FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010

HISTORY OF NURSING
• Intuitive Period VII. ROME
• Apprentice Period  Roman Catholic
• Educated Nursing Period  Fabiola – made her home as the first hospital
Page • Contemporary Period under the Christ Era
|1
INTUITIVE PERIOD APPRENTICE PERIOD
 Nursing was untaught and instructive  11TH century – 1836
 Beliefs and practices  On the job training period
i. Nomads  From the rise of religious orders from secular orders up
ii. Women to the dark period of nursing up to the establishment
iii. Black magic/ evil spirits (voodoo) of the 1st training school.
iv. White magic/ shaman/ witch doctors
v. Trephining RELIGIOUS ORDERS
• Knights of St. John – ranks and superiority
ANCIENT CITIES AND CONTRIBUTIONS • Teutonic Knights – tent hospitals
I. BABYLONIA • Knights of St. Lazarus – lepers/leprosy
 Code of Hammurabi (Law affecting medical
practice) SECULAR ORDERS
 RA 9173 – Phil. Nursing Act of 2001 • St. Catherine of Siena – “Lady with a lamp”
 RA 7164 – Old Phil. Nursing Act of 1991 • St. Elizabeth of Hungary – “Patroness of Nurses”
II. EGYPT • Clara Barton – “Founder of American Red Cross”
 Art of Embalming (Enhance the knowledge • St. Claire – founded the 2nd order of St. Francis de Asisi
about human anatomy)
 Recognize 250 diseases Dark Period of Nursing
III. ISRAEL  Religious upheaval led by Martin Luther
 Moses “Father of Sanitation”
 Give laws on communicable disease Theodore Fliedner
 Ritual circumcision  Establish the 1st training school in Germany
IV. CHINA  Kaiserwerth Institute for the Training of the
 “Materia Medica” (pharmacology) Deaconesses
 Used girl clothes for male babies
V. INDIA EDUCATED NURSING PERIOD
 Intuitive Asepsis • Florence Nightingale – May 12, 1820 in Florence, Italy
 SUSHURUTU – record of function and  Crimean War
responsibility of nurses  Lady with a lamp
VI. ANCIENT GREECE  St. Thomas School of Nursing
 Hippocrates – “Father of Scientific Medicine”  Mother of modern nursing
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 FUNDAMENTALS OF NURSING
 Notes: on nursing/ on hospital
 Environmental Theory (first theorist)
• Lilian Wald
 Founder of the Public Health Nursing
Page 18 THEORIES AND THEORIST
|2 • Linda Richards
 1st graduate as a nurse in US
 Initiated the use of white uniforms
 Use of Nurse’s Notes and Doctor’s Order
• Mary Mahoney
 1st African American Nurse
• Lavinia Dock
 Active in Protest
 Women has privilege to VOTE
• Margaret Higgins Sanger
 Founder of the Planned Parenthood (Family Planning)
CONTEMPORARY PERIOD
 World War II up to the present
 Scientific and Technological Advancement
 Computer, Sophisticated Equipment, Disposable
Supplies
 Own Nursing Law (RA 9173)
ROLES AND RESPONSIBILITIES OF NURSES
• CAREGIVER – providing care
• COUNSELOR – supporting emotionally
• CHANGE AGENT – modification of lifestyle
• CLIENT’S ADVOCATE – protects client’s right
• CASE MANAGER – collaborates with other member
• MANAGER – Planning, Organizing, Delegation,
Controlling
• TEACHER – health promotion and teaching
• LEADER – attaining goals and objectives
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GLADYS BAUTISTA JAIME 2010
• RESEARCHER – development of profession
1) FLORENCE NIGHTINGALE
 “ENVIRONMENTAL THEORY”
 Cleanliness, Light, Air, Water, Diet, Warm, Noise Free,
Drainage
2) LYDIA HALL
 “CORE, CARE and CURE”
 Core – person (therapeutic use of self/communication)
 Care – body (bed bath, oral care, hygiene)
 Cure – disease (medication, IV Therapy)
3) VIRGINIA HENDERSON
 “14 Basic Human Needs”
 Breath normally, Eat and Drink, Eliminate, Move and
Maintain Posture, Sleep and Rest, Dress and Undress,
Maintain Body Temperature, Keep Clean, Avoid
Danger, Communicate, Worship, Work, Play and Learn
4) HILDEGARD PEPLAU
 “Psycho dynamic Theory”
 4 Phases of Nurse Patient Relationship
• Orientation – problem identification
• Identification – feeling of belongingness, trust,
Setting GOALS
• Exploitation – use all resources to resolve
problem, IMPLEMENTATION
• Resolution – goals met, TERMINATION Phase
5) DOROTHEA OREM
 “Self-care Deficit”
• Whole Compensatory – 100% nurse
• Partially Compensatory – 50-50 nurse-patient
 FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010
• Supportive-Educative – discharge planning and • STRUCTURAL INTEGRITY – physical boundaries of
health teaching human should be intact (skin and mucus
membrane)

Page
|3 6) MARTHA ROGERS
 “Science of Unitary Human Beings” 12) BETTY NEUMAN
 Man is a unified whole – inter-related parts  “Health Care System Model”
 Origins of Stressors
7) IMOGENE KING • INTRA – within the person/inside
 “Goal Attainment Model” • INTER – between friends and family
 Transaction (Communication Skills) • EXTRA – outside the person

8) DOROTHY JOHNSON 13) SISTER CALLISTA ROY

 “Behavioral Model”  “Adaptation Model”
 7 SUBSYSTEMS  Process of Adaptation
• AGGRESSIVE – self-protective behavior • INPUT – stressor
• AFFILIATE – security seeking behavior • CONTROL – manage physically and emotionally
• ACHIEVEMENT – master of oneself • OUTPUT – outcome and result
• DEPENDENCY – nurturance seeking • FEEDBACK – how it affects the next input
• ELIMINATIVE – moving out of wastes
• INGESTIVE – taking-in nutrients 14) PATRICIA BENNER
• SEX – procreation and satisfaction  “Stages of Expertise”
• NOVICE – bounded with rules and standards, no
9) FAYE GLENN ABDELLAH experience
 “21 Nursing Problems” • ADVANCE BEGINNER – demonstrate marginally
 Interrogative = ? acceptable procedure, real experiences
• COMPETENT – 2-3yrs. experience, consciously
10) MADELIENE LEININGER plan the care
 “Transcultural Theory” • PROFICIENT – 3-5yrs. Experience, perceive
 Beliefs and Practice = Respect situation as a whole rather than in parts,
HOLISTIC VIEW
11) MYRA LEVINE • EXPERT – highly fluid and flexible
 “Conservational Model”
• ENERGY – Input (Food, O2, Water) = Output = 15) ROSEMARIE RIZZO PARSE
Energy  “Human Becoming Theory”
• PERSONAL INTEGRITY – self-worth/ self-identity
• SOCIAL INTEGRITY – interpersonal needs 16) IDA JEAN ORLANDO
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 FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010
 “Dynamic Nurse Patient Relationship” • Basic Metabolic Rate • Conduction
• Activity • Radiation
17) JEAN WATSON • Thyroxin Output • Convection
 “Caring Model” • Epinephrine/Nor- • Evaporation
Page Epinephrine
|4 18) ERNESTINE WIEDENBACH • Fever
 “Helping Art of Clinical Nursing”

SMITH’S MODEL OF HEALTH

Healthy Illness
Clinical Model Signs/Symptoms X 
Adaptation Model Adapt  X
Role Duties  X THERMOMETER
Performance ROUTE ADVANTAGE NSG.CONSIDERATI N°
Eudemonistic Self-  X ON VALUES
Model actualization RECTAL Most accurate 0.5-1.5 inches 37-38.1
Most reliable 1-2 minutes
STAGES OF EXPERTISE AXILLARY Safest Pat dry before use 35.8-37
• SYMPTOM EXPERIENCE – subjective Non-invasive 5-9 minutes
• ASSUMPTION OF SICK ROLE – accept illness and seek ORAL Most 30min rest before 36.5-
advice convenient 2-3 minutes 37.5
• MEDICAL CARE CONTACT – seek advice from Most
professionals, validation and explanation of disease accessible
• DEPENDENCY ROLE – healthcare, passive communication TYMPANIC Very fast Prevent puncture of 36.8-
• REHABILITATION – going back to the pre-illness stage, TM 37.9
RECOVERY Within seconds

NURSING PROCESS: Cleaning – Before Use: bulb to stem

• ASSESSMENT After Use: stem to bulb
Vital Signs: TEMPERATURE
Pyrexia – more than normal temperature
HYPOTHALAMUS Hyperpyrexia – more than 41°C

DETERMINED BY METABOLISM TYPES OF FEVER

• INTERMITTENT – fluctuation of temperature bet. normal
BALANCED BETWEEN HEAT PRODUCTION AND HEAT LOSS and abnormal
• REMITTENT – fluctuation of temperature but all above
HEAT PRODUCTION HEAT LOSS normal
• RELAPSING – fever with 1-2 days of normal temperature
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 FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010
• CONSTANT – minimal fluctuation, consistently high KUSSMAUL’S – deep rapid labored breathing
BIOT’S – very shallow with apnea
PULSE
Sounds:
Page Autonomic Nervous System STRIDOR – harsh, shrill sound on inspiration
|5 - Laryngeal obstruction
Pulse Sites: STRETOR – snoring sound on expiration
Temporal, Carotid, Apical, Brachial, Radial, Femoral, - Obstructed or narrowed airway
Popliteal, Posterior Tibia, Dorsalis Pedis WHEEZE – squeaky musical sound on expiration
- Narrow or constricted bronchus
PULSE RATE: BUBBLING – gurgling sound, air passing through secretions
1 month – 80-180 - Heard both on inspiration and expiration
1 year – 80-140
2 years – 80-130
6 years – 80-120 Volumes:
Adult – 60-100 TIDAL VOLUME – inhalation and exhalation
PULSE FORCE INSPIRATORY RESERVED VOLUME – maximum air that can be
3 – Full Bounding inhaled after normal breathing
2 – Normal EXPIRATORY RESERVED VOLUME - maximum air that can be
1 – Weak Thready Pulse exhaled after normal breathing
0 – No Pulse RESIDUAL VOLUME – remaining in the lungs
TOTAL LUNG CAPACITY – (T I E R)
PULSE Pressure – (Systole-Diastole=PP) N°= 30-40mmHg
PULSE Deficit – (Apical-Peripheral Pulse) CHEST INDRAWING – retraction
• Suprasternal – above the clavicle
RESPIRATION • Subcostal – below the breast bone
• Medulla • Intercostal – between the ribs
• PONS – Pneumotaxics Center (rhythmic)
- Apneustic Center (deep prolonged respiration) BLOOD PRESSURE
- Aortic and Carotid Bodies Normal Value: Systole = 100-140
Diastole = 60-90
Rate:
APNEA – cessation of breathing Nursing Consideration:
ORTHOPNEA – inability to breathe except in upright • Rested = 30minutes
EUPNEA – normal breathing • Position: at the level of heart and supported
TACHYPNEA – increased respiratory rate - Above = false low
BRADYPNEA – decreased respiratory rate - Below = false high
• Palpatory BP (+30mmHg)
Rhythm: • Bell – low pitch sound (Korotkoff)
CHEYNE’S STOKE – very deep to very shallow then apnea
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 FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010
• BP Cuff – Too narrow = false high Wheal – irregular shape, insect bite
- Too wide = false low • Vesicle - <.5cm (early chicken pox)
• Inflate 2-3mmHg at a time – Too slow = false high Bullae - >.5cm (blister, sign of herpes)
- Too fast = false low Pustule- pus
Page • Meniscus – lower, at the level of eye to prevent ERROR OF
|6 PARALLAX HAIR
• Popliteal Pulse – 10-40mmHg higher than the brachial • Thickness/Thinness – normal = thick
artery • Infection and Infestation
• Amount of Hair
• Texture of Hair
• Growth of Hair

NAILS
• Normal Angle = 160° angle
PHYSICAL EXAMINATION • Flat = 180°angle – indication of early clubbing
- Long term lack of oxygen
Skin, Hair, Nails  color and lesion • Capillary Refill Test – Blanch Test
- Pedia = >2seconds
Pale – Pallor - IMCI = more than 3seconds
Blue – Cyanosis - Funda = 4seconds
Yellow – Jaundice
Red – Erythema EYES
Virtiligo – Patches or hypopigmented skin
• Darken the room (dilate)
• Pupils – PERRLA
Lesion:
FLAT – non palpable • Size – 3-7mm
• Macule <1cm • Miosis – constricted
- Patch >1cm • Mydriasis – dilated
CIRCUMSIDE – elevated form by solid mass • Anisocona – unequal
(papule, plaque, nodule, tumor) • Visual Acuity – Snellen’s Chart
C/E – formed by free fluid - Normal = 20/20
Loose of Skin Surface - 20/200 = legal blindness
- Erosion (epidermis, without scar) • Myopia – near = concave
- Ulcer (epidermis, dermis, subcutaneous with scar) • Hyperopia – far = convex
- Fissures (linear crack with sharp edges) • Presbyopia – loss of elasticity of lens caused by aging
• Papule - <1cm (warts, acne) • Astigmatism – uneven curvature of the cornea
Plaque – coalescence of papule (psoriasis)
Nodule – 0.5-2cm (squamous and carcinoma) EARS
Tumor - >2cm • 4 years old – up and back
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 FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010
• 3 years old above – up and back • 24hours urine specimen
• 3 years old below – down and back - First void discard
• WEBER’S TEST – bone conduction, lateralization of sounds - Collect with same container
- Bad Bone Conduction = conductive hearing loss • Catheterization
Page - Good = sensory neural hearing loss - Do’s: clamp below the cord (30-60mins)
|7• RINNE’S TEST – conductive hearing loss - Sterile syringe inserted diagonally (self-sealing)
- Don’ts: do not collect from bag
THORAX • Acetic Acid Test – protein
• Shape – oval, elliptical (adult), equal or cylindrical (infant) - Do not heat could explode
• Spinal Alignment - (+) cloudiness of solution
• Sound – percussion • BENEDICT’S TEST – glucose
ABDOMEN • Result – Blue (-)
• Palpation – void first - Green (+)
• Dorsal Recumbent – supine with knees flexed to relaxed - Yellow (++)
abdominal muscle - Orange (+++)
- Red (++++)
• Warm hands during palpation – rub
• Slow approach
STOOL
• Indusperpal – prevent the distortion of abdominal sounds
• Routine fecalysis
- 1inch or 2.5cm/tsp
LABORATORY EXAMS
- 15-30ml liquid stool (diarrhea)
• URINE – routine urinalysis
• Guiac Stool Exam
- 24hour urine specimen
- Occult blood exam
- Catheterization
- Don’t give dark color foods (red meat, Iron
• STOOL – routine fecalysis Supplement)
- Guiac Stool Exam - Avoid turnips and radishes
• SPUTUM – AFB • False Positive for 3days
- Blood specimen
• False Negative – vit.C 250mg/day for 3days
URINE
SPINAL ALIGNMENT
• Routine urinalysis
• Lordosis – lumbar region is affected
- First thing in the morning
• Kyphosis – thoracic region is affected
- First voided (collect)
- Best position when assessing: standing straight
- First flow is discarded (midstream catch)
- Perineal Care first • Scoliosis – lateral deviation of spine
- Send to laboratory (ideal: add preservatives as - Best position: bending forward in 90°angle
protocol of agency)
SOUNDS
• Collect – 30-50ml
• Bronchial – high pitch sound; hear over the trachea
• Culture and Sensitivity – 5-10ml
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• Bronchovesicular – moderate pitch sound; hear over main • Lubricant
bronchi - Nasopharyngeal – water soluble lubricant (KY Jelly)
• Vesicular – low pitch sound; heard over the lung fields - Oropharyngeal – sterile water
• Use diaphragm for high pitch sound • TIME – 5-10seconds (15sec. maximum) with 20sec.
Page interval
| 8 PERCUSSION - 30 seconds for hyper oxygenation
• Dull – liver and heart • TECHNIQUE – Never apply suction during the insertion
• Flat – bones and muscles - Apply only during withdrawal; intermittent
• Resonance – normal lung sound suctioning (on&off)
• Hyper resonance - hyper inflated lung • SIZES
• Tympany – stomach - Adult = 18-12 French
- Children = 10-8 French
• Thorax – Normal Resonance
- Infant = 8-5 French
- If dull; solidation of lung tissue
OXYGENATION
- Patient with Pneumonia, Emphysema and Asthma
• Support combustion
ACID FAST BACILLI - No smoking
- No faulty electrical devices
• Early AM collection
- No friction
• No toothbrush, mouthwash and food
- No wool fabrics
• Plain water only
• Emergency: nurse can give 2-3liters/min. (independent)
• Carbon dioxide – major stimuli for respiration
BLOOD SPECIMEN
TYPES CONCENTRATION LITERS PER
• FASTING – BUN = triglyceride
MINUTE
- CREATININE = serum lipid amylase
Nasal Cannula 24-45 2-6
- indicative for kidney function
Simple Face Mask 40-60 5-8
• NON-FASTING – CBC, Hemoglobin, Hematocrit, Serum
Partial 60-90 6-10
Electrolytes, Clotting Studies
Rebreather 95-100 10-15
Non Rebreather 24-40-50 4-10
BASIC NURSING SKILLS
Venturi Mask
SUCTIONING
• POSITION – Conscious: semi-fowlers CATHETERIZATION
- Unconscious: Side-lying or lateral to prevent
• Straight catheterization – common
aspiration
• Indwelling – 5-10ml, inflate balloon, sterile balloon
• PRESSURE
• SIZES
AGE WALT PORTABLE
- Male: 18-16 French
Adult 120-100mmHg 15-10
- Female: 14-12 French
Child 110-95mmHg 10-5
Infant 95-50mmHg 5-2 • LENGTH
- Male: 6-9 inches
• LENGTH – nose to earlobe (13cm or 5inches)
- Female: 3-4 inches
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 FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010
• POSITION - Infant: 12 French
- Male: supine with legs slightly abducted • LENGTH
- Female: dorsal recumbent with knees flexed - Lubricate: 2 inches or 5cm
• LUBRICANT – water soluble lubricant - Insert: 3 inches or 7cm
Page • LOCATION • POSITION
|9 - Male- tip of glands penis - A: left lateral position to follow the contour
- Female: urethral meatus between clitoris and - C: dorsal recumbent
vagina
• ANCHOR MEDICATIONS
- Male: lower abdomen • Traditional Five Rights:
- Female: inner aspect of thigh - Right Drug
- Right Dose
- Right Time
- Right Patient
NASOGASTRIC TUBE (NGT) - Right Route
• For feeding - Gavage 60mg = 1gram 1tsp = 5ml/cc
• For irrigation – Lavage 1gram = 15 grains 1tbs = 3tsp = 15-30ml
• Decompression – preparation for surgery 1ml = 15gtts 1 cup = 240ml
• POSITION – Feeding: high-fowler’s for 30minutes • DRUGS
• LENGTH – Nose  Earlobe Xiphoid (50cm or 20inches) - 3x check the label:
- Before removing from shelves
• PLACEMENTS – Air: aseptosyringe/stethoscope
- After removing from container
LUQwhooshing sound
- Before returning to the drawer or shelves
- Aspirate: color = greenish or yellowish
• DOSE – Desired Dose/Stock on Hand X Dilution
- pH: Acid = <6
- Lithmus Paper: Blue to Red • PATIENT – check for ID band (safest)
- X-Ray: most effective • TIME
• RESIDUAL VOLUME – 50ml withhold the fluid (12inches) - AC = before meals
- PC = after meals
ENEMA - PRN = as needed
RETENTION COMPARISON NON-RETENTION - STAT = immediately
- BID = twice a day
Oil, Carminative SOLUTION Plain NSS, Soap
12 inches HEIGHT Suds • ROUTE
1-3 hours TIME 18 inches - Oral and Sublingual – easy absorbed thru
105-110°F TEMPERATURE 5-10 minutes bloodstream
115-125°F - Less expensive, most convenient, safest
o Disadvantage – remain under the tongue, if
• SIZES
swallowed notify the physician. Dissolved by
- Adult: 32-22 French
gastric juice
- Children: 18-14 French
o Cause staining of teeth
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 FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010
o Contraindicated with Nausea and Vomiting Vaccine (Mantoux test)
- TOPICAL – dermatologic Tuberculin Test
- Only applied at the thin layer Gauge: 25, 26, 27
- Patch (Nitroglycerin Patch) – clean, hairless, Length: 3/8, 5/8, ½
Page proximal surface Degree: 10-15
| 10 - OPTALMIC – Sitting Position or Lying o SUBCUTANEOUS
- OINTMENT – clean, inner to outer canntus Sites: outer upper arm
- Instill at the lower canntus – 2drops, wait for 5mins Abdominal (insulin)
to absorb Anterior Thigh
- Prevent the systemic effect – press nasolacrimal Ventro Gluteal
and close eyes Dorso Gluteal
- OTIC – side-lying; use cotton tip applicator for Indications: Insulin, Vaccine, Heparin
cleaning Gauge: 25, 26, 27
- Instill: allow to flow to side; to change the temp. of Length: 3/8, 5/8, ½
meds to body temp.; absorption for 5minutes Degree: 0-90 (obese); 45 (thin and average)
- INHALATION o INTRAMUSCULAR
- Position: semi-fowler’s / high fowler’s (for full lung Ventro Gluteal – best site for adult
expansion) Position: Prone
- Instill: nebulizer – 1-2inches away from the mouth Location: Greater Trochanter
Metered dose inhaler – hold breath for Dorso Gluteal – contraindicated for 3years
10seconds; wait for another minute before giving below
another dose Position: Prone
Bronchodilator – with multiple medications Location: Lateral superior, upper outer
Steroid Inhalation – oral hygiene; cause oral fungal quadrant
infection Vastus Lateralis – best site for infant
- VAGINAL – vaginal suppository, vaginal duche Position: Sitting or Lying
- Position: dorsal recumbent, remain free for 5- Location: middle third anterior lateral aspect
10minutes of thigh
- During irrigation – BL with hips higher than the Rectus Femoris – same with vastus lateralis (NT
shoulders LATERAL)
- RECTAL – left lateral position/ Sim’s Position, right Deltoid – 0.5-1.5ml
leg flexed Position: Sitting
- Insert until something has grabbed it away – Location: Acromian Process 2-3 finger
20mins absorption breaths below
- PARENTERAL Gauge: 20, 21, 22, 23
o INTRADERMAL Length: 1, 1 ½, 2
Sites: inner lower arm (skin test) Degree: 90
Upper chest and back
Beneath the scapula - Z-TRACK Technique
Indications: Check for allergy - Used for parenteral IRON preparations
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 FUNDAMENTALS OF NURSING GLADYS BAUTISTA JAIME 2010
- Retract the skin, inject slowly, hold retraction of the
skin until needle is withdrawn, do not massage
- Principles: Use separate needles for aspiration and
injection of medication, Introduce air into the vial
Page before aspirating, Introduce needle in quick twist
| 11
INTRAVENOUS THERAPHY
• TYPES OF SOLUTION
- ISOTONIC – plain NSS(green) , LR(dark blue) ,
D5W(red)
- HYPOTONIC – lower concentration; D.45/D.33 (light
blue)
- HYPERTONIC – higher concentration; D5LR(pink),
D5NSS(yellow)
• GAUGE
- 16 – biggest (gray)
- 18 – blood transfusion (green)
- 20 (pink)
- 22 (blue)
- 24 – pedia (yellow)
• Points to remember in IVT
- Place in the non-dominant hand, distal side
(metacarpal)
- Select: large vein, easily palpable and naturally
splinted by bone
- Avoid highly visible, areas of flexion, damage by
previous use and surgically compromised
• Nursing Consideration
- Air Embolism (5ml of air) – prime to remove air
- Change IV site and tubing every 72hours, bottle
every 24hours regardless how many cc is
remaining
- Regulate every 15-30 minutes

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