibuprofen.
(decrease or inhibit prostaglandin release)
• Adjuvant analgesics –are medication that developed for uses other than
analgesia but have found to reduce certain types of chronic pain.
e.g. mild sedatives or tranquilizers, diazepam; Antidepressant(Elavil),
Anticonvulsant(tegretol) for neuropathies in Herpes zosters.

2. Nonpharmacologic pain Mgt.

Goal of Physical intervention :
- Provide comfort
- Correct physical dysfunction
- Alter physiologic responses
- Reduce fears associated with pain-related immobility or activity restrictions.

a. Cutaneous stimulation – can provide effective temporary pain relief.

It distracts the client & focuses attention on the tactile stimuli, away
from the painful sensations, thus, reducing pain perception.
- Create the release of endorphins that block the pain stimuli.
- Stimulate large diameter A-beta sensory nerve fibers thus decreasing the
transmission of pain impulses through the smaller A-delta & C fibers
b. Immobilization – Immobilizing painful body parts.
c. Tanscutaneous Electric Nerve Stimulation
(TENS) – same function as cutaneous stimulation.
• Goals of Cognitive-Behavioral Interventions:
• Alter pain perception
• Alter pain behavior
• Provide clients with greater sense of control over pain.
• Distraction - it draws the client’s attention away from the pain & lessen the
perception of pain.
- e.g. slow rhythmic breathing, masssage & slow-rhythmic breathing, Active
listening, Guided imagery.
-
 Hypnosis – is an altered state of consciousness in which an individual’s
concentration is focused and distraction is minimized.

Example of Cutaneous stimulation:

 Massage
 Application of heat & colds
 Acupressure – based on the ancient chinese healing of acupuncture.
 Contralateral stimulation – stimulating the skin in an area opposite to the painful
area.
REST AND SLEEP

A. Rest
- implies calmness, relaxation without emotional stress, and
freedom from anxiety.
- it restores a person’s energy, allowing the individual to resume optimal functioning.
- people deprived of rest are often irritable, depressed, tired and have a poor control
of their emotion,

B. Sleep
- a state of consciousness which the individual’s perception and
reaction to the environment are decreased.
- it is characterized by minimal physical activity , variable levels
of consciousness, decreased responsiveness to stimuli.

C. Physiology of Sleep
- Circadian rhythm – came from the latin term, circa dies, “about a day”.
- biological clock, controlled from within the body and synchronized with
environmental factors, such as light and darkness, gravity and electromagnetic
stimuli.

D. Stages of sleep
- NREM
- slow wave sleep
- sleep during night, deep, restful sleep & brings a decrease in physiologic functions.

E. REM Sleep
- Constitutes 25 % of the young adult
- Usually recurs about every 90 minutes & lasts 5-30 min.
- It is not as restful as NREM sleep
- Most dreams takes place and retained in the memory.
- During this stage the brain is more active and brain metabolism increases.

F. Stages & Characteristics of NREM

Stage 1
Relaxed & drowsy, Profound restfulness, usually lasts only a few minutes, floating
sensation, eyes roll from side to side – lasts only a few minutes.
Stage 2
Stage of light sleep, body processes continue to slow down, eyes are generally still,
heart & respiratory rates slightly decreases, and body temp falls easily aroused– 10 to
15 min
Stage 3
HR & RR and other body processes slow further because of the denomination of PNS;
Less easily aroused; not disturbed by sensory stimuli; skeletal muscles are very
relaxed; reflexes are diminished & snoring may occur.
Stage 4
Deep sleep; HR&RR drop 20% to 30% below as compared when awake; very relaxed,
rarely moves & very difficult to arouse; eyes roll & some dreaming occurs; it restore the
body physically.

G. Sleep Cycle
• People pass through the 4 stages of NREM sleep, usually lasting about 1 hr.
• Sleeper passes from stage I NREM through stages III to IV in about 20 to 30 min.
• Stage IV last for 30 min.
• Followed by III & II; then 1st REM stage occurs for 10 min. (1st sleep cycle)
• Usual sleeper exp 4-6 cycles in 7-8 hrs of sleep.

H. Function of Sleep
- It exerts physiologic effect on the nervous system & other body structures.
- It increases muscle tone
- Necessary for protein synthesis, thus, allow the muscles to repair.

I. Factors affecting Sleep

 Quality of sleep- ability of an individual to stay asleep & to get appropriate
REM & NREM.
 Quantity of sleep – total time the individuals sleeps.
 Age – sleep pattern variation occurs with age.
e.g. NB –14 to 18 h; Inf – 12to 14h; Tod –10-12; PS –11h; Sch age – 10; Adol –8
 Environment – can promote or hinder sleep.
 Fatigue – it is thought that a person who is moderately fatigued usually
has a restful sleep.
 Lifestyle- exercise, work shift
 Psychologic stress – Anxiety & depression disturb sleep.
 Alcohol & stimulants – excessive alcohol disrupts REM sleep. Often
experience nightmares when effect of the alcohol has worn off.
 Diet – dairy products (contains tryptophan)
 Smoking – has a stimulating effect in the body.
 Motivation – the desire of an individual to stay awake.
 Illness – people who are more ill require more sleep.
 Medications – affect the quality of sleep

J. Common Sleep Disorder

CATEGORY of Sleep Disorder
 Primary Sleep disorders – sleep problem is the main disorder
 Secondary – sleep disturbances cause by another clinical disorder such as thyroid
dysfunction, depression & alcoholism.
SLEEP DISORDERS
1. Insomnia – the most common sleep disorder
- inability to obtain an adequate amount or quality of sleep.

3 types of insomnia:
a. Initial insomnia – difficulty of falling asleep.
b. Intermittent or maintenance – difficulty of staying sleep bec of frequent waking
c. Terminal insomnia –early morning or premature waking.

Causes of insomnia
 Physical discomfort
 Mental over stimulation due to anxiety.
 Over consumption of drugs & alcohol

2. Hypersomnia – opposite of insomnia; excessive sleep, particularly in daytime.

Causes of Hypersomnia
 Nervous system damage
 Kidney & liver disorder
 Diabetic acidosis
 Hypothyroidsm
 Coping mechanism

3. Narcolepsy – “Narco”, numbness

Lepsis, seizure
- sudden wave of sleepiness that occurs during the day.
- Also referred as sleep attack
- Cause is unknown, but believed to be a genetic defect of the CNS in w/c REM cant
be controlled

4. Sleep apnea
– it’s the periodic cessation of breathing during sleep.
- Often suspected when a the person has a loud snoring, frequent nocturnal
awakenings, excessive daytime sleepiness, insomnia.
- Last from 10 sec – 2 min; occur during REM or NREMs

3 types of Sleep Apnea

a. Obstructive apnea – occurs when the structures of the pharynx or
oral cavity block the air flow.
b. Central apnea – involves a defect in the respiratory center of the brain.
-. all actions involve in breathing ceased (chest movement, airflow)
c. Mixed apnea –combination of the 2.
5. Parasomnias – refers to a cluster of waking behaviors that may interfere with sleep.

TYPES
a. Somnabulism – sleep walking
- occurs during stages III&IV of NREM
- episodic & occurs 1-2 h after falling asleep.
b. Sleeptalking – occurs during NREM sleep before REM sleep.
- Rarely presents a problem to the person unless
it is troublesome to others.
c. Nocturnal enuresis – Bedwetting
- occurs in children over 3 yrs
- often occurs 1 – 2 h after falling asleep,when rousing from
NREM stage III - IV
d. Nocturnal erection / emission – occur during REM sleep.
- begin during adolescence, does not
present a problem.
e. Bruxism – clenching & grinding of teeth.
- occurs during stage II NREM

K. ASSESSMENT
Sleep assessment includes a sleep history, sleep diary & Physical examination.

1. Sleep history
 Usual sleeping pattern, sleeping & waking hours; quality or satisfaction of sleep;
time & duration of naps.
 Bedtime rituals
 Use of medications
 Sleep environment – dark room, temp.
 Recent changes in sleep patterns or difficulty of sleeping.

2. Sleep diary
• Clients with sleeping problem should keep & maintain a SD for at least 1 wk.
• Total number of sleep hours/day
• Activities performed by 2-3 hrs before bedtime (type, duration and time)
• Bedtime rituals – food,fluid medication
• Time of going to bed; trying to fall asleep, instances of waking up, duration;waking
up in the am.
• Any worries that may affect sleep

3. Physical Examination
• Observation of the client’s:
• Facial appearance – darkened areas around the eyes, puffy eyelids, reddened
conjunctiva, glazed or dull appearing eyes.
• Behavior – irritability, restlessness, inattentiveness, slowed speech, slumped
posture, hand tremor, yawning, rubbing the eyes, withdrawal, confusion, &
incoordination.
• Energy level – physically weak, lethargic, fatigue

L. Nursing care
 The major goal for the client with sleep disturbance is to develop or maintain a
sleeping pattern that provides sufficient energy for daily activities.
 Reducing environmental distractions.
 Promoting bedtime rituals
 Teaching stress reduction
 Relaxation techniques

M. Promoting Comfort & Relaxation

 Provide loose fitting nightwear.
 Assists client’s with hygienic routines.
 Make sure that the bed linen is smooth, clean & dry.
 Assist or encourage the client to void before bedtime.
 Offer to provide a back massage before sleep.
 Position dependent clients appropriately to aid muscle relaxation; provide
supportive devices to protect pressure areas.
 Schedule medications to prevent nocturnal awakenings.
 Administer analgesic 30 min before sleep for patient suffering from pain.
 CHAPTER XI
NUTRITIONAL AND WATER NEEDS

Topic Description:
This topic teaches how nurses can aid in providing nutritional and water needs to
those clients who can not provide it for themselves.

Competencies:
1. Knowledge about proper nutrition and the digestive system.
2. Determine how to assist patients with special food and fluid intake
problem.
3. Knowledge on how to care for patients with anorexia and vomiting.
4. Determine how to perform NGT insertion, Gastric Gavage, and removal of
NGT.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Discuss the Nutritional and Water 2 Days Lecture Pre- Test
nutrient Needs:
categories and Discussion Post- Test
the digestive Nutrient Categories
system. Return Recitation
Average percentage demonstration
Enumerate of water in relation to of Gastric gave. Performance
means to assist a body weight. Checklist
client with special
food and fluid Assisting the patient
intake problems. with special food and
fluid intake problems.
Properly discuss
ways to care for a Care of patient with
client with anorexia and
episodes of vomiting.
anorexia and
vomiting. Enteral Feedings

Demonstrate how NGT insertion

to insert and
remove a Gastric gavage
nasogastric tube.
Removal of
Demonstrate how NG/Levine tube
to provide Gastric
gavage.
 Chapter XI
NUTRITIONAL AND WATER NEEDS

Nutrition- is the total processes involved in the taking in and utilization of food
substances.

Nutrients- are food containing elements for normal body functioning. It is divided into
six categories; carbohydrates, protein, fats, vitamins, minerals and water.

Nutrient Categories
Carbohydrates- are simple sugars (monosaccharides and disaccharides) and complex
sugars (polysaccharides). They are composed of carbon, hydrogen and oxygen.
Sugar, syrups, molasses, honey, fruit and milk are excellent sources of simple
carbohydrates. Bread, cereal, potatoes, rice, pasta, crackers, flour products, and
legumes contain complex carbohydrates

The main function of carbohydrates is to provide energy. Each gram of oxidized

carbohydrates yields about 4 kcal.

Dietary Fibers are polysaccharides not digested in the GI tract. It is a minimal source of
energy but plays an essential role in stimulating peristalsis and maintaining normal
bowel elimination.

Proteins- are organic compounds composed of polymers of amino acids connected by

peptide bonds. They contain carbon, hydrogen, oxygen and nitrogen. The body
synthesize protein for specific functions including hemoglobin for carrying oxygen
to tissues, insulin for blood glucose regulations, and albumin for regulating osmotic
pressure in the blood.

The main functions of proteins include growth, regulations of body functions and
processes, replacement of cellular proteins, energy and in the body’s immune
system. Protein catabolism supplies 4 kcal/g.

Fats- are also called lipids, include neutral fats, oils, fatty acids, cholesterols and
phospholipids. Fats are organic substances composed of carbon, hydrogen and
oxygen. Fat is a component of all body cells and ideally makes up approximately
20% of the body weight of healthy non obese people.

Fat performs many important functions, including cellular transport, insulation,

protection of vital organs in the form of padding, provision of energy, energy
storage of adipose tissue, vitamin absorption and transport of fat soluble vitamins
(A,D,E and K). And the energy value of fats is significant it supplies 9 kcal/g of
oxidize fat.

Vitamins- are organic compounds that are essential to the body in small quantities for
growth, development, maintenance and reproduction. They do not supply energy
but they assist in the use of energy nutrients. Most vitamins can not be
synthesized by the body and therefore must be supplied by the diet.

Minerals- are inorganic substances found in nearly all body tissues and fluids. When
plant or animal tissue is burned, what remains is ash or mineral matter. Minerals
help build body tissues and regulate metabolism.
Water- much of animal tissue is water. The water content of the body must be
maintained at a fairly constant level to preserve health. It is important for the
absorption of nutrients in the body and is the chief ingredient of extracellular fluids.
It is an important constituent of body secretions and excretions. Water is obtained
by drinking water and eating foods with a high water content. Generally thirst
signals the need for water.
Review of Anatomy and Physiology: Digestive System
The digestive system performs the vital function of converting food into substances
that the body’s cells can absorb and use. This conversion involves the process of
digestion, absorption, metabolism and excretion.

Digestion- the process by which food is broken down for the body to use in growth,
development, healing, and prevention of diseases.

Mechanical Process
 Mastication takes place in the mouth. Food particles are reduced in size and mixed
with enzymes in saliva.
 Deglutition (swallowing) begins in the mouth and continues in the pharynx and the
esophagus.
 Churning movements and peristalsis mix and move the ingested material through
the stomach and into the duodenum.
 Small Intestines, the ingested material is further churned and mixed with many
digestive enzymes. It comes in contact with the intestinal mucosa to allow for
absorption.
 Peristalsis moves the ingested material into the large intestines
 Further churning, peristalsis and absorption help move the residual ingested
mass along the full length of the large intestine, where it is stored until it is evacuated
from the body.

Chemical Process
The chemical process of digestion changes the composition of ingested material.

Absorption- is the process by which the digested proteins, fats, carbohydrates,

vitamins, minerals, and water are actively and passively transported through the
intestinal mucosa into the blood or lymphatic circulation.
Metabolism- after ingested food is absorbed, the products are ready to be metabolized.
Metabolism is the complex chemical process that occurs in the cell to allow for
energy use and for cellular growth and repair. It involves catabolic and anabolic
processes.
Excretion- the excretory organs (kidneys, sweat glands, skin, lungs and intestines)
remove waste products from the body. Digestive wastes are excreted through the
intestines and rectum.

Assisting the patient with special food and fluid intake problem

Helping the Patient Eat

 Position the patient in as near a sitting position as allowed, and support the patient
adequately. This position allows for swallowing with the greatest ease.
 Serve small quantities of food and beverages slowly to prevent the patient from
aspirating if the patient must remain flat or nearly flat on bed.
 Sit in a relaxed and comfortable position at the patients bedside while helping him
eat. This helps the patient feel as if he is not being rushed to eat and that the nurse is
willing to take time to help him.
 Allow the patient to say grace before eating if he desires, and remain respectfully
silent as he does.
 Follow the patient’s preference for the order in which he wishes to be served his food
and beverages.
 Serve the food and beverage at the rate the patient indicates, and slowly enough to
allow adequate time to chew and swallow.
 Encourage the patient to serve himself such foods as a piece of toast or a roll when
he is able to do so. This helps promote the patient’s feeling of independence and
control.
 Avoid leaving the patient after starting to help him eat, If it is absolutely necessary to
leave, offer an apology and return as quickly as possible so that the patient does not
feel neglected and abandoned.
 Arrange a signaling technique if the patient cannot see so that he can indicate when
he is ready for the next mouthful of food. Also, tell him what you are about to serve
him with each mouthful.
 Try to keep conversations pleasant, and avoid subjects that may disturb the patient.
Ordinarily it is a poor time to explain to teach a patient about his illness while helping
him eat.

Helping to Encourage the Patient’s Fluid Intake

 Explain to the patient in language he can understand, the specific goal of taking the
daily amount of fluid prescribed for him. This helps promote motivation and is more
meaningful than simply telling the patient to increase his fluid intake.
 Set short-term or interim goals with the patient. eg. A glass of water every hour, a
particular beverage by the time a particular TV program is finished.
 Plan to offer a proportionally larger amount of fluid during the early hours of the
patients waking day.
 Try to avoid making it necessary to offer large amounts of fluid before sleep.
 Encourage as wide a variety of liquids as possible.
 Keep fluids readily available to the patient.
 Serve fluids at the appropriate temperature.
 Use attractive, clean and easily handled cups and glasses.
 Have the patient assist in taking record of his intake when this is possible. This often
serve as a motivating factor to increase fluid intake.
 Provide support, understanding and encouragement since forcing fluid intake for the
person experiencing no thirst can be very uncomfortable.

Care of Patients with Anorexia and Vomiting

Anorexia- or loss of appetite, occurs for various reasons. Depression, GI dysfunction,
infection, illnesses, malignancies, and side effects of many medications can cause
anorexia, resulting in decrease food intake.

Nausea and Vomiting- interfere with normal food intake. They may be caused motion
sickness, viral or bacterial infection of the GI tract, gall bladder disease, general
anesthesia, disruption of inner ear function, side effects of various medications, or
pregnancy. Some people may feel nauseated or vomit from unpleasant smells,
sensations or sights.

 Try to eliminate the cause of the nausea and vomiting when possible. Eg. Unsightly
odors and sights.
 Administer anti emetics as prescribed.
 Turn the patient to his side and place his head over the edge of the pillow when he is
nauseated and vomiting.
 Suction the patient as necessary if there is any danger of the patient chocking and
aspirating vomitus.
 Splint an abdominal wound with binder, a firm pillow or the nurse’s hands while a
patient vomits to help reduce discomfort and strain on the wound.
 Provide oral hygiene, and wash the patient’s face after he has vomited to remove the
taste and odor of vomitus, which I it’s self produces more. For the same reason,
change soiled linens and clothing, and remove and clean an emesis basin promptly.
 Give the patient a back rub & keep the environment & comfortable to help relieve
tension often associated with nausea & vomiting.
 Use the following miscellaneous measures as indicated:
a. Limit the patient’s motion
b. Limit the patient’s intake until the symptom subside
c. Offer ice chips
d. Serve a cold carbonated beverage or hot tea
 Offer emotional support when the patient is upset
 Save a specimen of vomitus for laboratory analysis as indicated
 Note & record the time vomiting occurred, the nature of the vomiting & vomitus, any
unusual odors about the vomitus, & the amount of vomitus

ENTERAL FEEDINGS

Enteral Nutrition: direct delivery of the nutrients into the G.I. system, bypassing the
mouth

Tube Feeding: contain nutritionally balanced, commercial formulas given through a

tube directly into the esophagus, stomach, duodenum, or jejunum

TYPES OF TUBES
NGT (Nasogastric tube)
Used for short term feedings
Insertion of the catheter into the nose passing the esophagus & into the stomach

PEG (Percutaneous Endoscopic Gastrostomy)

Used for long term feedings
Insertion of mushroom catheter directly into the stomach

NGT Insertion

PURPOSE
 Decompresses the stomach to relieve pressure and relieve vomiting
 Provides a means of irrigating the stomach (lavage)
 Provides access to gastric specimens for laboratory analysis
 Provides a route for delivering liquid enteral feedings (gavage) in clients who can’t
swallow or ingest adequate calorie intake

ASSESSMENT
 Identify the client’s need for gastric intubation and type of tube to be placed
 Assess clients mental status and ability to understand and cooperate with procedure
 Review medical history for nosebleeds, deviated septum, nasal surgery
 Assess nostrils for size, lesion, obstructions, or deformity. Note: Have client breath
through one nostril while occluding the other. The tube should be inserted through the
most patent nostril

EQUIPMENTS
 Nasogastric tube of appropriate size ( adult: 14-18 Fr, infant/child: 5-10)
 Small bore feeding tube with guide wire if used for enteral feedings
 Water soluble lubricant
 20-50 cc syringe/ Asepto syringe
 Towel, stethoscope, disposable gloves
 Hypoallergenic tape

PROCEDURE
 Identify client and explain procedure. Insertion is not painful, but it is uncomfortable
because the gag reflex is usually stimulated
 Provide privacy by closing curtains or room door, Raise head in high-fowler’s position,
cover chest with towel, and place emesis basin nearby (elevated head protects head
against aspiration)
 Wash hands and put on gloves. Determine length of tubing to be inserted by
measuring nasogastric tube from tip of ear lobe, to tip of nose, to tip of xyphoid
process. Mark tubing with adhesive tape or note strip markings already on the tube.
(measures the length of esophagus from nares to stomach)
 Lubricate tip of tube with water-soluble lubricant. ( a water soluble lubricant will be
reabsorbed if tube inadvertently enters the lung. Do not use an oil-based lubricant
because respiratory complications may occur if aspirated)
 Gently insert tube to nostril. Advance toward posterior pharynx. ( Following the
natural contours prevents trauma to nasal mucosa)
 Have client tilt head forward and encourage client to swallow slowly. Advance the
tube as the client swallows. Advance tube until desired insertion length is reached.
(Forward tilt of head facilitates passage of tube into esophagus and not the larynx.
Swallowing moves epiglottis over the larynx and facilitates passage)
 Temporarily tape the tube to the client’s nose; then assess placement of the tube:
A. Aspirate gastric content with 20-50 ml syringe and test pH
B. Auscultate over epigastrium while injecting 10-30cc air into nasogastric tube.
 If placement in stomach is not verified, untape tube, advance tube tube 5 cm, and
repeat assessment
 Secure tube by taping to bridge of the clients nose. Anchor tubing to client’s gown.
( Correct taping prevents dislodging or pulling and traumatizing the nostril)
 Clamp end of tubing or attach to suction, as ordered by the health care provider.
 Wash hands, provide for client’s comfort and remove equipment.
 Establish and document a nursing plan for daily care of the nasogastric tube:
 Inspect nostril for irritation
 Cleanse nostril frequently
 Change adhesive as required to prevent skin irritation or pressure sore on nostril
from the tube.

GASTRIC GAVAGE

PURPOSE
To introduce food or nutritive materials into the stomach when the patient cannot or
will not swallow food.

EQUIPMENTS
Tray Containing:
Asepto syringe
Levine tube/NG tube
Water soluble lubricant
Clean pair of gloves
Adhisive tape
Outside the tray:
Osterized feeding in small pitcher or empty bottle
Towel
Stethoscope
Rubber band and safety pin ( to attach the tube to the patient’s gown)
Emesis basin lined with tissue paper

PROCEDURE

Assessment
 Check the physicians order
 Assess the patient's capabilities for assisting or cooperating with the procedure

Planning
 Wash your hands
 Gather the equipment and bring to the bedside

Implementation
 Identify the patient
 Explain the procedure to the client and tell him why it is needed
 Place the patient in high fowlers position, if possible. Put a clean towel over the
patient’s chest. Fowler’s position prevents aspiration of osterized feeding formula
during the introduction of fluids. The towel protects the linen and patient from getting
soiled.
 Remove the bulb of the asepto syringe and hold the syringe lower than the patient’s
chest, flush the tubing first with 30 ml of water.
 Then pour the feeding into the syringe slowly. Raise the syringe and allow the
solution to flow into the stomach by gravity.
 Solutions should always be luke warm or at room temp. Repeat the procedure until
required amount of feeding is consumed.
 Attach the asepto syringe to the NGT.
 Check to see if tip of the NG tube is in the stomach by the following bedside
methods:
 Aspiration of visually recognizable gastric contents. And check the pH of the
residual using a litmus paper.
 Auscultation over the episgastrium as you introduce about 10-15 ml of into the tube
with an asepto syringe.
 After the feeding is consumed a small amount of water (50 ml) is introduced in the
tube. The water is necessary to wash the remaining feeding in the tube into stomach.
It also prevents the souring of the feeding in the tube which may cause occlusion.
 Clamp the tube after each feeding. Cleanse the patient of any feeding that might
have spilled. Clamping the tube prevents the food from draining back. Make the
patient comfortable. The tube is further secured so that it is not a source of irritation
for the patient. The tip is covered by a plastic tip or a sterile gauze. Clamping the
 A further explanation before leaving the patient may ensure better reaction towards
the presence of a tube.
 Wash your hands.

PRINCIPLES
 Entrance of gas is avoided by clamping the tubing before pouring the feeding into the
syringe.
 Introducing the solution by force may cause gastric discomfort due to sudden
introduction of solution.
 Luke warm feeding is comfortable as it flows into the stomach. A water bath is used to
warm the exact amount for a specific feeding.
 A patient with nasogastric tube needs frequent oronasal care. The tube irritates the
nostrils and the back of the throat producing a drying condition. This is also because
the patient becomes a mouth breather and is neither eating or taking fluids.

EVALUATION
Evaluate using the following criteria:
 Patient is comfortable
 No abdominal distention noted

Removal of NG/Levine tube

 Explain to the patient that although removing the tube will be uncomfortable, it would
be over quickly.
 Put on gloves or hold the tubes with tissue wipes & pinch the tube.
 Withdraw the tube rapidly in a continuous smooth motion & place tube in the emesis
basin.

PRINCIPLES
 Pinching the tube prevents the secretions from dribbling into the esophagus &
pharynx (secretions in the tube are stomach acids & is therefore irritating).
 Any nausea and gagging that occurs is increase by pulling the tube slowly which
stimulates the posterior pharynx.
 TRINITY COLLEGE OF QUEZON CITY
ST. LUKE’S COLLEGE OF NURSING

Student’s Return Demonstration Checklist

STANDARDS ON TUBE FEEDING

Name:______________________________________ Section:_______________

Steps Done Needs Not Remarks

2 Improvement Done
1 0
I. Assessment
 Check the physicians order
 Assess the patient's capabilities for
assisting or cooperating with the
procedure

II. Planning
 Wash your hands
 Gather the equipment and bring to
the bedside

III. Implementation
 Identify the patient
 Explain the procedure to the client
and tell him why it is needed
 Place the patient in high fowlers
position, if possible. Put a clean
towel over the patient’s chest.
 Remove the bulb of the asepto
syringe and hold the syringe lower
than the patient’s chest, flush the
tubing first with 30 ml of water.
 Then pour the feeding into the
syringe slowly. Raise the syringe and
allow the solution to flow into the
stomach by gravity.
 Attach the asepto syringe to the
NGT.
 Check to see if tip of the NG tube
is in the stomach by the following
bedside methods:
a. Aspiration of visually
recognizable gastric
contents. And check the
pH of the residual using
a litmus paper.
b. Auscultation over the
episgastrium as you
introduce about 10-15 ml
of into the tube with an
asepto syringe.
 After the feeding is consumed a
small amount of water (50 ml) is
introduced in the tube.
 Clamp the tube after each feeding.
Cleanse the patient of any feeding
that might have spilled. The tip is
covered by a plastic tip or a sterile
gauze.
 Wash your hands.
IV. AFTER CARE
 Keep patient in fowler’s position

for 30 minutes.
 Wash and returns equipments in

their designated area.

V. EVALUATION
Evaluate using the following criteria:
 Patient is comfortable
No abdominal distention noted
Document the procedure.
Score:_______________

Evaluator’s Signature:_______________________________
Date:______________________________________________
 CHAPTER XII
FLUID BALANCE AND COMMON IMBALANCES

Topic Description:
This topic focuses on the importance of fluid balance in an individual as well as
the common imbalances that may occur to a person and what predisposes the said
imbalance. In this chapter the management and treatment for such imbalances will be
discussed.

Competencies:
1. Knowledge on the function of water in the human body.
2. Determine the movement of fluids and electrolytes in the human body.
3. Identify the regulators of fluid balance.
4. Determine how to care for clients with burn injuries.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Discuss the Fluid Balance and 1 Day Lecture Pre- Test
function of water in Common Imbalances:
the human body. Discussion Post- Test
Proportions of body
Gain an insight on fluid. Recitation
the movement of
fluids and Function of water
electrolyte in the
body and Fluid Compartment
determine the
affects to the body Fluid Pressures
if an alteration of
this movement Movement of Body
occurs. Fluid and Electrolytes

Determine the Methods by which

regulators of fluid Body Fluids and
balance and how it Electrolytes move.
functions.
Regulators of fluid
Determine the balance.
effects of burn
injuries to the Fluid Output
human body and
how to manage it. Electrolytes

Nursing Care of
Patients with Burn
Injury.
 Chapter XII
FLUID BALANCE AND COMMON IMBALANCES

Critical Thinking Challenge

 You are a student nurse on a Medical Unit. You are assigned to a patient with
Pneumonia. During endorsement, you are told that the client has had diarrhea for the
last 4 days, accompanied by wt loss. She has been experiencing fever and chills, and
she has had 150 ml of urine output during the shift.

 What is your client’s fluid volume balance status?

 What are the tentative nursing Diagnosis would you make?

 What nursing interventions may be indicated?

Proportion of Body Fluid

 47-55% fluids constitutes the wt. Of an average adult.

Factors influencing the amount of body fluids

1. Age
2. Gender
3. Body fat content

Functions of Water
 It serves as a medium for transporting nutrients to cells and wastes from cells.
 It serves as a medium to transport such substances as hormones, enzymes, blood
platelets, red and white blood cells.
 It is important for cellular metabolism and proper cellular chemical functioning
 It is a solvent for electrolytes and nonelectrolytes.
 It helps maintain normal body temperature
 It helps digestion and promotes elimination
 It is necessary for the manufacture of the body’s secretions.

Sources of the Body’s Water

 Ingested liquids
 Water in Food, or Preformed water
 Water from Metabolic Oxidation
Fluid Compartment
 Intracellular Fluid/ ICF
-Is found within the cells of the body
 Extracellular Fluid / ECF
- comprising the Fluid outside the cells of the body.

ECF is divided into:

1. Intravascular Fluid
-the fluid inside the blood and the lymphatics
2. Interstitial Fluid
- the fluid between the cells.

Fluid Pressures
 Body fluids shift between the interstitial and the vascular space in the capillary as a
result of:
 Hydrostatic Pressure- is the pressure due to water volume in vessels.
 Oncotic Pressure- is the pressure exerted by plasma protein

Movement of body fluids & electrolytes

First phase
- blood plasma moves around the body within the circulatory system,
nutrients are picked up from the lungs and GI tract.

Second phase
- Interstitial fluid and its components move between the blood
capillaries and the cells.

Third phase
- fluid and substances move from the interstitial fluid into the cells.

In the reverse direction:

-Fluids and its components move back from the cells to the interstitial
spaces and then to the intravascular compartment.
-The intravascular fluid then flows to the kidneys, where metabolic by
products of the cells are excreted.

Methods by which body fluids and electrolytes move

Diffusion
- is the movement of a solvent or solutes (molecules) from an area
of greater concentration to an area of lower concentration.
Filtration
- involves the transfer of water and dissolved substances through a
permeable membrane from a region of high pressure to a region
of low pressure.

Osmosis
- refers to the movement of a fluid through a semi permeable membrane.
- Water moves towards the higher concentration of solute.

Regulators of Fluid Balance

1. Thirst Mechanism
 Located in the hypothalamus and is activated by increase in ECF osmolality.
osmolality.

2. Hormonal influences
1.Antidiuretic hormone (ADH)
 Promotes water absorption from renal tubules
 Stimulation of the thirst mechanism and ADH release usually occur
concurrently in response to a body fluid deficit.

2. Aldosterone
 Secreted by the adrenal cortex and promotes sodium re
absorption and potassium excretion from the kidneys.

3. Lymphatic system
 Plasma protein and fluid escaping from the tissue spaces cannot be directly
reabsorbed into the blood vessels.
 Plays an important role in returning any excess fluid and protein from the
interstitial spaces of the blood

4. Kidneys
 Maintain fluid volume and concentration of urine by filtrating the ECF through the
glomeruli.
 Re-absorption and excretion of ECF occurs in the renal tubules

Fluid Output

1. Urine
formation of urine by the kidneys and its excretion from the urinary bladder
refers to fluid output.
Normal output - 1400 – 1500 ml / 24 hours
- 30 to 50 ml/hr
2. Insensible Loss
 Through the skin by diffusion
 Water exhaled in the air

3. Sweat
 Occurs when the body becomes overheated
 Sweat glands secretes large quantities of sweat unto the surfaces of the body to
provide cooling evaporation.

4. Feces
 Chyme that passes from small intestines to Large intestines contains water and
electrolytes.
 Approximately 1500 mL/ day

Electrolytes

Are substances found in the extra and intracellular fluid that dissociate into
electrically charged particles known as IONS
1. CATIONS
 ions carrying (+) charge
 Na. K, Ca, Mg
2. Anions
 Ions carrying ( - ) charge
 Phosphate, Bicarbonate

Electrolytes have major influences on:

1.Body water regulation
 Na concentration in the extra/ intra cellular fluid assists in the maintenance of
fluid balance
2. Acid Base regulation
 Na, K, Cl, bicarb, phosphate ions regulate acid base balance in the body
3. Neuromuscular Activity
 Necessary for the transmission of nerve impulses and stimulation of muscle
activity

Electrolytes are measured in mEq/ L / dL

Normal values
 Na - 135- 145 mEq / L
 K - 3.5 – 4.5 mEq / L
 Cl - 95 – 108 mEq / L
 Mg - 1.5 – 3.0 mEq / L
 Ca - 4.5 – 5.2 mEq / L
Factors affecting Fluid and Electrolyte Imbalance
 Age
 Climate
 Diet
 Stress
 Illness
 Medication treatment
 Medications
 Surgery

Nursing care of Clients with Burn Injury

Etiology
Burn injuries are categorized according to their mechanism of injury:
 Thermal Burns
 Chemical Burns
 Electrical Burns
 Radiation Burns

Movement of Fluids and Electrolytes when a patient when has Burns

Oliguric Phase: 1st 24-48 hrs Diuretic Phase: 48 hrs - up

Fluid shifts from intravascular to Fluids shifts back to intravascular
interstitial space from interstitial space

Decrease BP 1st Phase: gets nutrients from the lungs

Edema and GI( Arterial end- increase
Decrease urine output hydrostatic pressure)

2nd Phase: nourished fluids goes to the

cell

3rd Phase: waste products are absorbed

by the fluids ( Venous end-
increase oncotic pressure)

Increase osmotic pressure

Excretion (lungs/kidneys)
 Anatomy of the Skin in relation to Burns

Classification of Burn severity

Burn Depth
Divided into four categories:
 Superficial- epidermis
 Partial thickness- epidermis, dermis
 Full thickness- epidermis, dermis, subcutaneous tissue, muscle
 Fourth degree- epidermis, dermis, subcutaneous tissue, muscle, bones

Burn Size
The size of burn is determined by one of two inquiries:
 The Rule of Nines
 The Lund and Browner Method

Plan/ Implementation
Emergency care – on the scene;
 Stop the burning process
 Thermal- smother, stop, drop, and roll
 Chemical – remove clothing and flush/ irrigate skin/ eyes
 Electrical – shut off electrical current or separate person from source with a no
conducting implement.
 Ensure airway, breathing, and circulation
 Immediate wound care – keep person warm and dry.
Nursing care for Burn patient

GOAL
 Correct fluid and electrolyte imbalance
 Nursing Considerations
 First 24- 48 hrs.
 Iv fluids (Lactated ringers)
 Packed RBC’s
 Indwelling urinary catheter to monitor hourly output
 Monitor VS and electrolytes

Nursing care for Burn patient

 Goal
 Promote Healing
 Cap, gown, mask worn by the nurse
 Wound care at least once a day
 Debridement – (removal of nonviable tissue)
 Dressing – careful sterile technique
 Application of topical antibacterial agents.
 Tetanus prophylaxis

Nursing care for Burn patient

 Support Nutrition
 High caloric. High carbohydrate, high protein.
 May require TPN or tube feeding
 Vitamin B, C,and iron
 H2 histamine blockers and antacids to prevent Curling’s Ulcer
 Control Pain
 Pain medication (morphine/ meperidine)- given IV at first due to impaired circulation
and poor absorption.
 Monitor VS frequently
 Analgesic 30 mins. before wound care.
 Prevent complications of immobility
 Prevent Contractures – maintain joints in neutral position
 Shoes to prevent foot drop
 Active and Passive ROM
 Turn side to side frequently
 Stryker frame or Circ-O- Letric Bed may facilitate change in position
 Consult with a physical therapist
 Support Patient
 Counsel client regarding change in body image
 Encourage expression of feelings and demonstrate acceptance of pt.
 Assist pt. in coping with immobilization, pain, and isolation
 CHAPTER XIII
PROMOTING URINARY ELIMINATION

Topic Description:
This topic focuses on promoting urine elimination among our clients. In this
chapter factors that alter urinary elimination will be discussed as well as its effect to
client’s condition.

Competencies:
1. Anatomy and physiology of the genitor urinary system.
2. Determine the factors that affect voiding and its alteration.
3. Determine how to perform physical assessment to a client who has problems
with urinary elimination.
4. Perform urinary catheterization and collection of urine specimen.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITY
Discuss the Promoting Urinary 2 Days Lecture Pre- Test
Anatomy and Elimination:
physiology of Discussion Post- Test
the Genitourinary System:
genitourinary Review of Anatomy and Return Recitation
system. physiology. Demonstration
of Urinary Performance
Determine Factors Affecting Catheterization Checklist
affecting Voiding.
voiding, and
how an Alteration in Urine
alteration in Production.
urine
production and Alteration in Urine
elimination Elimination.
takes place.
Collecting a timed urine
Formulate specimen.
plans to
manage a Collecting a specimen
patient with from a foleycatheter.
urinary
incontinence. Managing urinary
incontinence.
Properly
demonstrate Managing Urinary
how to provide Retention.
urinary
catheterization Urinary Catheterization.
and how to
collect a urine
specimen
through a
foleycatheter.

Determine how
to accurately
collect a timed
urine
specimen.
 Chapter XIII
PROMOTING URINARY ELIMINATION

Urinary Elimination

Genitourinary System
Anatomy and Physiology

I. KIDNEYS
-Filters from the blood any products for which the body has no use

Nephron:
 functional unit of the kidney forms a fluid called glomerular filtrate(about 180L
daily, or 25ml/min) ; consists of water, electrolytes, creatinine, glucose, urea,
amino acids, uric acids, bicarbonates & other electrolytes

Glomerulus:
- tuft or cluster of blood vessels surrounded by bowman’s capsule
- It’s pores are large enough for water & some solutes to pass through but
are too small for large molecules (such as protein & formed elements in the blood)
- The presence of protein in the urine (proteinuria) is a sign of glomerular injury

Formation of Urine

Kidney

Glomerular Filtrate

Bowman’s Capsule

Tubular System

(99% of it is reabsorbed into the bloodstream; 1% forms the urine)

II. URETERS
 Once the urine is formed in the kidneys, it enters the ureters via
collecting ducts and then passes on to the bladder
 25-30 cms (10-12 in) long in adult; 1.5cm (0.5in) in diameter
III. BLADDER
 Hollow muscular organ that serves as a reservoir for urine and as organ of excretion
 The amount of urine normally stored in the bladder varies to some degree among
individuals & with age
 Adult:250-450ml
 Normal urine output (adult): 1500ml/day

IV. URETHRA
 Extends from the bladder to the urinary meatus
 Exit passageway for the urine
 Women are more prone to urinary tract infection because of the shortness of their
urethras
 Location of the urinary meatus: located between the labia minora in front of the
vagina & below the clitoris

Urination/Voiding/Micturition
 Process of emptying the urinary bladder
Cerebral cortex: Voiding control center

Factors Affecting Voiding

Growth and Development
 begins to excrete urine between the 11th & 12th week of development
 The placenta serves as a pseudo-kidney in regulating fetal fluid & electrolyte
balance
 The kidney does not function independently until after birth

Growth and Development

1. Infant:
 Minimal ability to concentrate urine
Absent voluntary urinary control
2. Children:
 Kidney functions reaches maturity between the 1 st & 2nd year of life; urine is
concentrated effectively & appears a normal amber color
3. 18-24mos:
 voluntary control of urine begins
4. 2y/o:
 daytime urinary control
5. 4-5y/o:
 Full urinary control
 Boys are slower than girls in gaining control
6. Adults:
 Kidneys reach maximum size between 35-40 years of age
7. After 50y/o:
 kidneys begin to diminish size & function
8. Elderly:
 Decrease renal blood flow due to decrease cardiac output & vascular changes

9. 80y/o:
 30% loss of glomeruli
 Urine concentratability declines
 Excessive urination at night (nocturia) & increased frequency of urination (polyuria)
occurs due to loss of concentratability & diminished bladder tone
 Residual urine may increase due to diminished bladder muscle tone & contractability
making elderly more prone to infection
 Urinary incontinence may occur due to mobility problems or neurologic impairments

Factors Affecting Voiding

• Psychosocial Factors
• For some, a set of conditions helps stimulate urination (privacy, normal position,
sufficient time, & occasionally running water
• Fluid & Food Intake
• Increase fluid intake increases urine output
• Certain fluids increase urine output such as alcohol, tea, coffee & cola drinks
• Foods high in fluid content could increase urine output such as lettuce, milk &
cooked cereals
• Some foods could change the color of urine (e.g. beef, blackberries, etc)
• Medications
• Muscle tone & Activity
• People who exercise regularly will likely have a good muscle tone, increased body
metabolism & good urine production
• Presence of indwelling catheter could lead to poor bladder muscle tone therefore
the client may have difficulty in regaining urinary control when the catheter is
removed
• Pathologic Conditions
 Diabetes Insipidus: increase urine formation
 Atherosclerosis: decrease u/o
 Any condition that would impairs the flow of the urine from the kidneys to
the urethra can impair urine excretion

Surgical & Diagnostic Procedures

 Some surgical & diagnostic procedures can affect the passage of urine & urine
itself
 Spinal anesthetics can also affect the passage of urine because they decrease
the client’s awareness of the need to void
Alteration in Urine Production
Polyuria/Diuresis: production of abnormally large amount of urine by the kidneys,
such as 2,500ml/day for an adult
Causes:
• Excessive fluid intake
• Ingestion of substances containing caffeine & alcohol
• Hormone imbalances (e.g. Deficient Antidiuretic hormone)
• Chronic kidney disease
 Oliguria: voiding scant amount of urine such as less than 500ml in 24 hours
 Anuria: voiding very scant amount of urine such as 100ml/day

Alteration in Urinary Elimination

 Frequency: Voiding at frequent intervals that is more often than usual
 Nocturia/Nycturia: increase frequency of voiding at night that is not a result of an
increase in fluid intake
 Urgency: feeling that the person must void immediately
 Dysuria: Painful or difficult voiding
The burning may be described as severe, like a hot poker or more
subdued, like a sunburn
 Enuresis: repeated involuntary urination in children beyond the age when voluntary
control is normally acquired, usually 4 or 5 years of age

Primary Enuresis
• there has never been a long, dry, symptom-free pad
Secondary Enuresis
• occurs after a dry pd of at least a yr.
Nocturnal (nighttime); Diurnal (daytime or both)
Urinary Incontinence:
 It is a symptom not a disease
Retention:
 Accumulation of urine in the bladder with associated inability of the bladder to
empty itself

Physical Assessment
Percussion: detect areas of tenderness
Palpation: contour, size, tenderness & lumps
Inspection: Urethral Meatus: swelling, discharge & inflammation
Perineum: inspected for irritation because contact with urine excoriate the skin

Collecting Urine Specimens

Number of tests:
 Clean voided specimen (routine urinalysis, clean-catch or midstream specimens for
urine culture)
Urine Test Time Specimen
 Collected at timed intervals
(1-2hrs or 12-24 hrs)
 Must be refrigerated to prevent bacterial growth & decomposition of urine
components
 About 120ml or 4oz of urine is generally required

Collecting a timed urine specimen

 Place alert signs about the specimen collection at the client’s bedside or bathroom
 Label specimen containers to include date & time of each voiding as well as the usual
client identification data. Containers may be numbered sequentially (i.e. 1 st specimen,
2nd specimen & so on)
 Explain to the client the purpose of the test
 Ensure that the urine is free of feces

Collecting a Specimen from a Foley catheter

 Don disposable gloves
 Wipe the area where the needle will be inserted with a disinfectant swab
 If there is no urine in the catheter, clamp the drainage tubing for about 30mins.
 Unclamp the catheter
 Insert the needle at a 30-45 degree angle
 Withdraw the required amount of the urine
 Transfer the urine to the specimen container (make sure that the needle does not
touch the outside of the container
 Cap the container
 Remove gloves & discard appropriately
 Label the container
 Send to the laboratory immediately for analysis
 Record collection of the specimen

Nursing Management
• Promoting Fluid Intake
• Normal Average Intake: 1200-1500ml; additional amount is required for those who
have abnormal fluid losses (excessive perspiration, vomiting or diarrhea)
• Immobilized clients/susceptible to renal calculi: 2000-3000ml/day (unless C/I)
Maintaining Normal Voiding Habits
• Positioning
• Relaxation
• Timing
• For bed-confined patients
 Warm bed-pan
 Fowlers position; place a small pillow or rolled towel at the back to increase
physical support & comfort
Assisting with toileting
 Assists clients to the bathroom & stay with them if the client is high risk for falling
 Bathroom should contain an easily accessible call signal to summon help if needed
 Encourage to use hand rails near the toilet seat

Managing Urinary Incontinence

Independent Nursing Interventions:
Behavior-oriented continence training program
 Continence/Bladder Training:
 Education of the client & support persons
 Bladder training: requires client postpone voiding (void according to a timetable
rather than urge to void)
 Habit Training/timed voiding or scheduled toileting: Attempts to keep clients dry
by having them void at regular intervals. No attempt to motivate the client to
delay voiding, if the urge occurs
 Prompted Voiding: Encourage clients to try to use the toilet & reminding the
client when to void
 Pelvic Muscle Exercises (PME): referred to as perineal tightening or Kegels
Exercises
 Positive Reinforcement: Praised for attempting to toilet & for maintaining
continence
 Maintaining Skin Integrity
 Applying External Urinary Devices: Condom

Managing Urinary Retention

 Cholinergic Drug (i.e. Urecholine): stimulates bladder contraction & facilitate voiding
 Crede’s Maneuver: With physician’s order
 Used only for clients who have lost and are not expected to regain voluntary
bladder control

Urinary Catheterization
 Introduction of a catheter through the urethra into the urinary bladder
 Usually performed only when absolutely necessary because it incurs certain hazards:
 Introduction of microorganisms into the bladder
 Trauma

Catheter: tubes commonly made of rubber or plastic although certain types are made
up of woven silk or metal

Types of Catheter
Urethral Catheter: inserted through the urethra into the urinary bladder
 Straight Catheter/Robinson Catheter
 Retention Catheter/Foley Catheter
1. Straight/Robinson Catheter
 Single lumen tube with a small eye or opening about 1¼ cm (1/2 inch) from the
insertion tip
 Coude’ (elbowed catheter): has curved tips
used for elderly men who have a hypertrophied prostate because it is often less
traumatic

2. Retention/Foley Catheter
 Contains a second, smaller tube throughout it’s length on the inside
 Tube is connected to a balloon near the insertion tip
 Three-Way Foley Catheter: has a 3rd channel through which sterile fluid can flow
into the urinary bladder
 TRINITY COLLEGE OF QUEZON CITY
ST. LUKE’S COLLEGE OF NURSING

Student’s Return Demonstration Checklist

STANDARDS ON CATHETERIZATION

Name:____________________________________________ Section:_____________

Steps DONE Needs Not Remarks

2 Improvement Done
1 0

I. PREPARATORY PHASE:
A. Female Patient
1. Put the patient at ease
2. Open catheter tray using aseptic technique.
Place water receptacle I accessible place
3. Direct light for visualization.
4. Place the patient in supine position with
knees bent, hips flexed and feet resting on bed
about 2 ft. apart. Drape the patient
5. Position moisture proof pad under the
patient’s buttocks.
6. Wash hands. Put sterile gloves
II. PERFORMANCE PHASE:
1. Separate the labia minora so that the
urethral meatus is visualized, one hand is to
maintain separation of the labia until
catheterization is finished.
2. Cleanse around the urethral meatus with a
povidone iodine solution.
a. Manipulate cleansing sponges with forceps,
cleaning with downward strokes from anterior to
posterior
b. Dispose cotton sponge after use.
3. Introduced well lubricated catheter 5-7 cm
into the meatus using strict aseptic technique.
a. Avoid contaminating surface of the catheter.
b. Ensure that the catheter is not too large or
too light at the urethral meatus.
4. Allow some bladder urine to flow thru the
catheter before collecting a specimen.
B. Male Patient
1. Carry out all of the preparatory phase except
#4
2. Place the patient in supine position with legs
extended.
3. Position the perineal area.
4. Lubricate the catheter well with lubricant or
prescribed topical anesthetic.
5. Wash off glans penis around urinary meatus
with betadine using forceps to hold cleansing
sponges. Keep the foreskin retraction.
Maintain sterility of dominant hand.
6. Grasp shaft of penis with nondominant hand
and elevate it. Apply gentle traction to penis
while catheter is passed.
7. Using sterile gloves, insert the catheter to
the urethra advance 15-25 cm or 6-10 inches
until urine flows.
8. If resistance is felt at the external sphincter,
slightly increase the traction on the penis and
apply steady, gently pressure on the catheter.
Ask patient to strain gently (as if passing urine)
to help relax sphincter.
9. When urine begins to flow, advance the
catheter another 2.5 cm or 1 inch.
10. Reduce/reposition the foreskin.

C. Management of Patient with Indwelling Catheter

1. Catheterize the patient using a catheter that is

preconnected to a closed drainage system.
a. Advance the catheter almost its bifurcation (for
male patient)
b. Inflate the balloon according to the
manufacturer’s directions. Be sure that the
catheter is draining properly before inflating the
balloon and then withdraw the catheter slightly.
2. Secure the indwelling catheter
a. Female: Tape the catheter and drainage tubing
to the anterior thigh. Male: Tape the catheter to
the hypogastric area.
b. Allow some slack of the tubing to accommodate
the patient’s movement.
c. Keep the tubing over the patient’s leg

Score:____________________

Evaluator’s Signature:________________________
Date:_______________________________________
 CHAPTER XIV
PROMOTING FECAL ELIMINATION

Topic Description:
This topic focuses on how to promote a client’s fecal elimination. This chapter will
discuss about problems that arises when proper fecal elimination is altered and how
nurses can aid in promoting adequate bowel movement.

Competencies:
1. Anatomy of the large intestines.
2. Determine the factors that affect defecation.
3. Knowledge on common fecal and elimination problems.
4. Determine how to properly collect a stool specimen.
5. Determine how to administer an Enema and the different bowel diversion
ostomies.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITY
Promoting Fecal 2 Days Lecture Pre- Test
Elimination:
Discussion Post- Test
Large intestines:
Review of anatomy Return Recitation
and physiology. Demonstration
Performance
Factors Affecting Checklist
Defecation.

Common Fecal and

Elimination
Problems.

Stool Specimen
Collection.

Administering
Prescribed
Medication.

Administering
Enemas.

Bowel Diversion
Ostomies.
 Chapter XIV
PROMOTING FECAL ELIMINATION

Fecal Elimination

Anatomy and Physiology

Large Intestine
• Generally about 125 cm to 150 cm or 50-60 inches long
• Has 7 parts:
• cecum, ascending, transverse, descending colons, sigmoid, rectum and anus or
external orifice
• Absorption of water and nutrients, protection and elimination

• Most of the waste products are excreted within 48 hours of ingestion

• Chyme- waste products leaving the small intestine

Three types of movements in the large intestine

1. Haustral churning or shuffling- movement of the chyme back and forth
within the haustra. Aids in the absorption of water.
2. Peristalsis- wavelike movement produced by the circular and longitudinal muscle
fibers of the intestinal walls. This propels the intestinal contents forward.
3. Mass Peristalsis- involves a wave of powerful muscular contraction that moves over
large areas of the colon

Rectum and Anal Canal

• Rectum in the adult is usually 10 to 15 cm or 4-6 inches long
• Anal Canal- 2.5 to 5 cm 0r 1-2 inches long
• Hemorrhoids- occurs when veins are distended due to repeated pressure

Defecation
 It is the expulsion of feces from the anus and rectum
 Also called bowel movement
 Normal feces are made of 75% water and 25% solid materials
 Frequency varies from every individual
Factors that Affect Defecation
 Age and Development- control of defecation starts at 1 ½ to 2 years of age
 Measures that are Helpful in assisting a child with toilet training:
• Provide clothing that the child can move independently
• Give the child a personal toilet seat
 • Allow sufficient time, and provide a consistent and relaxed routine
• Offer praise for successful behavior but avoid excessive praise
• Avoid punishment or disapproval when the child is unsuccessful. Children
generally wish to please adults but cannot always be successful
• Initiate toilet training during non stressful periods of the child’s life
 Diet- Sufficient bulk in the diet is necessary to provide fecal volume. Certain foods
are difficult or impossible for some people to digest.
 Fluid- When fluid intake is inadequate or output is excessive for some reason, the
body continues to reabsorb fluid from the chyme as it passes along the colon. This
results to drier and hard feces
 Usually needs 2000 to 3000 ml
 Activity- Weak abdominal and pelvic muscles are often ineffective in increasing the
intra-abdominal pressure during defecation
 Psychologic Factors- people who are angry or anxious experience increased
peristaltic activity and subsequent diarrhea
 Life-style- Early bowel training may establish the habit of defecating at a regular time
 Medications- Some medications taken in large doses such as tranquilizers and
repeated administration of morphine and codeine can cause constipation
 Laxatives- medications that stimulate bowel activity and so
assist fecal elimination
 Diagnostic Procedures- Some dx procedures like visualization of the sigmoid colon,
the client is allowed no food or fluid intake after midnight before the examination. And
often the client is given a cleansing enema prior to examination
 Anesthesia and Surgery- General anesthesia can cause the colonic movements to
cease or slow down by blocking parasympathetic stimulation to the muscle of the
colon
 Pathologic Conditions- Spinal cord injuries and head injuries for example can
decrease the sensory stimulation for defecation
 Irritants- Spicy foods, bacterial toxins and poisons can irritate the intestinal tract and
produce diarrhea and often large amounts of flatus
 Pain- Clients who experience pain when defecating often suppresses the urge to
defecate

Common Fecal and elimination Problems

Constipation
 Refers to the passage of small, dry, hard stool or the passage of no stool for a
period of time.
 Occurs when the movement of the feces through the large intestine is slow, thus
allowing time for additional reabsorption of fluid from the large intestine.

Causes and Factors that Contribute to Constipation

 Irregular defecation habits- When the normal defecation reflexes are inhibited or
ignored, these conditioned reflexes tend to be progressively weakened
 Overuse of Laxatives- habitual users of laxatives eventually requires larger or
stronger doses due to reduced effects of regular use
 Increased Psychologic stress- strong emotions inhibits intestinal peristalsis due to
epinephrine and the sympathetic nervous system
 Inappropriate Diet- Bland diets and low fiber diets are lacking in bulk and therefore
create insufficient residue of waste products to stimulate the reflex for defecation
 Insufficient Fluid- reduces the amount of fluid in the chyme which enters the large
intestine
 Medications- Drugs causes either constipation or diarrhea
 Insufficient Exercise- Clients on prolonged bed rest, generalized body weakness
extends to the muscles of the abdomen, diaphragm and pelvic floor which are used in
defecation
 Age- Muscle weakens and poor sphincter tone that occur in some elderly people
contribute to constipation
 Disease Process- such as bowel obstruction, paralysis which inhibits the clients
ability to bear down

Fecal Impaction
 Is a mass or collection of hardened, puttylike feces in the folds of the rectum. This
results from prolonged retention and accumulation of fecal material
 This is recognized by passage of liquid fecal seepage and no normal stool
 Can also be assessed by digital rectal examination
 When fecal impaction is suspected the client is often given an oil retention enema
and daily additional cleansing enema

Diarrhea
 Refers to the passage of liquid feces and an increased frequency in defecation
 With persistent diarrhea, irritation of the anal region extending to the perineum and
buttocks generally results
 Fatigue, weakness, malaise and emaciation are the results of prolonged diarrhea
Fecal Incontinence
Refers to the loss of voluntary ability to control fecal and gaseous discharges through
the anal sphincter

Two types of incontinence

• Partial Incontinence- inability to control flatus or to prevent minor soiling
• Major Incontinence- is the inability to control feces of normal consistency

Flatulence
 Presence of excessive flatus in the intestine and leads to stretching and inflation of
the intestines
 Also referred to as tympanites
 Flatus is the air or gas in the gastrointestinal tracts
 Eructation is the gas that is expelled through the mouth and is also referred to
as belching
Helminths
 Parasitic worms that infest the intestine
 Medication used to treat this problem is called anthelmintics
 Transmitted through soil when larvae comes in contact with the skin or by
contaminated food and water

Instruction in Stool Collection

 Defecate in clean bed pan or bedside commode
 Do not contaminate the specimen with urine or menstruation. Instruct patient to void
before the specimen collection
 Do not place toilet tissue in the bedpan after defecation
 Notify the nurse as soon as possible after defecation

Administering Prescribed Medication

 Cathartics- frequently referred to as laxatives. These drugs induces defecation
 Suppositories- Effective within 30 minutes. This needs to be inserted beyond the
internal anal sphincter
 Antidiarrheal Medications- Some mechanically coats the irritated bowel
(demulcents), some absorbs gas or toxic substances (absorbents), some shrink
swollen and inflamed tissues (astringents)

Administering Enemas
 Enema- A solution introduced into the rectum and sigmoid colon. Its function is to
remove feces and or flatus

Classified into four groups:

• Cleansing enema- stimulates peristalsis by irritating the colon and rectum and or by
distending the intestine with the volume of fluid introduced
-Two kinds- high and low enema
-Effective if held 5 to 10 minutes
• Carminative Enema- Given primarily to expel flatus. For an adult 60-180 ml
of fluid is instilled
• Retention Enema- Introduces oil into the rectum and sigmoid colon. The oil is
retained for a relatively long period of time (eg, 1-3 hrs)
• Return Flow Enema- also referred to as the Harris flush or colonic irrigation. It is
used to expel flatus. Alternating flow of 100 to 200 ml of fluid in and out the large
intestine that stimulates peristalsis and expulsion of feces

Types of Enemas for Adult

 Hypertonic
 Hypotonic
 Isotonic
 Soap
 Oil

Bowel Diversion Ostomies

Ostomy- is an opening on the abdominal wall for the elimination of feces or urine
Gastrostomy- opening through the abdominal wall into the stomach
Jejunostomy- opening through the abdominal wall into the jejunum
Ileostomy- opening into the ileum
Colostomy- opening into the colon
Ureterostomy- opening into the ureter
 TRINITY COLLEGE OF QUEZON CITY
ST. LUKE’S COLEGE OF NURSING

Student’s Return Demonstration Checklist

STANDARDS ON ENEMA

Name_______________________________ Section______________

STEPS DONE Needs Not Remarks

2 Improvement Done
1 0
ASSESSMENT:
1. Check the physician’s order
2. Asses the patient’s ability to retain
fluid and to tolerate the activity
ordered

PLANNING:
1. Wash your hands
2. Gather equipment and prepare
solution
a. Put 1 wooden spoon of soap
jelly into the pitcher.
b. Add a small amount of hot
water to dissolve the soap
3. Add enough water to get the
desired amount and temperature
(100F-105F / 37.7C – 40.5 C)
4. Assemble irrigating can by
attaching tubing to the can. Attach
clamp and close
5. Put enough lubricant in a piece of
toilet paper and place at the tip of
rectal tube. Attach the plastic
connector to the rectal tube.
6. Pour solution into the irrigating
can. Remove the bubbles on top of
the solution using the wooden spoon.
7. Cover tray . Clean all used
equipment with soap and water and
return to proper places.
Bring all equipment to bedside.

IMPLEMENTATION:
1. Identify the patient.
2. Explain the procedure. Allow the
patient to ask questions.
3. Screen the patient and loosen top
sheet at the foot of the bed.
4. Fanfold the top sheet away from
you and insert the rubber protector
and cover under the buttocks. Place
the patient in left Sim’s position.
5. Adjust top sheet so that only the
rectal area is exposed.
6. Place the bedpan on the bed at the
foot part and the emesis basin
alongside the buttocks.
7. Transfer the irrigating can to the
bed and with the left hand steadying
the can, the right hand holding the
rectal tube. Release clamp on tubing
also with the right hand holding the
rectal tube. Release clamp on tubing
also with the right hand. Have the
end of rectal tube be over the
bedpan. Raise the irrigating can
slightly to allow a small amount of
solution to run into the bedpan thus,
expelling air in tubing.
8. With your left hand steadying the
can, lift the patient’s upper buttocks
with your left hand to expose the
anus. Insert the lubricated rectal tube
upward 4-5 inches. Grasp the rest of
the rectal tube with the thumb and
forefinger just outside the anus.
9. Unclamp the tubing then raise the
irrigating can about 12-18 inches
above the patient’s hips.
10. Ask patient to breath through the
mouth while solution is being
introduced. Encourage the patient to
retain the fluid as long as possible.
11. Clamp tubing and remove rectal
tube gently
a. When the correct amount of fluid
has been instilled
b. When the patient has a strong
desire to defecate.
12. Let the remaining solution flow
through the tubing into the bedpan.
Detach the rectal tube from plastic
connector and put in emesis basin
lined with paper.
13. Assist the patient into a bedpan
or commode or the bathroom.
14. If the patient can be left alone,
provide a call light and toilet tissue
and leave the room. Make sure you
are close by to help the patient as
necessary.
15. Assist patient when she is
through defecating. If patient is
unable to expel the solution after 30
mins, siphon solution by;
a. Inserting a rectal tube attached
to a funnel and filling a funnel
with warm water while it is held
below the anus.
b. Gradually raising the funnel
allowing the fluid to flow into the
colon.
c. Lowering funnel over the bedpan
when funnel nearly empty.
16. After defecation, help the patient
to a position of comfort. The patient
may need help cleaning the anorectal
area. Also, provide an opportunity for
handwashing.
17. Allow the patient to rest.
18. Take all equipment to utility room
and clean and dry all used equipment
thoroughly.
19. Wash your hands.

EVALUATION:
Observe and evaluate the results.
During the procedure, observe the
patient for the response to the enema
as well as skin color, RR and signs of
fatigue. When the procedure is
completed, examine the contents and
amount of solution expelled.
Total Score: ___________________

Evaluator’s Signature: ________________________________

Date: ___________________________________________
 CHAPTER XV
PROMOTING RESPIRATORY FUNCTIONING

Topic Description:
This topic focuses on how to promote the respiratory functioning of the patient.
The discussion will be focused on how to promote respiration with and without the aid of
commercially prepared oxygen.

Competencies:
1. Anatomy and physiology of the respiratory tract.
2. Determine how to promote and control coughing.
3. Determine the measures to promote normal respiratory function.
4. Knowledge on how to properly administer Oxygen.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Discuss the the Promoting 2 Days Lecture Pre- Test
anatomy and Respiratory
physiology of the Functioning: Discussion Post- Test
respiratory tract and
the general principles Respiratory Tract: Return Recitation
behind respiratory Review of Anatomy Demonstrati
functioning. and Physiology and on of Performance
The General removing Checklist
Identify measures to principles of respiratory
promote normal respiratory tract
respiratory function. functioning. secretions.

Properly demonstrate Measures to

how to administer promote Normal
oxygen therapy to a Respiratory
client and discuss the function.
precautions to
observe during the Preparing the
procedure. patient for receiving
oxygen therapy.
Demonstrate how to
properly remove Removing
respiratory tract respiratory tract
secretions. secretions.
 Chapter XV
PROMOTING RESPIRATORY FUNCTIONING

General Principles of Respiratory Functioning

Anatomy and Physiology

Breathing (nose/mouth) delivers air

Nasopharynx (funnels incoming air through the mouth/nose

to the lower portions of the pharynx)

Epiglottis

Trachea

Lobar bronchi – Segmental bronchi

Lungs

Bronchioles

Alveoli (air sacs, air exchange)

VENTILATION - the physical process of moving air into and out of the lungs so gas
exchange can take place.

GAS DIFFUSION - oxygen and carbon dioxide move between the alveoli and the blood
by diffusion, the process in which molecules move from an area of a greater
concentration to an area of lesser concentration.

GAS TRANSPORT- as oxygen crosses the alveolar-capillary membrane into the blood,
the blood transports it in two forms; dissolved plasma and attached to hemoglobin
molecules on red blood cells.

CONTROL OF VENTILATION-specialized
VENTILATION-specialized neurons in the brain stem, known collectively
as the respiratory centers, generate regular impulses. These impulses are
transmitted to the respiratory muscles causing them to contract and relax
rhythmically. Carbon dioxide plays a primary role in determining ventilation. If its
level in the blood increase, chemoreceptors are stimulated causing more deep and
rapid breathing and vise versa.
 Measures to Promote Normal Respiratory Function

Deep Breathing
is done to produce hyperventilation, a condition in which there are more than
normal amounts of air entering and leaving the lungs. It is often used to overcome
hypoventilation.

Promoting and Controlling Coughing

Non Productive Cough- forceful expiratory effort caused by irritation

that produces no secretions (dry cough).
Productive Cough- produces respiratory tract secretions (phlegm).

Congested Lungs - person with secretions or fluids in his lungs.

 Congested with a non productive cough
 Congested with a productive cough

Voluntary Coughing
A cough does not does not occur as a result of reflex stimulation of the cough
sensitive areas. It can be induced voluntarily.

Involuntary Coughing
Involuntary cough often accompanies respiratory tract infections and irritations. It
helps clear the air way if it is productive, but it is fatiguing and irritating when it is
non productive.
Positioning the Patient Properly
Helping the patient assume a position that allows for the free movement of the
diaphragm and expansion of the chest wall promotes ease of respirations. Eg.
High fowler’s, semi fowler’s, side lying position.

Providing for an Adequate Fluid Intake

An adequate or an above-normal fluid intake helps to minimize the viscosity of
respiratory secretions. The patient’s fluid intake should be increased to the
maximum that his health will tolerate.

Providing for Humidified Air

When air humidity is low, artificial means for humidifying inspired air are often
advised. The inspiration of dry air removes the normal moisture in the respiratory
passages, which is essential for infection and irritation.
Promoting Ciliary Action
Cilia are hair like processes on the free surfaces of epithelium lining respiratory
passages.
2 Methods:
 Adequate hydration is important to decrease the viscosity of the secretions and to
help proper movement of cilia
 Eliminate/minimize conditions that destroy their ability to function. Eg. Smoking,
inhaling polluted air, and excessive use of alcohol.

Providing Supplemental Oxygen

Oxygen therapy - the provision of therapeutic oxygen.

The flow rate of Oxygen

The flow rate of oxygen is measure in liters per minute. The rate at which oxygen is
administered is ordinarily prescribed. However, the nurse should be especially
watchful of the flow rate for patients with chronic lung conditions, such as
emphysema.

Humidifying Oxygen
Excessive drying of the mucous membranes lining the respiratory tract occurs unless
oxygen is humidified. Since oxygen is only slightly soluble in liquids, it can readily
e passed through solutions with little loss. Distilled water, normal saline, or a
medicated solution may be used to humidify oxygen

Precautions When Administering Oxygen

Oxygen constitutes approximately 20% of normal air, is a tasteless odorless, and

colorless gas. It is heavier than atmospheric air. But careful consideration is
required: oxygen supports combustion. To prevent fires:
• Avoid open flames in the patient’s room, such as burning candles
• Place a “no smoking” signs in conspicuous places in the patient’s room.

• Check to see that electrical equipment used in the room is in good working order, and
be sure it emits no sparks.
• Avoid wearing and using synthetic fabrics, which build up static electricity.
• Avoid using oil, or wearing clothing stained with oil in the area. Oil can ignite
spontaneously in the presence of oxygen
Preparing the Patient for Receiving Oxygen Therapy
Receiving oxygen therapy is a frightening experience for most patients. The nurse
should explain the procedure and its purpose, as well as offer the patient support
and an opportunity to discuss fear he may have.
However oxygen therapy sometimes must be instituted in such speed that there is
little time for explanation, once the patient is out of danger he should be told about
the device.

Administering Oxygen by Nasal Cannula or Mask

Purpose
Deliver low to moderate levels of oxygen to relieve hypoxia

Assessment/Preparation
• Assess respiratory status
• Assess past medical history, noting chronic obstructive pulmonary disease (COPD)
• Assess for clinical signs and symptoms of hypoxia: anxiety, decrease level of
consciousness, inability to concentrate, fatigue, dizziness, cardiac dysrhythmias,
pallor or cyanosis, dyspnea.

Equipment
• Appropriate oxygen delivery system:
1. Nasal cannula and tubing (O2 concentrations: 22%-44%)
2. Simple oxygen mask (concentrations: 40%- 60%)
• Oxygen source
• Flow meter
• “No Smoking” sign
• Humidifier and distilled water (for high flow O2 therapy)

Procedure
 Review physicians order for oxygen to ensure that it includes method of delivery,
flow rate, duration of therapy; identify client.
 Wash your hands
 Explain the procedure to the client. Explain that O2 will ease dyspnea or
discomfort, and inform client concerning safety precautions associated with oxygen
use. If he is using the cannula, encourage him to breath through the nose.
 Assist client in semi fowlers position if tolerated.
 Insert flow meter into wall outlet. Attach oxygen tubing to nozzle on flow meter. If
using a high O2 flow, attach humidifier.
 Turn on the oxygen at the prescribed rate. Check that oxygen is flowing through the
tube.

Cannula:
a. Place cannula prongs in nares
b. Wrap tubing over and behind the ears
c. Adjust plastic slide under the chin until cannula fits snugly.

Mask:
 Place mask on face, applying from the nose and over the chin.
 Adjust the metal rim over the nose contour the mask to the face.
 Adjust elastic band around the head so mask fits snugly.
 Assess for proper functioning of equipment and observe client’s initial response to
therapy.
 Monitor continuous therapy by assessing for pressure areas on the skin and nares
every 2 hrs. and rechecking flow rate every 4-8 hrs.
 Document Procedure and observations

Removing Respiratory Tract Secretions

Humidification of Air and Maintaining an Adequate Fluid intake

Humidified air and maintaining an adequate fluid intake decreases the viscosity of
respiratory secretions, thus, making them easier to move out of the air passages.

Coughing
Respiratory tract secretions can often be removed by the patient’s voluntary
coughing.

Percussion
Cupping is used for the manual percussion of lung areas to loosen pulmonary
secretions so that they can be expectorated with greater ease.
• Cup the hand
• Strike rhythmically over the lobes of the lungs to be drained. Moved the cupped
hands from the bottom to the top.
• Listen for a hallow sound while percussing, and expect that the patient should
experience no pain.
• Do not percuss on bare skin. The patient may wear a gown or underclothing.
• Do not percuss below the ribs or over the spine or breast because of the danger of
tissue damage.
• Use percussion for 30-60 seconds over an area several times a day, but up to 3-5
minutes for patients with very tenacious secretions.

Vibration
Vibration is the rhythmic contraction and relaxation of the arm and shoulder muscles
while holding the hands flat on the patient’s chest wall.
• Place your hands flat on the patient’s chest wall, where vibration is desired, and hold
the hands side by side with the fingers extended and together.
• Ask the patient to inhale deeply the exhale slowly.
• While the patient exhales, vibrate the chest wall by contracting and relaxing your arm
and shoulder muscles rhythmically and quickly.
• Stop vibrations on the patient’s inhalations.
• Do not vibrate over the patient’s breast, spine, sternum, and lower rib cage.
• Use vibration for several minutes several times a day.
• Plan to deliver a vibration frequency of about 200 per minute.
Postural Drainage
Postural Drainage is the use of gravity to drain secretions from the lungs. The person
is positioned in a way that promotes the drainage of small pulmonary branches
into larger ones, where they can be removed by drainage or coughing. Postural
drainage is often preceded by vibration, percussion, or both.
• Have tissues and an emesis basin close at hand for the patient to use for coughing
and expectorating secretions.
• Use a high fowlers’s position to drain the apical secretions of the upper lobes of the
lungs
• Place a patient in a lying position, half on his abdomen and half on his side, right and
left, to drain the posterior secretions of the upper lobes of the lungs.
• Place the patient lying on his left side with a pillow under the chest wall to drain the
right middle lobe of the lung.
• Place the patient in trendelenburg’s position to drain the lower lobes of the lungs.
• Carry out postural drainage two to four times a day for 20 to 30 minutes. Discontinue
the drainage if the patient begins to feel weak or faint.
• Delay postural drainage after meals for 1 to 2 hours to avoid causing the patient to
vomit his meal.
 Suctioning Secretions from Airways

Purpose
 Remove excess mucous secretions to maintain patent airway
 Collect sputum or secretions for diagnostic testing.

Assessment/Preparation
• Assess respiratory system
• Assess client’s ability to cough. Note amount and character of sputum
• Assess vital signs, note for elevation in temperature
• Assess level of consciousness and ability to protect airway

Equipment
• Portable or wall suction apparatus with tubing and reservoir
• Sterile suction kit containing:
Appropriate sized catheter: infants, 5 to 8 Fr.
children, 8 to 10 Fr
adults, 12 to 18 Fr
Pair of gloves
Container for saline to flush and lubricate catheter
• Sterile saline
• Water resistant disposable bag
• Facial tissues
• Towel (optional)

Procedure
• Verify the physician’s order and identify the client
• Wash your hands
• Explain procedure and purpose to the client
• Position the conscious client with intact gag reflex in a semi-Fowler’s position
• Position the unconscious client in a side-lying position facing you.
• Turn on suction device and adjust pressure: infants and children, 50-75 mmHg;
adults, 100-120 mmHg
• Open and prepare sterile suction catheter kit,
 a. Unfold sterile cup, touching only the outside table
b. Pour sterile saline into cup
• Pre oxygenate client with 100% oxygen. Hyper inflate with manual resuscitation bag.
• Don sterile gloves. If kit provides only one glove, place it on dominant hand.
• Pick up catheter with dominant hand. Pick up connecting tubing with non dominant
hand. Attach catheter to tubing without contaminating sterile hand.
• Place catheter end into cup of saline. Test functioning of equipment by applying
thumb from non dominant hand over open port to create suction. Return catheter to
sterile field.
• Insert catheter to trachea through the nostrils , or artificial inspiration during
inspiration.
• Advance catheter until you feel resistance. Retract catheter 1 cm before applying
suction.
• Apply suction by placing thumb of non dominant hand over open port. Rotate the
catheter with your dominant hand as you withdraw the catheter. This should take 5-10
seconds.
• Hyperoxygenate and hyperinflate using manual resuscitation bag for a full minute
between subsequent suction passes. Encourage deep breathing.

Single glove suctioning technique

 TRINITY COLLEGE OF QUEZON CITY
ST. LUKE’S COLLEGE OF NURSING

Student’s Return Demonstration Checklist

STANDARDS ON SUCTIONING

Name:__________________________________________Section:__________

STEPS Done Needs Not Remarks

Improvement Done
2 1 0
Assessment/Preparation
• Assess respiratory system
• Assess client’s ability to
cough. Note amount and
character of sputum
• Assess vital signs, note for
elevation in temperature
• Assess level of
consciousness and ability to
protect airway
• Verify the physician’s order

Planning
• Gather all the equipments
needed.
• Wash your hands

Implementation
• Identify the patient
• Explain procedure and purpose
to the client
• Position the patient :
a. Conscious client with intact
gag reflex in a semi-Fowler’s
position

174
 b. Unconscious client in a side-
lying position facing you.
• Turn on suction device and
adjust pressure: infants and
children, 50-75 mmHg; adults,
100-120 mmHg
• Open and prepare sterile
suction catheter kit,
a. Unfold sterile cup, touching
only the outside table
b. Pour sterile saline into cup
• Pre oxygenate client with 100%
oxygen. Hyper inflate with
manual resuscitation bag
• Don sterile gloves. If kit
provides only one glove, place
on dominant hand.
• Pick up catheter with dominant
hand. Pick up connecting
tubing with non dominant hand.
Attach catheter to tubing
without contaminating sterile
hand.
• Place catheter end into cup of
saline. Test functioning of
equipment by applying thumb
from non dominant hand over
open port to create suction.
Return catheter to sterile field.
• Insert catheter to trachea
through the nostrils, or artificial
inspiration during inspiration.
• Advance catheter until you feel
resistance. Retract catheter 1
cm before applying suction.
NOTE:
NOTE: Coughing reflex is
activated when catheter enters
trachea.
• Apply suction by placing thumb
of non- dominant hand over
open port. Rotate the catheter
with your dominant hand as you
withdraw the catheter. This
should take 5-10 seconds.

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• Hyperoxygenate and
hyperinflate using manual
resuscitation bag for a full
minute between subsequent
suction passes. Encourage
deep breathing.
• Rinse catheter thoroughly with
saline
• Repeat suctioning until airway
is clear.
• Rinse catheter and tubing by
suctioning saline through.
• Removes gloves by holding
catheter with nondominant
hand and pulling glove off
inside out. Catheter will remain
coiled inside the glove. Pull
other glove off inside out.
Dispose properly.
• Turn off suction device
• Assist client to comfortable
position. Offer assistance too
oral hygiene. Replace oxygen
device if needed.
• Wash your hands

Evaluation
• Observe and evaluate
results. During the procedure,
observe the patient for the
response to the suctioning, RR
and signs of fatigue. When the
procedure is completed, examine
the characteristic and amount of
secretions.
• Document procedures and
observations.
Score:______________________
Score:______________________
Evaluator’s Signature:___________________________
Signature:___________________________
Date:__________________________________________
Date:__________________________________________

176
 CHAPTER XVI
ADMINISTRATION OF THERAPEUTIC AGENTS

Topic Description:
This topic focuses on how to administer therapeutic agents to a patient. The
different forms and preparations of medications will aso be discussed. And also
information on how to interpret a physicians medication order will also be dealt with.

Competencies:
1. Determine the forms and preparations of Medications.
2. Knowledge on how to interpret a medication order.
3. Determine the proper administration of each form of medication.
4. Determine proper blood transfusion administration.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITY
Determine the forms Administration of 1 Day Lecture Pre- Test
and preparations of Therapeutic
different medications Agents: Discussion Post- Test
and the reason for
being prepared in Name of Drugs. Case Recitation
such. Analysis
Medication Order (Doctors Interpretation of
Interpret a Medication Doctors order.
medication order Classification of order)
and transcribe it in a Medication
medication card. administration.

Identify the Blood Transfusion.

guidelines in
properly Medication Card
administering a
blood product. Common medical
abbreviations
Determine the
common Drug Computation
abbreviations being
used in hospitals.

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 Chapter XVI
ADMINISTRATION OF THERAPEUTIC AGENTS

Nightingale Pledge
“ I will abstain from whatever is deleterious and mischievous and will not take or
knowingly administer any harmful drugs.”

 Therapeutic agents – includes drugs and pharmacological substance used to treat

pathological conditions.
 Drugs/Medications – any substance that modifies body function when taken into the
living organism.
 Pharmacology (Pharmakon) – is a broad science which includes all aspects of the
subjects of chemical substance that act upon cells.

Name of Drugs
 Official Name – a name under which the drug is listed in one of the official
publications. (BFAD)
 Chemical Name – name that clearly and precisely identifies the chemical structure of
the drug and the exact description of the atoms or atomic groupings.
e.g. N-acetyl-para-aminophenol
 Brand Name – a name assigned by the manufacturer that appears
frequently in the literature.
- has an R in the upper right of the name.
- First letter is capitalized.

Medication Order
 Prescription
 Order or directives for medication administration
 The Physician is legally responsible for the prescription.

TYPES of Medication Order

Standing Order – carried out as specific until it is cancelled by another order.

e.g. Give Toradol 30 mg IV q 8 hrs.

Single Order – carried out only once at time specified.

e.g. Lactulose 30 cc po at hs.
Nubain 5 mg slow IV on call to OR.

STAT Order
- single order bit is one that is carried out at once.
e.g. Xylocaine HCL 50 mg IV STAT.
Toradol 30 mg IM NOW.

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PRN Order
- carried out when a client requires it.
e.g. Novaluzid 2 sachet PO prn for gastric discomfort.
Tempra 125mg/5ml 5 ml prn for Temp = or > 37.8 C

Parts of Medication Order

 Name of patient
 Date and time order is taken.
 Name of Drug to be administered.
 Dosage
 Route
 Time of administration or Frequency.
 Signature of person writing the order

Classification of Medication Administration

A. Enteral
– means within the intestines, drugs administered via GIT.
a. Oral
b. NGT ( Nasogastric Tube)

DOSAGE FORMS

Capsules
• Small cylindrical gelatin containers that holds dry powder or liquid medicinal agents.
• Available in variety of sizes and are convenient way of administering drugs with an
unpleasant odor or taste.
• Do not require coating or activities to improve the taste.
• The colors and shape of the capsules, as well as the manufacturer symbol on the
capsule surface are means of identifying the product.

Lozenges
 Flat disc containing a medical agent in a suitable flavored base.
 The base maybe a hard candy or the combination of sugar with sufficient mucilage to
give its form.
 Held in mouth to dissolve slowly thus releasing the therapeutic ingredients.

Pills
 Obsolete dosage form that no longer manufactured due to the development of
capsules and compressed tablets.
 Lay persons still use the term to refer to tablets or capsules.

179
Tablets
• Dried powdered drugs that have been compressed into small disks.
• Sometimes scored or grooved, indention may be used to divide the dosage.
• Can be formed in layers.
• Enteric coated tabs has a special coating that resist dissolution in the in the acidic pH
of the intestines; often used for administering meds that are destroyed in an acidic
pH; Must NOT be crushed or chewed or the active ingredients will be released
prematurely and be destroyed in the stomach.

Elixir
 Clear liquids that are made up of drugs dissolved in alcohol and water.
 Used when primarily when that drug will not dissolve in water alone.
 Flavoring agents are frequently added to improve taste.

Suspensions
 Liquid dosage forms that contains solid, insoluble drug particles dispersed in a liquid
base.
 All suspensions should be shaken well before administration to assure thorough
mixing the particles.

Syrups
 Contains medicinal agents dissolved in a concentrated solution of sugar, usually
sucrose.
 Particularly effective for masking bitter taste of a drug.

Equipments Needed
 Soufflé cup
- small paper or plastic cup may be used to transport solid
medication forms to prevent contamination by handling.
 Medicine cup
- glass or plastic container that has 3 scales ( Apothecary,
metric and household )
 Medicine Dropper
- used to administer eye drops, ear drops and pediatric meds.
 Teaspoon
- most liquid meds are prescribed in terms using the teaspoons
as the unit of measurement.
 Oral Syringes
- maybe used to measure liquid meds accurately.

B. Percutaneous
• Drugs applied to skin and mucous membrane principally have local effects.
• Methods of Applying Medication:

180
• Direct application of liquid.
• Inserting drug into the body cavity.
• Installation of drug into the body cavity.
• Irrigation of body cavity.
• Spraying

Advantages
• Therapeutic effects provided by local application to the involved site.
• Aqueous solution are readily absorbed & capable of causing systemic effect.
• Provide a route of administration when oral drugs are contraindicated.

Disadvantages
• Mucus membrane are highly sensitive to certain drug concentration.
• Client with ruptured eardrums cannot receive irrigation.

I. Creams, Lotions and Ointments

CREAMS
-semi solid emulsion containing medical agents for external application.
-non-greasy and can be removed with water.

LOTIONS
- preparation that contains suspended material.
- must be gently but firmly patted on the skin.
- soothing agents to protect skin, relieve rashes and itchiness.

OINTMENTS
- semi solid preparation in an oily based as lanolin and petrolatum.
- applied directly to the skin and mucous membrane.
- base keep the medicinal substance in prolonged contact with the skin.

TECHNIQUES
• Application
- use gloves during application
- for Lotion prep – shake well.
- ointments and cream – use tongue blade or cotton tip applicator
ointments – gentle firm strokes
creams – gently rubbed
• Dressings
- check specific order regarding type of dressing to be surface.
• Wet Dressing
- solution used is KMNO4 or AgNO3 and are added to plain water or
saline. Use measure to prevent staining since these solution stain everything

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II. Nitroglycerin Ointments
• Nitro; NitroBid
- provides relief of anginal pains.
- effective against nocturnal attack of angina.
• Site of administration
- any area without hair, chest, flank or upper arm.

III. Mucous Membrane

• Well absorbed and easy to obtain therapeutic effects.
• Highly selective in absorptive activities and differ in sensitivity of
mucous membrane of the vagina, urethra or rectum.
• Maybe dissolved and absorbed in the mouth, applied to the eyes or ears
for local action.

Suppositories
• Solid dosage form mixed with gelatin and shaped in form of pellet for
insertion into the body cavity.
• Melts when it reaches the body temperature releasing medication
for absorption.

Sublingual
• Drugs that tend to be destroyed by gastric juices.
• Liquid drugs in gel caps that is dissolved under the tongue

IV. Eye Drops and Ointments

• Dosage Form
- meds for use in eye should be labeled OPHTHALMIC.
- ocular solutions are sterile, easily administered and do not interfere
with vision.
- ocular ointments do not cause alterations in visual acuity but have
no longer duration of action than solutions.
` - always use a separate bottle or tube of eye medication for each patient.
• Sites – OD, OS, OU
• Eye Drops
- conjunctival sac from inner to outer cantus.
• Eye Ointments
- strip ointment to conjuctival sac.

V. Ear Drops
• Dosage Form
- Meds should be labeled OTIC

182
 - ear drops solution containing medication which is used for treatment
of localized infection of the ear.
- should be warmed to room temperature.

VI. Vaginal Meds

• Dosage Form
- creams, jellies, tablets, foam, suppositories, irrigations ( Douche ).
- inserted using special applicators and suppositories are usually
inserted with a gloved index finger

C. Parenteral Administration
• Refers to the injection of drug into subcutaneous tissue, muscle or vein.
• Drugs can also be in injected into the artery, spinal canal, pleural cavity,
cardiac muscle or peritoneal cavity.
• Involves giving a drug other than through the GIT.

Major site of Injection

1. Subcutaneous
• Tissues just below the dermis of the of the skin ( Hypodermic )
Injection Sites
- abdomen, lateral aspect of the upper arm or thigh.
Purpose
- for medications that are absorbed slowly to produce sustained effect.
Amount Injected
- small amount of fluid, less than 1 cc.
- if repeated doses are necessary, as with Insulin for diabetic, rotate
injection site.

2. Intramuscular
Injection Sites
• Vastus Lateralis – lateral aspect of the thigh.
• Gluteus Maximus – Buttocks
• Ventro-Gluteal
• Deltoid – upper arm

Purpose
- to promote rapid absorption of drug.
- to provide alternative route of when drug is irritating to SQ.
- to provide less painful route of parenteral injection.
Amount Injected – variable; if more than 5 cc use 2 syringes.

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 Absorption Rate – depends on the circulatory state of the patient

3.Intradermal
- dermis just under the epidermis
Injection Sites
- inner aspect of the forearm
- scapular area of back
- upper chest
Purpose - for ST,PPD or other tuberculin test.
Amount injected – 0.01 – 0.1 ml
Absorption Rate – Slow
* Injection site is not massaged

4. Intravenous - vein
• Sterile technique is observed.
• Disposable infusion tubing and needles are used.
• Equipments used:
- intravenous catheters
- tourniquet
- adhesive tapes( Micropore )
- antiseptic swabs
- arm board
- IV stand

IV Fluids
Blood Transfusion Set
Connect the piercing pin to the
IV fluid bag
Adjust the IV flow rate by loosening or tightening the roller clamp
Administer IV medications at the y-type injection site
Administration Sites – varies with individual circumstances

Factors Influencing IV Site

a. Accessibility of the vein:
a. Most Common – cephalic, basilic and metacarpal vein.
b. Determine pt’s condition
e.g burns
c. Avoid antecubital veins for long term infusions.
d. Avoid veins in the legs unless other sites are not
accessible because of stagnation of peripheral circulations.
e. Avoid veins in the surgical areas.

b. Condition of the vein

- avoid thin-walled and scarred veins specially in elderly pts.

184
c. Type of fluids to be infused
- Hypertonic solutions, those containing irritating meds, those administered at
rapid rate, and those with high viscosity should be given in a large vein to minimize
trauma and facilitate the rate of flow.

d. Anticipated duration of infusion

- select a site where restriction in & movement is kept to a minimum.

** change site q48-72 hrs if possible start at distal to proximal site.

Other Sites of Injection

5. Epidural –epidural space via catheter

e.g. analgesia
6. Intrathecal – subarachnoid space or ventricles of brain.
7. Intraosseous – bone marrow
8. Intraperitoneal – peritoneal cavity
9. Intrapleural - chest wall and directly into the pleural space
10. Intraarterial – arteries

Advantages
• Provides an effective route for the delivery of drug when other routes are
contraindicated.
• Drugs are not altered by gastric acids nor do they cause irritations to GI system.
• Drugs absorbed rapidly

Disadvantages
• More dangerous because it is difficult to correct any medication dose, technique
or choice of site.
• Drugs absorbed rapidly and cannot be recovered.
• Cost is greater and sterile technique is essential.

Special Techniques
• The needle that was used to withdraw the drug from the vial or ampule
should be wiped clean with a sterile cotton ball or gauze to remove the traces
of drug.
• Air Lock technique – after the drug has been withdrawn, and before the
injection is given, a small amount of air is drawn into the syringe.
• Z-tract technique – for drugs that are irritating to SQ tissue and skin.

185
Equipments Use:
• Syringe
– Disposable plastic or glass syringe ( 3,5,10,30,50 cc )
– Insulin syringe
– Tuberculin syringe
– Pre-filled syringe
• Needles
– Needle gauge
– Plastic needles
– Intracatheters
• IV sets
– Macrodrip
– Microdrip
– Soluset
• Ampules
- contains single dose medicine
• Vials
- glass bottles with self- sealing stopper through which the meds
is removed.
• Mix-o-vials
- 2 compartments; single dose medication.

11. Inhalation
• Via respiratory tract
• Deeper passage of respiratory tract provide a large surface area for
medication absorption.
• Meds can be administered through the nasal passages, oral passages, or
tubes that have been placed into the client’s mouth to the trachea.
• May have local or systemic effect

Blood Transfusion

• Transfusion of whole blood from a healthy person into a recipient .

Recipient – person receiving blood
Donor – person giving the blood

Types:
Direct – blood is infused as it is being taken from the donor.
Indirect – blood is infused after it has been collected from a donor and was
processed .

Antigen - Substance that causes formation.

Antibody- CHON substance developed in response to presence of antigen

186
Agglutinin- antibody that causes clumping of specific antigen.

Blood Products
PRBC
- Anemia, bone marrow failure, CHF,CRF,GI Bleeding
- usually infused for four hours
- ranging from 450-500 cc per Unit
Whole Blood
- Acute Massive loss, hypovolemic shock
- fast drip transfusion
- 500 cc per Unit
Platelets
- Thrombocytopenia
- Fast drip transfusion
- 150 per Unit
Fresh Frozen Plasma
- Hypovolemia, Burns
- 250 per Unit
- Fast drip transfusion

Standards of Care – action that ensure safe nursing practice

• Rights of Medication Administration
• Right Patient
• Right Room
• Right Drug
• Right Dosage

187
• Right Route
• Right Time and Date
• Right Documentation
To ensure right drug/medication, the Nurse MUST:
Compare the medication container with the medication form 3 times.
• Before removing the container from the drawer or shelf.
• As the amount of meds ordered is removed from the container.
• Before returning the container storage.

*Administer only the meds you prepare.

*Never prepare meds from unmarked container.

Unit Dose System (UDS)

• Pharmacy-coordinated system of medication distribution w/c aims to
control dispensing of medication.
• Provides a system check and balance
• Minimizes medication error.
• Minimize potential of medico-legal liabilities.
• More efficient and accurate pt billing.
• Quality of care is enhanced
– Medications are given on time
– Drug potency & stability are better maintained.
– Guards against harmful open-ended drug orders

Making Of Medication Cards

Purpose: To standardize all medication cards done by nurses.
Procedure:
1. To make out card or slip of paper, the nurse must include the ff info:
a. Standard time of administration
b. Patient’s full name
c. Bed Number
d. Hospital Number
e. Medication and Dosage
f. Route of administration
g. Ordered frequency

188
 PHARMACOLOGY IN NURSING
Dosage and Solution

COMMON MEDICAL ABBREVIATION

Abbreviation Interpretation Abbreviation Interpretation
Routes Frequency
IM Intramuscularly b.i.d. Twice a day
IV Intravenous t.i.d. Three times a day
IV PB Intravenous q.i.d. Four times a day
piggyback
SC Subcutaneous min. Minute
SL Sublingual h Hour
ID Intradermal q.h Every hour
GT Gastostomy tube q.2h Every two hours
NJ Nasogastric tube q.3h Every three hours
p.o. By mouth, orally q.4h Every four hours
p.r. Per rectum q.6h Every six hours
O.D. Right eye q.8h Every eight hours
O.S. Left eye q.12h Every twelve
hours
O.U. Both eyes Generals:
A.D. Right ear a Before
A.S. Left ear p After
A.U. Both ears c With
Frequency s Without
a.c. Before meals q Every
p.c. After meals aq Water
ad. Lib. As desired, freely NPO Nothing by mouth
p.r.n. When necessary ss One half
h.s. Hour of sleep, at gtt Drop
bed time
Stat Immediately, at tab Tablet
once
q.d. Once a day, every cap Capsule
day
q.o.d. Every other day et And
noct Night

189
 Drug Computations

Example:
Administer Lasix 40 mg IV push now. How many ml will you give having a stock dose of
20 mg/2 ml for lasix?

Solution 1:
D x Q Legend:
S D - Desired
= 40mg / 20 mg x 2ml S – Stock dose
= 4ml Q – Quantity

Solution 2:
Ratio and Proportion
20 mg : 2 ml = 40 mg : x
20 mg (x) = 2 ml x 40 mg
x = 2 ml x 40 mg
20 mg
x= 4 ml

Example:
Start IV fluid D5.3NaCl 1 liter to run for 8 hours. Infuse IV using a Macro set. What is the
flow rate of the IV solution in (1) gtts/min and (2) cc/hr?

Principle: Drop factor

Micro drop – 60 drops / ml
Macro drop – 15 drops / ml
BT set – 10 drops / ml

Solution 1:
Flow Rate = Amount of IVF x Drop Factor
No. of Hrs. x 60 mins.
= 1000 ml x 15 drops / ml
8 hrs x 60 mins.
= 31 drops / minute

Solution 2:
Flow Rate = Amount of IVF

190
 No. of Hrs.
= 1000 ml
8 hrs
= 125 cc/hr

CHAPTER XVII
PROMOTING TISSUE HEALING

Topic Description:
This topic focuses on how to promote tissue healing of patients. In this chapter
the function of the inflammatory process during trauma will be discussed, and nursing
management relevant to the presenting conditions will be brought to light.

Competencies:
1. Define Trauma.
2. Determine how the inflammatory process takes place.
3. Determine how tissue healing takes place.
4. Identify managements to promote tissue healing.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Define trauma and Promoting Tissue 2 Days Lecture Pre- Test
determine how it Healing:
affects the client. Discussion Post- Test
Trauma
Discuss the Return Recitation
Inflammatory Inflammation and Demonstration
process and the Inflammatory of Wound Performance
determine its Process. Care. Checklist
participation in
tissue healing. General Principles
of tissue healing.
Demonstrate proper
wound care Wound Care.
technique.
Applying common
Determine the types of bandages.
common types of
bandages and Binders
binders and the
principle behind its General principles
application. of applying

191
 bandages and
Determine the binders.
purpose of cast
application and how Cast
to care for it.
Basic Cast Care.
Identify the benefits
of heat and cold Heat and Cold
application Application.

192
 Chapter XVII
PROMOTING TISSUE HEALING

TRAUMA (INJURY)
- physical injury caused by violent or disruptive action or by the introduction into the
body of a toxic substance.

Types of Wound:
OPEN
The wound is open when the skin or mucous membrane surface is broken.
CLOSED
The tissue is traumatized without a break in the skin

Wounds can either be:

1. Intentional ( Surgical )
- occurs during therapy
eg. operations, venipunctures

2. Unintentional ( Accidental )
- are accidental
eg. fractured arm due to automobile collision

Nature of the Break in the Continuity of Normal Tissue

1. INCISION
- a wound made with a sharp instrument.
eg. knife, scalpel, razor
2. CONTUSION
- blow from a blunt instrument.
eg. baseball bat
3. ABRASION
- a wound that results from scraping or rubbing off skin or
mucous membrane.
eg. scraped knee

According to the likelihood and degree of wound contamination

1. CLEAN WOUNDS
- are uninfected wounds in which no inflammation is
encountered and the respiratory, alimentary, genital
and urinary tracts are not entered.

2. CLEAN-CONTAMINATED WOUNDS
- are surgical wounds in which the respiratory,
alimentary, genital or urinary tract has been entered.

193
194
 INFLAMMATION
- is the defensive local response of the body to injury. Inflammation works to
limit the tissue damage, removed the injured cells, and repair the traumatized
tissue.

1. MATURATION PHASE
- begins about day 21 and can extend 1 or 2 years after the injury
- Fibroblasts continue to synthesize collagen.
- The scar becomes a thin, less elastic, white line.

2. SECONDARY INTENTION HEALING

a wound that is extensive and involves considerable tissue loss, and in which
the edges cannot be approximated. It differs from primary intention healing in 3
ways: a.) the repair time is longer; b.) the scarring is greater; c.) the susceptibility to
infection is greater.
EXAMPLE: Pressure ulcers

3. TERTIARY INTENTION HEALING

- is indicated when there is a reason to delay suturing a wound. These wounds are
sutured later after the initial stage of deposition of granulation tissue. The wounds
require more connective tissue than that heal by primary intention but less than
those that heal by secondary intention.
EXAMPLE: an abdominal wound that is initially left open for
drainage but is later closed.

GENERAL PRINCIPLES OF TISSUE HEALING

1. The healthy body has an innate capacity to protect and restore itself
2. The body’s ability to handle tissue trauma is influenced by the
extent of the damage and by the person’s general state of health.
3. The body responds systematically to trauma in any of its parts.
4. The blood transports substances to and from injured tissue.
5. Both open and closed wounds of soft tissue or bone can be
invaded by pathogens with resulting infection.
6. Intact skin and mucous membranes serve as first lines of defense
against microorganisms.
7. Normal healing is promoted when the wound is free of foreign
bodies, including bacteria.

195
 WOUND CARE

THE UNCOVERED WOUND

3 Basic Reasons for leaving the Wound Incovered
1. Friction and irritation of dressing destroy epithelial cells.
2. The normal flora on the skin can be rubbed into the wound by
a covering and if the area is moist and dark, bacterial growth can flourish.
3. A covering may act to impede circulation to the area.

DRESSING
- A protective covering placed over a wound.
Purpose of Wound Dressing
1. Dressings protect a wound from mechanical injury.
2. Dressings protect the wound from microbial contamination.
3. Dressings help immobilize or splint the wound site and thereby facilitate healing and
prevent injury.
4. Dressings serve to help keep the wound free of drainage and debris.
5. Dressings provide or maintain high humidity of the wound.
6. Dressings provide thermal insulation.
7. Dressings provide psychologic(aesthetic) comfort.
8. Dressings prevent hemorrhage.

TYPES OF DRESSING
A. GAUZE
1. 4x4
2. 2x2
3. Surgipads / Abdominal Pads
4. Roller Gauze
5. Nonadherent absorbent dressing
B. SYNTHETIC DRESSINGS
- hydrocolloids, foams and thin films

BANDAGES AND BINDERS

BANDAGE
- is a strip of cloth used to wrap some part of the body or to cover a wound.
1. Gauze - use to retain dressings on wounds and to bandage the
fingers, hands, toes and feet.
2. Elastic Bandages - are applied to provide pressure to an area. They
are commonly used as tensor bandages or as partial
stockings to provide support and improve the venous
circulation in the legs.
3. Plastic Adhesive Bandages - are also used to retain dressings. They
are waterproof and thus retain wound drainage
or keep the area dry.

196
APPLYING COMMON TYPES OF BANDAGES
1. SPIRAL TURN - used to bandage parts of the body that are fairly uniform
in circumference, such as the upper arm or upper leg.
2. SPIRAL REVERSE TURN - are used to bandage cylindrical parts of the
body that are not uniform in circumference such as the
lower leg or forearm.
3. RECURRENT TURN - are used to cover distal parts of the body, such
as the end of a finger, the skull or the stump of an amputation.
4. FIGURE-EIGHT TURN - are used to bandage an elbow, knee or ankle,
because they permit some movement after application.
5. SPICA - a variation of the figure-eight bandage. It is commonly used to
bandage the hip, groin, shoulder, breast or thumb.

BINDERS
- is a type of bandage designed for a specific body part. It is designed to
fit a large body area, such as the abdomen, the chest, or the breast.
1. TRIANGULAR ARM BINDER (SLING)
- is usually applied to support the arm, elbow, and forearm of the
client or to reduce or prevent swelling of a hand.
2. T- BINDER ( SINGLE/DOUBLE )
- are used to retain pads, dressings, or packs in the perineal area.
SINGLE- for females
DOUBLE - for males to prevent undue pressure on the penis.

GENERAL PRINCIPLES OF APPLYING BANDAGES AND BINDERS

1. Unclean bandages and binders may cause infection if applied over a wound
or skin abrasion.
2. When objects in contact move in opposition to each other, friction is
produced that can destroy or damage epithelial cells.
3. Prolonged heat and moisture on the skin may cause its epithelial cells
to deteriorate.
4. Placing and supporting the body part to the bandaged in the
normal functioning position prevents deformities and discomfort and
enhances circulation of blood to the body part.
5. Blood flow to the tissues is decreased by applying excessive pressure
on blood vessels.
6. The tension of each bandage turn should be equal, and unnecessary
and uneven overlapping of turns should be avoided.
7. Pins and knots, often used to secure a bandage or a binder, are placed
well away from a wound or a tender and inflamed area.

197
CAST
- is a rigid external immobilizing device that is molded to the contours of
the body.
- are made of bandages impregnated with plaster of Paris

PURPOSE:
to immobilize a part of the body to provide protection and support. It is generally used to
immobilize/hold bone fractures in place until healing occurs.

BASIC CAST CARE

1. Know the type of fracture the patient has and the reason why a specific type of
cast has been applied.
2. Elevate a wet cast on an extremity as high as possible.
3. Do not allow anything to rest on a wet cast, and do not allow a wet cast to be
placed on a flat surface.
4. Avoid using plastic material over a wet cast.
5. Use a heat lamp or a cradle with lights to help dry a cast.
6. Use eyes and hands to test for numbness and to observe for swelling,
paleness, cyanosis, and coolness of the skin.
7. When a leg or arm is casted, pinch the nailbeds between your thumb and fingers,
and then release the pressure to test for circulation in the fingers and toes.
8. Take pulse rates in and near casted areas to the extent the cast permits.
9. When a leg or arm is casted, ask the patient to move each finger and each toe
to test for movement.
10. Watch for spots on the cast owing to drainage
11. Make an inked line around an area of drainage on the cast, and time and date
the ring.
12. Test for “hot spots” by feeling over a cast.
13. Check for signs and symptoms of excess pressure and drainage frequently.
14. Report promptly when signs and symptoms of excess pressure and drainage
are noted.
15. Plan that it will take about 48 hours for a cast to dry.
16. Change a casted patient’s posotion frequently to avoid pressure areas that
may cause decubitus ulcers.
17. Turn the patient to his unaffected side when moving him. Handle a wet cast
with palms of the hands, not the fingers.
18. Use range-of-motion exercises for unaffected joints for a casted patient, and use
a trapeze in bed, when possible, to promote activity.
19. Rub areas near the edge of the cast with alcohol to help keep the skin clean and
in good condition.
20. Avoid inserting instruments, such as clamps, bobby pins, tongue blades, and
coat hangers, under the cast when the skin itches.
21. Clean the outside of a dry cast with a damp cloth.
22. Protect casts that are near the perineal area with pieces of plastic to help keep
the cast clean and free of odor.
23. Teach the patient to avoid getting his cast wet.

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 HEAT AND COLD APPLICATION
HEAT
-Vasodilation
-Increases capillary permeability
-Increases cellular metabolism
-Relaxes muscles
-Increases inflammation; increases blood flow to an area, bringing phagocytes

COLD
-Vasoconstriction
-Decreases capillary permeability
-Decreases cellular matabolism
-Relaxes muscle by decreasing muscle contractility
-Slows bacterial growth, decreases inflammation.

HEAT
- Decreases pain by relaxing muscles
- Sedative effect
-Reduces joint stiffness by decreasing viscosity of synovial fluids

COLD
- Decreases pain by numbing the area, slowing the flow of pain impulses, and
by increasing the pain threshold
- Local anesthetic effect
- Decreases bleeding

THERAPEUTIC USES OF HEAT

1. To promote wound healing.
2. To relieve discomfort.
3. To relieve muscle tension.
4. To relieve congestion in remote tissue.
5. To warm a part of the body.
6. To reduce edema.

SPECIAL PRECAUTIONS FOR USING HEAT APPLICATIONS

1. Heat is contraindicated in the presence of an acute inflammatory process.
2. Heat is contraindicated in the presence of malignant tumors because of
the danger of increasing metastasis.
3. Heat is contraindicated for a patient who is a candidate for
hemorrhaging because heat tends to decrease the blood’s clotting ability.
4. Heat is given with greatest care to those patients who have impaired arterial
or venous sufficiency because of the danger or burning the skin.
5. Special care is indicated for persons who are delibitated, unconscious
or insensitive to cutaneous stimulation.

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THERAPEUTIC USES OF COLD APPLICATION
1. To relieve discomfort.
2. To limit inflammation and suppuration.
3. To control bleeding.

SPECIAL PRECAUTIONS FOR USING COLD APPLICATIONS

1. Cold is contraindicated when tissues are poorly nourished and when
blood circulation is poor in an area of the body.
2. Cold is contraindicated when fluid in tissues has accumulated in an area.
3. Cold is ordinarily contraindicated when the patient has a low body temperature.
4. Cold is not used when muscle tension and spasms are present because
cold will aggravate these conditions.

APPLYING HEAT AND COLD

1. DRY HEAT AND COLD

A. Hot Water Bag - common source of dry heat used in the home.

STEPS in applying HOT WATER BAG:

1. Measure the temperature of the water using a bath thermometer.
Make sure the correct temperature is used.
ADULT - 52 C
DEBILITATED/UNCONSCIOUS - 40.5-46 C
CHILD UNDER 2 Y/O - 40.5-46 C
2. Fill the bag about two-thirds full.
3. Expel the remaining air and secure the top. By removing the air, the
bag can be molded to the body part.
4. Dry the bag and hold it upside down to test for leakage.
5. Wrap the bag in a towel or cover, and place it on the body site.
6. Remove after 30 to 45 minutes or in accordance with agency protocol.
Prolonged application initiates the rebound phenomenon.

B. Aquathermia Pad ( K-PAD)

- is a pad constructed with tubes containing water. Pad is attached by tubing to an
electrically powered control unit that has an opening for water and temperature
gauge.

C. Hot and Cold Packs

- provide heat or cold for a designated time

D. Electric Pads
- provide a constant, even heat, are light weight, and can be molded
to a body part.

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.E. Heat Cradle
- is a metal frame with a row of 25-watt light bulbs.

F. Heat Lamp
-are gooseneck lamps with a 60-watt bulb. The lamp is placed 18-24 inches
from the area to be heated.

G. Ice Bag, Ice Glove, Ice Collar

-are either filled with ice chips or alcohol based solution.

2. MOIST HEAT AND COLD

a. Compresses
- can be either warm of cold. A compress is a moist gauze
dressing applied frequently to an open wound.

b. Packs
- a pack is a moist cloth applied to the body area.

c. Soak
- refers to immersing a body part in a solution or to wrapping a part
in gauze dressings and then saturating the dressing with a solution.

d. Sitz bath
- or hip bath, is used to soak a client’s pelvic area. The client sits in
a special tub or chair and is usually immersed from the midthighs to
the iliac crests or umbilicus.

e. Cooling Sponge Bath

- the purpose of a cooling sponge bath is to reduce a client’s fever
by promoting heat loss through conduction and vaporization.

3. HYPERTHERMIA AND HYPOTHERMIA BLANKETS

- are used to decrease or increase the client’s body temperature. The
blanket has an associated control panel on which the desired temperature
is set and the client’s core temperature registers.

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 TRINITY COLLEGE OF QUEZON CITY
St. Luke’s College of Nursing

Student’s Return Demonstration Checklist

STANDARDS ON WOUND CARE

Student’s Name:__________________________________Section:_________

STEPS Done Needs Not Remarks

2 Improvement Done
1 0
I. ASSESSMENT
 Identify patient’s chart correctly
 Determines patient’s diagnosis,
current condition.
 Checks out for specific
instructions
II. Prepares to carry out
procedure
 Washes hands
 Prepares and collects all
equipment, brought it to the
bedside.
III. Implementation
 Enters the pt’s room
 Introduces self and identifies
client.
 Explains procedure to patient/
relatives
 Provides privacy
 Regulates room temperature/
ensures adequate lighting
 Assist the patient in a comfortable
position

 Expose the area to be dressed

and drape the patient.
 Make a cuff on the moisture proof
bag for disposal of the soiled
dressings, and place the bag
within reach. It can be taped to the
bedclothes or bedside table.
 Put on a face mask, if required.
 Remove binders and tapes.
 Put on clean disposable gloves
and remove the outer abdominal
dressing or surgipad.
 Lift the dressing so that the
underside is away from the client’s
face.

202
 Assess the location, type ( color
consistency), and odor of wound
drainage and the number of
gauzes saturated or diameter of
drainage collected on the
dressing.
 Discard the soiled dressings in the
bag as before.
 Remove gloves, dispose of them
in the moisture-proof bag and
wash hands.
 Open sterile dressing set, using
surgical aseptic technique.
 Place the sterile drape beside the
wound.
 Open the sterile cleaning solution,
and pour it over the gauze
sponges in the plastic container.
 Put on sterile gloves.
 Clean the wound, using your
gloved hands or forceps and
gauze swabs moistened with
cleaning solution.
 If using forceps, keep the forceps
tips lower than the handles at all
times.
 Use the cleaning methods
discussed or one recommended
by agency protocol.
 Use a separate swab for each
stroke, and discard each swab
after use.
 Dry the surrounding skin with dry
gauze swabs as required. Do not
dry the incision or wound itself.
 Apply the ordered
powder/ointment:
 POWDER- shake
powders directly
onto the wound.
Antibiotic powders
may be ordered.
 OINTMENT - use
sterile applicators
or tongue blades to
apply ointments.
 Apply dressing on the wound.
 Apply the sterile dressing on at a
time
over the wound.
 Apply the final surgipad.
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 Remove gloves and dispose
them.
 Secure the dressing with tape or
ties.
Performs after care procedure
 Discard properly all disposable
supplies used.
 Washes hands thoroughly
Documents the procedure
 Records pertinent observations
and patient’s response to the
procedure.

Total Score: ___________________

Evaluator’s Signature: ________________________________

Date: ___________________________________________

204
 CHAPTER XVIII
DEATH AND DYING

Topic Description:
This topic focuses on the process of death and dying among our patients. The
nurse’s role in the dying process will also be discussed.

Competencies:
1. Determine one’s concept of Death and Dying.
2. Identify the stages of grieving.
3. Determine the nurse’s role during death and the dying process.
4. Determine how to perform Post Mortem Care.

OBJECTIVE TOPIC TIME STUDENT EVALUATION

FRAME ACTIVITIES
Define death and Death and Dying: 2 Days Lecture Pre- Test
dying.
Death and It’s Discussion Post- Test
Determine the Causes.
possible causes of Return Performance
death among Nurse’s Feeling Demonstration Checklist
patients. about Death and of Post
Dying. Mortem Care.
Determine ones’s
own feelings about Stages of Grieving.
death and dying.
The Nurse’s Role.
Determine the
Stages of the Signs of Clinical
Grieving process. Death.

Identify the nurse’s Post Mortem Care

role during
occurance of
patient death and
in the dying
process.

Identify signs of
clinical death.

Properly
demonstrate Post
Mortem care.

205
 Chapter XVIII
DEATH AND DYING

“To everything there is a season, and a time to every purpose under heaven: A time to
be born, and a time to die . . . . “
Ecclesiastes 3: 1-2
DEATH
 End of life
 Cessation of apical pulse, RR, and BP
 Natural part of life, something to be experienced by every living thing
 Viewed as personal failure on part of health personnel
 Thanatology – study of death and its medical and psychological effects.

Causes of Death
 Diseases
 Accidents
 Wars
 Homicides and suicides
 Sacrificial death
 Legal execution
 Abortion, infanticide, genocide

Nurse’s Feelings about Death and Dying

 Questions the nurse should ask herself to clarify her feelings
 If I could control the event that result in my death, where would I want to be?
What cause of death would I choose? Whom would I want to have present during
my terminal illness.
 What fears do I have about death ?
 How would I answer these same questions for a patient for whom I have been
caring?
 How could I improve the quality of care for a terminally ill patient for whom I am
caring?
 If I were a member of the patient’s family, what things would I want nurses do for
me?

Important Concepts
 Grief – characteristic pattern of psychological and physiological responses a person
experiences after the loss of a significant person
 Bereavement – state of desolation that occurs as the result of a loss, particularly
death.
 Mourning – socially prescribed behavior after death of significant other
 Anticipatory grief – Physiologic and psychologic responses to impending loss of a
significant person, object, belief or relationship.

206
 Loss – actual or potential situation in which something that is valued is changed, no
longer available or gone.
 Actual loss – identified by others and can arise either in response or anticipation
of situation.
 Perceived loss – experienced by person but cannot be verified by others.

Stages of Grieving
 Formulated by Dr. Elisabeth Kubler-Ross
 Studied emotional responses to death and dying
 These stages do not always follow one another or they may overlap. The duration of
any stage varies from the individual.

1. Denial and Isolation - Patient says Death happens to others but not to him.
He isolates himself from reality. Pt. says – “ No, not me. “
2. Anger - Characterized by rage and anger. The pt is very critical or everyone
and everything. Anger is the pt’s defense mechanism but his real anger
lies with health and life.
- “Why me?”
3. Bargaining - Anger has ordinarily subsided. Time for truce, and the patient
now tries to barter for more time. He often make promises to
God is he is a believer in exchange for more time. - “ Yes me, but ….”
4. Depression - State of mourning over past losses and the present loss of
his own lifeand is very sad time. Pt tend not to speak much
and often cries. The nurse sits quietly as the pt goes through
his own period. - “Yes me. “
5. Acceptance - Marked acceptance of death. Unfinished business
has been taken cared of. Period of peace and tranquility.
This doesn't mean death is near.
- “ Let death take me soon for I am ready.”
Nurses’ Role
 Recognize the patient’s needs. Not one’s own and attempt to meet them.
 Allow and encourage the patient to talk and to express his emotions freely in a
nonjudgmental environment
 Be available to the patient
 Respect patient’s behavior
 Listen to the patient while he speaks.

Meeting Psychological Needs of Terminally ill Patients

 Fear of catastrophic force of death
 Role of listening
 Role of communication
 Role of touch

207
Meeting Physical Needs of Terminally ill Patients
 Meeting nutritional and fluid needs
 Caring for mouth, nose, eyes and skin
 Promoting elimination
 Protecting from harm/preventing injury
 Caring for the environment
 Providing comfort

Signs of Impending Clinical Death

Loss of muscle tone

 Relaxation of the facial muscle
 Difficulty speaking
 Difficulty swallowing
 Decreased activity of the GI with N/V, accumulation of flatus, abdominal distention
and retention of feces
 Possible urinary and rectal incontinence
 Diminished body movement

Slowing of circulation
 Diminished sensation
 Mottling and cyanosis of the extremities
 Cold skin, first in feet and later in hands, ears, nose but the client fell warm
because of elevated temperature

Changes in vital signs

 Decelerated and weaker pulse
 Decrease blood pressure
 Rapid, shallow, irregular or abnormally slow respiration: Cheyne-Stokes
respirations; noisy breathing or death rattle, mouth breathing

Sensory impairment
 Blurred vision
 Impaired senses of taste and smell

Signs of Death

 Total lack of response to external stimuli

 No muscular movement, especially breathing
 No reflexes
 Flat encephalogram
 If with artificial support, absence of electric current from the brain for at least 24
hours.

208
POST MORTEM CARE

 Body Changes
 Rigor Mortis – stiffening of the body that occurs about 2-4 hours after death.
– Lack of ATP which is not synthesized because of lack of glycogen in the
body
 Algor Mortis – gradual decrease of the body’s temperature after death.
 Livor Mortis – discoloration of the skin which appears in the lowermost or
dependent areas of the body due to RBC breakdown releasing hemoglobin

 Purpose:
To clean and prepare the patient’s body before it is transported
out of the unit

 Equipments:
 Bath basin with tap water
 Patient's wash cloth and bath towel
 Wrap sheet
 Patient’s gown
 Patient’s clothes (optional)
 Yellow plastic bag

 Mortuary box
 Cotton balls (2 packs)
 Micropore
 Rubber bands (2 pcs)
 Death tags with rubber bands (2 pcs)
 Calen gloves
 4x4 pcs gauze (2 pcs)
 Glass rod
 Linen charge slip
 Disposable face mask

 Death forms
 Notice of death (3 copies)
 Death tags (2 pcs)
 Death certificate (4 copies) from admission office

PROCEDURE:

1. Prepares to carry out the procedure

A. Checks completeness of mortuary box
B. Accomplishes the ff:

209
  Notice of Death and death tags
 Secure death certificate form from admission office
 Request the resident/physician to accomplish the death certificate
C. Sends the following forms to :
 Notice of death – Admission office, Billing office and Nursing unit
 Death certificate
D. Informs the relatives of discharge procedure, securing funeral service, availability
of hospital chaplain and autopsy procedure (if necessary)

2. Brings the needed equipments to the bedside

3. Explains post mortem care to the immediate relatives
4. Provides privacy
5. Washes hands

6. Performs actual procedure

 Wear clean gloves, gowns and face mask
 Makes all itemized list of all personal belongings, endorses them to immediate
relatives and ask them to affix their signatures in the logbook
 Aligns body with arms at the side and places patient in a supine position
 Closes patient’s eyes by grasping eyelashes of the upper lid and pulling it
upward and downward over the eyes

7. Places back dentures and closes patient’s mouth (Optional)

8. Removes all contraptions (except radiation implants) and apply new dressings
9. Provides sponge bath
10. Packs all orifices with pieces of gauze/cotton balls
11. Dresses the body with patient’s gown or clothes.
12. Attaches one death tag around the wrist, fold the patient’s hand
over the chest and position legs.
13. Cover the body with wrap sheet
14. Attaches the other death tag to the foot part of the sheet
15. Transports the body to the morgue

16. Performs After Care procedure

 Discards all used supplies in a yellow plastic bag
 Removes al linen items and places it in a separate yellow
 Cleans and disinfects al equipments used
 Accomplishes ands sends housekeeping request for scheduling
 Replenishes mortuary box

17. Records the following:

 Time patient was pronounced dead
 Time post mortem care was rendered
 Observations noted during post mortem care
 Staff who rendered the post mortem care
 Staff who transported the cadaver to the morgue

210
  Time the cadaver was transported to the morgue
 Immediate relative who considered to the autopsy (optional)
TRINITY COLLEGE OF QUEZON CITY
ST. LUKE’S COLLEGE OF NURSING

Student’s Return Demonstration Checklist

STANDARDS ON POST MORTEM CARE

Name:______________________________________ Section:______________

211
 STEPS DONE Needs Not Remarks
2 Improvement done
1 0
I. Prepares to carry out the
procedure
 Checks completeness of
mortuary box
 Accomplishes the ff:
 Notice of Death and
death tags
 Secure death
certificate form from
admission office
 Request the
resident/physician to
accomplish the death
certificate
 Sends the following
forms to :
 Notice of death –
Admission office,
Billing office and
Nursing unit
 Death certificate
 Informs the relatives of
discharge procedure,
securing funeral service,
availability of hospital
chaplain and autopsy
procedure (if necessary)
 Brings the needed
equipments to the bedside
 Explains post mortem care
to the immediate relatives
 Provides privacy
 Washes hands

II. Performs actual procedure

 Wear clean gloves,
gowns and face mask
 Makes all itemized list of
all personal belongings,
endorses them to
immediate relatives and
ask them to affix their

212
 signatures in the logbook
 Aligns body with arms at
the side and places
patient in a supine
position
 Closes patient’s eyes by
grasping eyelashes of
the upper lid and pulling
it upward and downward
over the eyes
 Places back dentures and
closes patient’s mouth
(Optional)
 Removes all contraptions
(except radiation implants)
and apply new dressings
 Provides sponge bath
 Packs all orifices with
pieces of gauze/cotton balls
 Dresses the body with
patient’s gown or clothes.
 Attaches one death tag
around the wrist, fold the
patient’s hand over the
chest and position legs.
 Cover the body with wrap
sheet
 Attaches the other death
tag to the foot part of the
sheet
 Transports the body to the
morgue

213
III. Performs After Care
procedure
 Discards all used
supplies in a yellow
plastic bag
 Removes al linen items
and places it in a
separate yellow
 Cleans and disinfects al
equipments used
 Accomplishes ands
sends housekeeping
request for scheduling
 Replenishes mortuary
box
IV. Records the following:
 Time patient was
pronounced dead
 Time post mortem care
was rendered
 Observations noted during
post mortem care
 Staff who rendered the
post mortem care
 Staff who transported the
cadaver to the morgue
 Time the cadaver was
transported to the morgue
 Immediate relative who
considered to the autopsy
(optional)

Score:________________________

Evaluator’s Name:__________________________
Date:_________________________________

214
REFERENCE:

1. Craven, Ruth; Hirnle, Constance J. (1992). FUNDAMENTALS OF NURSING.

(1992). Philadelphia; J.B. Lippincott

2. Kozier, Erb, Berman and Synder. (2004). FUNDAMENTALS OF NURSING:

CONCEPTS, PROCESS, AND PRACTICE. 7th Edition, Pearson, Prentice Hall

3. Wolff, Lu Verne. (1979). FUNDAMENTALS OF NURSING. 6th Edition.

Philadelphia: J.B. Lippincott

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