FUNDAMENTALS OF NURSING

Man
 Forms the foundation of Nursing

Four Components or Attributes of Man

 Capacity to think on an Abstract Level
 Establish a family
 Establish a territory
 Ability to use verbal symbols as language

Concept:
 Animals form a family by instinct
 Via hormonal scents

Nursing Concepts of Man

Biopsychosocial Spiritual Being
 By Sister Calista Roy
 Man interacts with the environment

Open System
 By Martha Rogers
 Man interacts with the environment
 Exchanges matter with energy
 Exchanges energy with environment

Unified Whole
 By Martha Rogers
 Man is composed of certain parts
 Total of those parts is more than the sum of all parts
 This is because man has attributes

Vital Reparative Process

 By Florence Nightingale
 Man is passive in influencing the nurse or the environment

Man is a whole. Man is complete

 By Virginia Henderson
 Man has fourteen (14) fundamental needs

Human Needs
 Needs are physiologic and psychologic
 Both these needs must be met in order to maintain well-being.

1
Key Concept:
 Basic Human Needs are equivalent to COMMON NEEDS

Characteristics of Human Needs

 Universal
 Interrelated
 One need is related to another need
 May be stimulated by internal or external factors
 May be deferred (but not indefinitely)

Maslow’s Hierarchy of Needs

Why do we study this?

 In order to prioritize nursing actions

1. Physiologic needs
 Food, maintenance of homeostasis
2. Safety and security
3. Love and belongingness
4. Self-Esteem
 Feeling good about one’s self
 Two factors affecting Self-esteem
o Yourself
 Sense of adequacy
 Accomplishment
o Others
 Appreciation
 Recognition
 Admiration
 Belongingness
5. Self-Actualization
 Able to fulfill needs and ambitions
 Maximizing one’s full potential
6. Aesthetics
 Beauty

Two Additional Needs by Maslow

 Need to know
 Need to understand

Richard Kalish
 Man needs stimulation
 Needs to explore
o Sex

2
 o Activity
o Novelty
 Stimulator
 Desire to come up with something of your own

Characteristics of Self-Actualized Persons

 Judges people correctly
 Superior perception
 Decisive
o Capable of making decisions
 Clear notion as to what is right and wrong
 Open to new ideas
o Not adopts new ideas
o Not one track mind
 Highly creative and flexible
 Does not need fame
 Problem-centered rather than self-centered

Concept:
 Self-Actualization is very difficult to attain
 It is impossible to attain
 New needs come after getting one need

Illness
 Highly subjective feeling of being sick or ill

Two types of Illness:

Acute Illness
 Sudden in onset (most of the time, but not always)
 Less than six (6) months

Chronic Illness
 Gradual in onset (most of the time, but not always)
 Types of Chronic Illness
o Exacerbation
 Period characterized by active signs and symptoms of the
illness
o Remission
 Periods where no signs and symptoms are present

Disease
 Objective pathologic process

Concepts:

3
  Illness without disease is possible
 Disease without illness is possible
 Illness may or may not be related to a disease
 One can have a disease without necessarily feeling ill

Deviance
 Any behavior that goes against social norms
 Shortens life span
 Results to disrupted family and community

Concept:
 Deviant behavior can be considered a disease

Rationale:
 Because it also shortens the life span like a disease

Example:
 Alcoholism
o A disease rather than a social problem

Wellness
 Feeling of being well

Definitions of Health

World Health Organization

 Health is the complete physical, mental, social (totality) well-being and not
merely the absence of disease or infirmity
 A high-level wellness!

Claude Barnard
 Ability to maintain internal milieu

Walter Cannon
 Ability to maintain homeostasis
 A dynamic equilibrium
 A state of balance of the internal environment while external environment
is changing

Florence Nightingale
 Health is using one’s power to the fullest
 Being well
 Can be maintained by manipulating the environment

4
Virginia Henderson
 Viewed in terms of ability to perform the fourteen (14) fundamental needs
or components of nursing care UNAIDED

Martha Rogers
 Positive health symbolizes wellness
 Health is a value term defined by a certain culture

Sister Calista Roy

 A state and process of being and becoming an INTEGRATED PERSON

Dorothea Orem
 Characterized by soundness and wholeness of DEVELOPED HUMAN
STRUCTURES and FUNCTIONS

Imogene King
 A dynamic state in the life cycle (contrasted with illness)
 Illness is interference in the life cycle

Betty Neuman
 Wellness is that all parts and subparts are in harmony with each other and
the whole system

Dorothy Johnson
 Elusive dynamic state influenced by biologic, psychologic and social
factors

Models of Health and Illness

Health-Illness Continuum
Dunn’s High Level Wellness and Grid Model
 X-axis is HEALTH
 Y-axis is environment
Quadrant 1
 High-level wellness in favorable environment
Quadrant 2
 Protected poor health in favorable environment
Quadrant 3
 Poor health in unfavorable environment
Quadrant 4
 Emergent high-level wellness in unfavorable environment

Health Belief Model

 By Rosentock
 Based on a motivational theory

5
  It assumed that good health is an objective common to all people
 Consider perceptions (influences individuals motivation toward results)
o Perceived susceptibility
o Perceived seriousness
o Perceived threat
 Likelihood of Action influenced by:
o Perceived benefit out of the action
o Perceived barriers

Smith’s Four Levels of Health

1. Clinical Model
 Man is viewed as a Physiologic Being
 If there are no signs and symptoms of a disease, then you are healthy
 Against WHO definition of health
 This is the NARROWEST concept of health
2. Role Performance Model
 As long as you are able to perform SOCIETAL functions and ROLES you
are healthy
3. Adaptive Model
 Health is viewed in terms of capacity to ADAPT.
 Therefore, goal of treatment is to restore capacity to adapt.
 Failure to adapt is disease
4. Eudaemonistic Model
 This is the BROADEST concept of health
 Because health is viewed in terms of Actualization

Leavell and Clark’s Agent, Host, Environment Model

 Also known as the Ecologic Model
 Expands to the MULTI-CAUSATION of a DISEASE
 Definitions of a disease as to its cause is expanded to a multi-causation of
a disease (i.e. cancer is a multi-factorial disease)
 Triad is composed of the agent, host and susceptible host
 Based on the interplay of three components of the model

Concept of Health and Illness

Stress
 By Hans Selye
 Is a non-specific response of the body to any demand placed upon it.
 General Adaptation Syndrome (GAS)
 Local Adaptation Syndrome (LAS)

6
General Adaptation Syndrome
Involves two (2) body systems:
 Nervous System
 Endocrine System

Nervous System involves:

 Sympathetic Nervous System
 Parasympathetic Nervous system

Endocrine System involves:

 Adrenal Glands

The Adrenal Gland is composed of:

 Adrenal Medulla
 Adrenal Cortex

Adrenal Medulla releases Adrenalins or Fight or Flight Hormones:

 Epinephrine
 Norepinephrine

Effects of Adrenalins
 Increases Cardiac Rate
 Response to increased metabolic rate and oxygen demand
 Increases Respiratory Rate
 Response to increased metabolic rate and oxygen demand
 Bronchodilation
 Vasoconstriction
 Increased Peripheral Resistance
 Increased Cardiac Workload
 Increased Blood Pressure
 Decreased Renal Perfusion
 Decreased Renal Output
 Pale, Cool, Clammy Skin

Adrenal Gland is composed of:

1. Adrenal Medulla
 Releases adrenalins
2. Adrenal Cortex
 Releases the following:
 Mineralocorticoids
o Aldosterone
 Glucocorticoids
 Cortisol
o A potent vasoconstrictor

7
Mineralocorticoids
 Increased Aldosterone levels
 Increases sodium retention and water retention
 Increases circulating blood volume
 Increases cardiac workload (due to vasoconstriction)

Glucocorticoids
 Increased hyperglycemia (transient)
 Increased glycogenolysis
 Increased neogenesis
 Increases blood sugar
 Increases osmotic pressure
 Increases fluid retention (glucose is a colloid which attracts water and
adheres to it)
 Increases cardiac workload

Concept:
Complications of Stress:
 Cerebrovascular Attack
 Increased Diabetic Ketoacidosis (if patient is diabetic)
 Hypertension leading to cardiac arrest

Local Adaptation Syndrome

 Also known as non-specific inflammatory response
 Bradykinin
o Activates inflammatory response
o Activates histamine
 Histamine
o Activates the following:
 Prostaglandin
 Serotonin

Concept:
 Bradykinin, Histamine, Prostaglandin, and Serotonin all increase swelling

Key Concept!
 Hans Selye
o Author of Physiologic Response to Stress

Lazarus
 Stress is a transaction
 Stress resulted from interaction of man with his environment and
fellowman

8
  Therefore, Lazarus describes the SOCIAL ASPECT OF STRESS
 Also an adopted PHYSIOLOGIC RESPONSE

Key Concept!
 The most comprehensive concept of stress is the stress concept of
LAZARUS as it combines Physiologic and Social aspects of stress.

Statements about Stress

 Stress is NOT a nervous energy
 Man, whenever he encounters stress, tends to adopt
 Are you going around all stress? ANSWER IS NO!!! because stress is not
always to be avoided and stress is not always undesirable
 Stress may lead to another stress
 A single stress does not lead to a disease

Concepts:
 Adaptation to stress comprises of adjustments made in order to cope with
a stressor

 Man is holistic in his adaptation to stress

 It involves the totality of man:
o Physiologic
o Psychologic
o Social

Illness Behavior and Stages of Illness

Illness Behavior
 Pertains to any activity undertaken by a person who feels ill in order to
 Define his state of health
 Discover a suitable remedy

IGUN – Eleven stages of Illness and Health-seeking Behaviors

1. Symptom Experience
 Client realizes there is a problem
 Client responds emotionally
2. Self-medication / Self-treatment (if not effective)
3. Communication to others
4. Assessment of symptoms
 Purpose is to verify the veracity of the complaint
5. Sick-Role Assumption
6. Concern Stage
7. Efficacy of treatment
 Assess sources of treatment
 Assess potential effectiveness of treatment

9
8. Selection of Treatment Stage
 Availability
 Cost of Treatment
9. Treatment Proper
10. Assessment of Effectiveness of Treatment
 May go back to stage 7 (Efficacy of Treatment) if treatment is not effective
 May go to next stage if treatment is effective
11. Recovery and Rehabilitation

Compliance
 Adherence to professional’s advice

Factors Affecting Compliance

 Client motivation
 Degree of required change in lifestyle
 Perceived severity of health problem
 Difficulty of understanding instructions
 Belief about the effectiveness of the therapy
 Nature of the therapy itself
o Adverse effects
o Cost
 Cultural influences
 Degree of satisfaction with the relationship with health care providers

Suggested Nursing Actions in case of Non-compliance

 Assess the reasons
 Correct the misconception
 Demonstrate a caring attitude
 Encourage and provide positive reinforcement
o Focusing on the positive rather than on the negative
o Focus on things patient can still do and not on what the patient can
no longer do
 Establish a therapeutic relationship of freedom and mutual responsibility
o Make patient realize he is also responsible for his recovery
o He is a partner with the health care team
o He is an active participant

Guidelines to Enhance Compliance

 Be sure patient understand procedure by giving information
 Make sure patient is capable of performing activity
o Set realistic goals
 Ensure that he is a WILLING participant
o Look for buying signals
 Looking at wound

10
  Looking at materials needed

Definitions of Nursing:
American Nurses Association
 Nursing is the diagnosis and treatment of human responses to illness (to
actual and potential health problems)

Canadian Nurses Association

 The same definition plus…
 … includes the supervision of functions and services in collaboration with
others to promote health

Florence Nightingale
 Nursing is the act of utilizing the ENVIRONMENT for the following
purposes:
o Recovery
o Reparative process

Virginia Henderson
 The unique function of the nurse is to assist individuals, sick or well, with
the activities towards health that he would do unaided, if with strength and
knowledge. If that is not possible, towards a PEACEFUL DEATH

Martha Rogers
 Nursing is a HUMANISTIC SCIENCE dedicated to compassionate
concern for the promotion of health, prevention of illness and rehabilitation
of the sick

Sister Calista Roy

 Nursing is a THEORETICAL SYSTEM OF KNOWLEDGE that prescribes
analysis and action related to the care of the sick or ill
 It is a set of knowledge

Dorothea Orem
 Nursing is a helping service to any individual who is sick
 It comprises of wholly dependent or partly dependent care when the
person is unable to do so.
 Defines nursing in terms of a NEED!

Imogene King
 Nursing is a helping profession that assists a person (same with
Henderson) towards a DIGNIFIED DEATH

Betty Neuman

11
  Nursing is a profession that is concerned with INTRAPERSONAL,
INTERPERSONAL, and EXTRAPERSONAL VARIABLES affecting a
person’s response to stressors

Dorothy Johnson
 Nursing is an EXTERNAL REGULATORY FORCE that regulates the
ACTION or BEHAVIOR of a person when such behavior constitutes a
threat, in order to preserve his organization

 Example:
o In a COPD patient who remains a smoker, the nurse who
encourages the patient not to smoke, serves as an external
regulatory force

Faye Abdella
 Nursing is a service to individuals, families… and therefore, to society
 Conceptualized nursing as an ART and SCIENCE of MOLDING THE
INTELLECT, ATTITUDE and SKILLS of the nurse
 Nursing in terms of providing education

Hildegard Peplau
 Nursing is the INTERPERSONAL process of THERAPEUTIC
INTERACTION between the nurse and the patient.

NURSING THEORIES

Concept:
 First Nursing School – Florence Nightingale

1. Florence Nightingale
 Environmental Nursing Theory

2. Dorothy Johnson
 Behavioral Systems Model
 Seven Subsystems
o Attachment and Affiliative
o Dependency
o Ingestive
o Eliminative
o Sexual Achievement
o Aggressive

3. Virginia Henderson
 Fourteen (14) Fundamental Needs focusing on PHYSIOLOGIC SOCIAL
RECREATION

12
4. Faye Abdella
 Problem Solving Approach to Twenty-One (21) Nursing Problems
 Focus is on PROPER IDENTIFICATION of the problem
 Particularly about the proper nursing diagnosis

5. Marjorie Gordon
 Proposed the Human Functional Health Patterns used as a systematic
framework for data collection
 Focus is on Eleven (11) Health Patterns
 Advantage to the nurse:
o It enables the nurse to determine the client’s response as functional
or dysfunctional
 Eleven Functional Health Patterns
o Health perception
o Nutritional / Metabolic
o Elimination
o Activity and Exercise Pattern
o Cognitive Perceptual Pattern
o Role Relationship Pattern
o Sexuality / Reproductive
o Coping-Stress-Tolerance
o Value Belief Patterns

6. Imogene King
 Goal Attainment Theory
 Patient has three (3) interacting systems:
o Individuals / Personal systems
o Group systems / Interpersonal systems fraternity
o Social systems

7. Madeleine Lehninger
 Transcultural Nursing Theory / Model
 Nursing is a HUMANISTIC and SCIENTIFIC mode of helping through
CULTURE-SPECIFIC PROCESS

8. Myra Levine
 Four (4) Conservation Principles of Nursing
 1. Conservation of Energy
o Example: complete bed rest without bathroom privileges
 2. Conservation of Structural Integrity
o Example: turn patient from side to side every two hours to avoid
bed sores
 3. Conservation of Personal Integrity

13
 o Example: maintain patient’s privacy
 4. Conservation of Social Integrity
o Example: maintenance of patient’s relationships

9. Betty Neuman
 Health Care Systems Model
 The concern of nursing is to PREVENT STRESS INVASION

10. Dorothea Orem

 Self-care and Self-care Deficit Theory
 Three (3) Nursing Systems based on Art of Care of Patient Needs
 1. Partial Compensatory
o Patient performs some of nursing care needs
 2. Wholly Compensatory or Total Compensatory
o For paralyzed patients, for ICU patients
 3. Supportive-Educative
o For up and about patient

11. Hildegard Peplau

 Interpersonal Model
 Four (4) Phases of Nurse-Patient Interaction
 1. Orientation
o Nurse and patient test the role each one assumes
o Prepares patient for termination
o Patient identifies areas of difficulty
 2. Identification Phase
o Patient identifies with the personnel who can satisfy his needs
 3. Exploitation Phase
o Nurse maximizes all the resources to benefit the patient
 4. Resolution Phase or Termination Phase
o Occurs when patient’s needs have been met

Concepts:
 Various settings for application of:
o Pre-Interaction Phase
 In psychiatric setting, this consists of gathering data
o Pre-Entry Phase
 In community health nursing, this consists of a courtesy call
12. Martha Rogers
 Science of Unitary Human Beings
 Man is composed of energy fields, which are in constant interaction with
the environment

Concept:

14
  The most reliable method of identification is the Energy Field. This is
better than the fingerprints as a person’s energy field is absolutely unique!

13. Sister Calista Roy

 Adaptation Model
 Man is a BIOPSYCHOSOCIAL BEING
 Four (4) modes of Adaptation
o Physiologic Mode
 Compatible with Hans Selye
o Self Consent
o Role Function
o Interdependence

14. Lydia Hall

 CARE, CORE, CURE
 Care
o Comfort measures given by the nurse to a patient
o Nurturance aspect of Nursing
 Core
o Therapeutic use of self
 Cure
o Activities in relation to doctors’ orders
o Dependent orders

15. Jean Watson

 Human Caring Model
 Nursing involves the application of ART and HUMAN SCIENCE through
TRANSPERSONAL TRANSACTIONS in order to help the person achieve
mind, body and soul harmony

16. Rosemarie Rizzo Parse

 Theory of Human Becoming
 Emphasis is a FREE CHOICE (with personal meaning)
 Actions of patients may either be:
o Revealing or concealing
o Enabling or limiting
 Therefore, there is a consequence
o This pertains to behavior and action

17. Josephine Patterson and Loretta Zderad

 Humanistic Nursing Practice Theory
 Nursing is an EXISTENTIAL EXPERIENCE between the nurse and the
patient (nagkataon-nagkatagpo!)

15
  Nursing is a LIVE DIALOGUE between the patient who wants to be
nursed and the nurse who has the skill to nurse

18. Helen Tomlin, Evelyn Tomlyn and Mary Ann Swain

 Modeling and Remodeling Theory
 Focus is on the PERSON
 Emphasis is on the UNCONDITIONAL ACCEPTANCE of the PATIENT

19. Ann Boykin and Savina Schoenhofer

 Grand Theory of Nursing as Caring Theory
 Nursing is NOT BASED on a DEFICIT but rather it is an EGALITARIAN
MODE of helping
 This theory is against the theory of OREM
 Nursing is an obligation towards humanity, whether there is a need or
NOT!

20. Margaret Newman

 Health as Expanding Consciousness
 Humans are Unitary Human Beings
 The nurse is a NOT A GOAL-SETTER or an OUTCOME PREDICTOR,
rather is a PARTNER OF THE PATIENT

21. Joyce Travelbee

 Interpersonal Process Theory
 Nurse needs to go beyond nursing roles to establish therapeutic
relationship
 TRANSPERSONAL COMMUNICATION as the means to establish
therapeutic relationship
 This implies that the nurse should not be rigid in the nursing role

22. Ida Jean Orlando

 Dynamic Nurse-Patient Relationship Model
 There is movement, the relationship is not static
 If the patient’s condition improved, then the intervention is effective and
the patient moves on to new problems

23. Nola Pender

 Health Promotion Model
 Motivation to participate in health care activities is influenced by
COGNITIVE and PERCEPTUAL FACTORS, which are:
o Importance of health to the person
o Perceived control of health
o Self-efficiency
o Perceived health status

16
 o Definition of health
o Perceived barriers to action

24. Poppy Buchanan, Barker and Phil Barker

 Tidal Model (Psychiatric Nursing)
 Helping patients recall their own personal stories of DISTRESS is the
FIRST STEP in helping them regain control of their lives again!

25. Corbin and Strauss

 Trajectory Model
 The patient moves in a TRAJECTION of Eight (8) Phases
 Nurse needs to follow the patient along the eight phases of trajection:
 1. Pre-Trajectory Phase
o Patient shows no signs and symptoms of illness
o No sickness

 2. Trajectory Onset Phase

o Patient now has signs and symptoms of illness
 3. Crisis Phase
o Patient is unstable
o Patient is in a life-threatening situation
o Patient is critical
 4. Acute Phase
o Patient is in a state of active illness
 5. Stable Phase
o Patient’s illness is controlled
o Patient may still be in the hospital
 6. Unstable Phase
o Patient is on a critical period
o Signs and symptoms are present
o Patient is NOT in the hospital
o Patient is NOT under control
o Patient is OUT of the hospital
 7. Downward Phase
o Patient is in a deteriorating phase
 8. Death

26. Bonnie Weaver and Duldt Battey

 Humanistic Nursing Communication Theory
 Emphasis is on the interpersonal relationship between the nurse, the
patient, the peers and colleagues

17
27. McGill Model of Nursing
 Emphasis is to encourage and engage the patient and the family to
actively participate in learning about health

28. Kathryn Barnard

 Parent-Child Interaction Model (Pediatric Nursing)
 In order to produce a healthy person, the baby’s need should be
ADDRESSED AT ONCE!
 Application: Bonding

29. Alfred Adler

 The personality of an individual is affected by the BIRTH ORDER

30. Gladys Husted and James Husted

 Symphonological Bioethical Theory
 Symphono- means harmony and agreement
 Governed by ethical standards, which influence nursing actions.

LEVELS OF PREVENTION:

1. Primary Prevention
 Emphasis on:
o Generalized health promotion and specific protection
o Recipients are GENERALLY HEALTHY PEOPLE
 When given:
o Before onset of illness or before onset of disease
 Examples:
o Generalized health education
 Prevention of accidents
 Standards of nutrition
o Immunizations
 Specific preventions
o Risk Assessment for specific disease
o Family Planning Services and Marriage Counseling
o Environmental Sanitation
o Recreation and Housing

2. Secondary Prevention
 Emphasis placed on:
o Early detection / diagnosis
o Prompt treatment
o Health maintenance of persons already having health problems
o Prevention of complications
 When given:

18
 o During illness
 Examples:
o Screening survey
o Encouraging regular check-ups
o Complying with regular check-ups
o Teaching Breast-self-examination
o Teaching Testicular-self-examination

 Concept:
o Most effective method of teaching is DEMONSTRATION

 Additional Examples of Secondary Prevention

o Assessment of growth and development
o General nursing assessment and care at the hospital, community
and the home

3. Tertiary Prevention
 Emphasis placed on:
o Support of the client to achieve the following:
 Successful re-adaptation
 Optimal reconstitution
 Regain high-level wellness
 Therefore, the purpose is more of REHABILITATION
 When given:
o Begins after the illness or when a defect or disability is fixed or
irreversible
 Examples:
o Referring a client to support groups
o Teaching a diabetic client how to inject insulin

ROLES OF A NURSE

1. Caregiver / Care Provider

 To convey understanding and support
 Activities:
o Support and comfort measures (mothering aspect of nursing /
nurturance aspect of nursing)

2. Counselor
 Involves helping patient identify and avoid stressful and psychological
problems
 Focuses on:

19
 o Helping client establish capacity for successful interpersonal
relations
o Helping the patient develop new coping skills

Concept:
 Do not give advice!
o This is meant to facilitate decision-making on the part of the client
o This is observed so that the client would not develop
DEPENDENCY

3. Client Advocate
 Protects rights of patients
 Activity:
o Speaking on behalf of the patient

4. Change Agent
 Brings change or adjustments
 Nurse only influences a patient
 Nurse does not change the patient

5. Teacher
 Teaching
 Imparting of knowledge

6. Leader
 Application of interpersonal influence to bring out desired behavior
(leadership)

7. Manager
 Decision-making
 Planning
 Giving directions
 Monitoring operations
 Facilitating staff development
 Therefore, this is done on the supervisory level of organization

8. Researcher
 After graduation, nurse cannot yet be a researcher
 He can only be a researcher after he receives his Master of Arts in
Nursing (M.A.N) degree

TEACHING AND LEARNING STRATEGIES

Basic Guidelines
 Develop a well-defined objective

20
  Assess client’s readiness to learn
 Start with what the client is concerned about
 Assess and start with what the client already knows; proceed from the
known to the unknown
 Start with the simple proceeding to the complex
 Schedule a review of the content

Concept:
 Areas of Learning Domain
o Knowledge – cognitive
o Skills – motor
o Attitude – emotional

TEACHING STRATEGIES

1. Explanation and Description

 Address cognitive aspect of learning

2. One-to-one Discussion
 Addresses affective and cognitive learning

3. Answering Questions
 Cognitive

4. Demonstration
 Motor

5. Discovery
 Cognitive and Affective

Concept:
 Learning is more effective if the learner discovers the content for himself.
(That is, through experience!)

6. Group Discussion
 Affective and Cognitive
 Sharing feelings during group dynamics

7. Practice
 Motor

8.Printed and Audiovisual Material

9. Role-playing
 For pediatric and psychiatric nursing settings

21
10. Modeling
 What you say is what you do

11. Computer Assisted Learning Programs

 Online review

THE NURSING PROCESS

Concept:
 The Nursing Process was introduced by LYDIA HALL!

Definition:
 The Nursing Process is a systematic, organized, rational method of
planning and providing individualized, humanistic nursing care

Purposes of the Nursing Process:

 To identify health status
o Actual health problems
o Potential health problems
 To establish plans
 To deliver specific nursing care

Characteristics of Nursing Process (MEMORIZE THIS!!!)

1. Goal-oriented and client-centered
2. Cyclical (no absolute beginning and end), dynamic (moving) rather than
static
3. Plan of care organized according to client problems rather than nursing
goals
4. Basis of prioritizing nursing activities would be the problems and not the
goals
5. Follows a logical sequence
6. Universally applicable (to any type of patient)
7. Interpersonal and collaborative
 Work with patients and relatives
 Work with colleagues and other members of the health team
8. Adaptation of problem-solving techniques and principles
9. Problem-oriented, flexible, open to new information
10. Allows creativity of nurse and patient

BENEFITS DERIVED FROM THE NURSING PROCESS

Concepts:
 Both the nurse and the patient benefit from the nursing process
 Patient obtains greater benefit

22
  Remember:
 Nursing process is CLIENT-CENTERED or PATIENT-CENTERED and
NOT NURSE-CENTERED

Benefits from Nursing Process:

 Improves quality of care
 Ensures continuity and appropriate level of care
 Facilitates client participation through planning with patient
 Enables nurse to maximize resources
 Feedback allows nurse to evaluate care
 Serves as a framework for accountability through documentation
 Promotes a positive working atmosphere through collaboration
 Helps the nurse define roles to those outside the profession
 For job satisfaction
 Facilitates professional growth
 Avoidance of legal action
 Meeting standards of accredited hospitals

PARTS OR COMPONENTS OF THE NURSING PROCESS

ASSESSMENT PHASE OF THE NURSING PROCESS

Nursing Activities in the Assessment Phase

 Data collection
 Data Organization
 Data Validation
 Data Recording

IMPORTANT CONCEPT!
 No conclusion is developed in the assessment phase

Purposes of the Assessment Phase

 To create a data base of the client’s response to health and illness
 To determine the nursing care needs of the patient

Four (4) types of Assessment:

1. Initial Assessment
 When performed:
o At specified time after admission
 Where done:

23
 o Done at the ward
 Where Admitted:
o At the ward
 Purpose of Initial Assessment:
o To create a data base for problem identification
o For reference and future comparison

2. Focus Assessment or On-going Assessment

 When performed:
o Integrated throughout the nursing process
 Purpose of On-going Assessment:
o To identify problems overlooked earlier
o To determine the status of a health problem (i.e. hydration status
every fifteen minutes)

3. Emergency Assessment
 When done:
o During acute physiologic and psychologic crisis
 Where done:
o Emergency Room
o Comfort Room
o Anywhere!!!
o On site!!!
 Purpose of Emergency Assessment
o To identify life-threatening condition
 Framework or Principle in Emergency Assessment
o A – Airway
o B – Breathing
o C – Circulation
o Utilize either Maslow’s Hierarchy of Needs or ABC principle

4. Time-Lapsed Assessment
 When done:
o Several months after initial assessment
 Purpose of Time-Lapsed Assessment
o To compare current status of patient with base line data (initial
assessment)

ASSESSMENT PROCESS

Concepts:

24
  Data is equivalent to information

What is the initial output of the Assessment Phase?

 Data or Recorded Data
 Never validated data!!!

Types of Data:

1. Subjective or Covert Data

 Felt by the patient
 During the recording of data, this should be stated using the patient’s own
words
 These are the symptoms felt by the patient

2. Objective or Overt Data

 Capable of being observed by use of senses – sight, touch, smell, taste,
hearing
 These are the signs which are observable

Sources of Data:

1. Primary Source
 Patient himself except when:
o He is unconscious
o Patient is a baby
o Patient is insane

2. Secondary Source
 Patient’s record
 Health care members
 Related literature or journals
 Significant others (they become primary source when patient is
unconscious
 Family or relatives
 The person who brought the patient to the hospital

3. Environment of the Patient

 Example:
o Patient with diabetes mellitus exhibits acetone breath
 Assess for diabetic ketoacidosis

Methods of Data Collection

 Observing
 Interviewing
 Examining

25
1. Observing
 It should be deliberate
 Exert effort

Two (2) aspects of observation process:

 Noticing the stimuli
 Do an interpretation of the stimuli

2. Interviewing
Two (2) types of Interview:

Directive Type of Interview

 Structured
 Uses closed-ended questions calling for specific data
 When used:
o When you need to elicit specific data
o When there is little time available

Concept:
Characteristics of Closed-ended questions:
 Yes or No questions
 Asks when or asks for the time when event happened
 Asks how many
 Point with finger when asking to provide clarity
 Therefore, they call for highly specific answers

Non-Directive Type or Rapport-Building Interview

 Uses more open-ended questions
 Advantage is that it allows the patient to volunteer information

Types of Interview Questions:

1. Open-Ended Questions
 Questions not answerable by “yes” or “no”
 Questions that elicit information or explanation

2. Closed-Ended Questions
 Questions answerable by “yes” or “no”
 Leading Questions
 Phrasing of question suggests what answer the interviewer is expecting

3. Neutral Questions
 Phrasing allows patient to answer with least pressure
 Usually NOT addressed to patient personally (i.e. what is your opinion
about…)

26
  Raised as a general topic

Planning the Interview Setting

Concepts:
 Before the interview, determine what information you already know or
what information is available
 An interview is a planned conversation with a purpose

 An interview is a two-way process

 When is it done?
o When patient is available
o When patient is comfortable

 Recommended distance from the patient is three (3) to four (4) feet.

Stages of the Interview

1. Opening Stage
Key Concept!!!
 This is the most important part of the interview
Rationale
 What was said and done during the opening stage sets the tone all
throughout the interview

2. Body of the Interview

 Occurs when patient responds to questioning

3. Closing Stage
 How to close the interview:
o Summarizing Technique

Validation of Data
 Act of double-checking the data
 Purposes of Data Validation
o To ensure the:
 Correctness
 Completeness
 Accuracy
of the data

Guidelines in Validating Data

 Compare subjective and objective data
 Be familiar with word usage (particularly if the patient is a child)
 Reassess / double-check data which are extremely abnormal

27
  Be sure that your data contains CUES and not INFERENCES
 Be sure that your data is FREE OF BIASES
 Avoid jumping to conclusions

Data Recording
Concepts:
 Data Recording COMPLETES the Assessment Phase
 Initial Output of the Assessment Phase is DATA
 Final Output of the Assessment Phase is RECORDED DATA

DIAGNOSING PHASE OF THE NURSING PROCESS

Activities during the Diagnosing Phase:

 This involves sorting, clustering, analyzing and interpreting data

Concept:
 The final output in the Diagnosing Phase is a NURSING DIAGNOSIS!!!

Different Types of Nursing Diagnoses:

1. Actual Nursing Diagnosis
 Problem present at the time the statement was made

2. High-Risk Nursing Diagnosis

 A diagnosis that a patient is more vulnerable or susceptible compared with
others in the same situation

3. Possible Nursing Diagnosis

 There is an evidence of a health problem but the causes are NOT fully
understood

4. Wellness Nursing Diagnosis

 A positive statement
 Indicates a healthy response
 Examples:
o Potential for increased compliance related to increased level of
knowledge
o Potential for enhanced body image related to regular exercise
o Potential for effective coping related to adequate support systems

Domains of Nursing Diagnosis

Key Concept!
 It only includes health problems that a nurse is capable and licensed to
treat

Parts of a Nursing Diagnosis

28
1. Problem Statement
 Example:
o Fluid Volume Deficit
2. Presumed Etiology
 Example:
o …related to frequent loss of bowel movement
3. Defining Characteristics
 Example:
o …as manifested by decreased skin turgor

Advantages of Using Standardized Diagnostic Terminology

 Provides professional accountability and autonomy by defining and
describing the independent areas of practice
 Provides effective vehicle of communication
 Provides an organizing principle for meaningful research
 Facilitates continuity and individualized care

PLANNING PHASE OF THE NURSING PROCESS

Concept:
Planning means:
 Determining ahead of time
 Forecasting a course of action

Key Concept!!!
 For your plans to be effective, involve the patient and the family

IMPORTANT CONCEPT!!!
 Final output of the Planning Phase is a NURSING CARE PLAN or a
WRITTEN CARE PLAN

Types of Planning

1. Initial Planning
 Done by the nurse
 When done:
o At specified time upon or after admission of the patient

2. On-going Planning
 Who are involved:
o Done by all nurses who worked with the patient
o The patient himself
o The family
o But primarily, the NURSE
 Purposes of On-going Planning

29
 o To determine if the client’s health status has changed
o To decide which problems to focus on during the shift
o To set priorities for client care during the shift
o To coordinate the patient care and activities so that more than one
problem can be addressed at the same time

3. Discharge Planning
 Purpose of Discharge Planning
o To ensure continuity of care

Characteristics or the Planning Process

 S – Specific
 M – Measurable
 A – Attainable
 R – Realistic
 T – Time bound

Activities during Planning Process

 Set priorities
 Set goals
 Identify alternatives of nursing care
 Select nursing measures
 Write nursing orders (supervisors do this)
 Write the nursing care plan

Purposes of Goal-setting
 To set direction
 To provide a time span
 To have a criteria for evaluation
 To enable the nurse and the patient to determine whether the problem has
been resolved or not
 To help motivate the client and the patient by providing a sense of
accomplishment

Key Concept!!!
 For your goal to be useful during evaluation, it should be stated in
BEHAVIORAL TERMS

IMPLEMENTING PHASE OF THE NURSING PROCESS

Implementation
 Putting the care plan into action

Purpose of Implementation

30
  To carry out planned activities
 To help the client

Concept!!!
 The implementation phase ends upon recording of the care given and the
response of the patient to that procedure

Requirements for Implementation

 Adequate knowledge
 Technical Skills
 Communication skills
 Therapeutic use of self
 Right attitude as a requirement

Nursing Activities during the Implementation Phase

 Reassess the patient
o Rationale
 To determine if the procedure is still needed
 Determine the need for nursing assistance
 Implement the nursing strategies
 Communicate the procedure performed by documenting the procedure
 Understand orders
o Clarify / verify doctors’ orders
 Encourage patient to participate actively

Guidelines for Implementation of the Nursing Strategies

Key Concept!!!
 It should be based on scientific knowledge, research, professional
standards of practice (care)
o Rationale:
 This is done to ensure safe nursing care
 It should be adapted to the individual patient
 It should always be safe. Do not compromise
 It should be holistic
 It should be accompanied by support, comfort and teaching

EVALUATION PHASE OF THE NURSING PROCESS

Purpose of the Evaluation Phase

 To determine client’s progress
 To determine the effectiveness of the care plan

31
  To determine as to what extent the nursing goals have been met
Importance of doing an Evaluation
 It determines if the care plan will be:
o Continued
o Modified
o Discontinued

Activities during the Evaluation Phase

 Identify the OUTCOME CRITERIA to be used as measurement
 Gather information (data) relevant to the outcome criteria
 Compare outcome (data) with the criteria
 Assess the reasons for the outcome
 Revise the nursing care plan as needed

Types of Evaluation
1. On-going Evaluation
 When done:
o During or immediately after the intervention
 Importance:
o Allows the nurse to decide and make on-the-spot modification/s in
an intervention

2. Intermittent Evaluation
 When done:
o At a specified time
 Purpose:
o It shows the extent of progress of the patient
 Importance:
o Enables the nurse to correct deficiencies and modify the nursing
care plan

3.Terminal Evaluation
 When done:
o At or immediately before discharge
 Importance:
 States the status of a health problem at the time of discharge
 It determines whether the goals are:
o Met
o Partially met
o Unmet

32
DOCUMENTATION
 It is a written, formal document
 A record of client’s progress

Purposes of Documentation
 Planning Care
 Communication
 For legal documentation purposes
 For research
 For education
 Reimbursements
 For statistics, reporting, epidemiology
 Accreditation, licensing

Guidelines on Documentation
 Timing
o Document patient care as soon as possible
 Observe confidentiality
 Observe permanence
o Use non-erasable ink
o Do not use sign pen
 Signature
o Sign full name and append R.N.
 Accuracy
o Ensure that data is correct
o Avoid biases
o Avoid ambiguous terms
 Appropriateness
o Write only appropriate information
 Completeness
 Use standard terminology
 Brevity
o Make it concise yet meaningful
 Legal Awareness
o Cross out erroneous entry
o Write “Error”
o Countersign

TYPES OF RECORDS

Source Oriented Clinical Record

 Accumulation of chronological, variative notations that are difficult to follow
because they are not assembled into an orderly or scientific manner
 Classification of information is based on SOURCE

33
  Each person or department maintains a different section on chart

Components of a Source Oriented Clinical Record

 Admission Sheet
 Face Sheet
 Medical History and Physical Examination Sheet
 Diagnostic Findings Sheet
 TPR Graphic Sheet
 Doctor’s Treatment and Order Sheet
 Therapeutic Sheet

Problem Oriented Clinical Record

 Same as Problem Oriented Medical Record
 Entry of data is based on CLIENT’S PROBLEM
 Example:
o Problem No. 1: constipation
 Increase fluid intake: doctor
 Diatabs: pharmacist
 NPO:
 Includes observations about the patient
 Example:
o Radiologist’s notes are with doctor’s notes under one problem

Problem List
 Contains only ACTIVE problems (and relevant information about the
problem)
 No potential problems (these are contained only in the progress notes)

Four (4) Basic Components of Problem Oriented Clinical Record

1. Baseline Data
 All information gathered from a patient when he first entered the agency

2. Problem List

3. Initial list of orders or Care Plans

4. Progress Notes
 Includes:
o Nurses’ narrative notes (SOAPIE)
o Flow sheets
o Discharge Notes and Referral Summaries

Formats:

34
  SOAPIE – for revisions

COMMON METHODS OF COMMUNICATION AMONG NURSES

1. Referring
 To endorse patient’s special concern to a higher authority or a specialized
department or personnel

2. Confer
 Verifying information

3. Reporting
 Giving information to a concerned person

KARDEX
 Is the Kardex a part of the patient’s record?
 No, it is not!!!
 It is just a bulletin board

Purpose of the Kardex

 To make valuable information readily available
 Allergies are written in red ink
 It is a reminder
 It is not a record

Concept:
 A Nursing Care Plan is not a record

COMMUNICATION TECHNIQUES IN NURSING

Communication
 Exchange of ideas, information, feelings, data between two
communicators

Concept:
 Communication is the basic component of Human Relationships

Elements of Communication
1. Message
 Data
2. Sender
 Encoder
3. Receiver
 Decoder
4. Feedback

35
5. Context
 Setting
 Overall environment where the communication takes place

Modes of Communication
1. Verbal
 Oral
 Spoken
 Written communication
 Texted communication
 Cable communication
 Telex communication
 Facsimile communication

2. Non-verbal communication
 Facial expression
 Grimacing
 Posture
 Gait
 Adornment
 Make-up
 Gestures

Factors Affecting Communication

 Ability of the communicator
 Perceptions
 Proxemics
o Distances between communicators
 Intimate Distance
• Actual physical contact to 1.5 feet
 Personal Distance
• 1.5 feet to 4 feet
• 3 feet to 4 feet for interview
 Social Distance
• 4 feet to 12 feet
 Public Distance
• 12 feet and beyond
 Territoriality
o One person believes that the space and all the things in that space
belongs to him
o Do not enter abruptly; this may result in breach of privacy
 Roles and relationships

Therapeutic Communication in Nursing

36
  Using Silence
o Supplement with non-verbal communication
 Provide General Leads
o Examples:
 “…go on”
 “…tell me more”
 Open-ended questions
 Use Touch
o But assess the culture of the patient
o If the patient is a child, touch the patient on the top of the head
o If the patient is an elderly, touch the patient on the hand
o If the patient is of the same age level, touch the patient on the
shoulder
 Offering yourself
o For autistic child
 Stay nearby or stay beside the patient
 Presenting Reality
o Example:
 “You are in the hospital”
 Reflecting
o Example:
 “What do you think will make you happy”
o Never agree nor disagree
o Reflect it back or throw it back

Non-therapeutic Communication
 Stumbling blocks to effective communication
 Stereotyping
 Generalizing
 Agreeing and Disagreeing
 No confrontation
 No argument
 Being defensive
 Moralizing or Passing Judgment
 Giving Common Advise
 Examples:
 “If I were you…”
 “You should have done it…”

PROMOTING REST AND SLEEP

Circadian Rhythm
 A biological rhythm
 A biological clock

37
  Regulated from outside the person’s body

Types of Sleep
1. Rapid Eye Movement Sleep (REM sleep)
 Increased brain metabolism and activity
 Also called PARADOXICAL SLEEP
 Characterized by:
o Vivid dreams
o Easily recalled upon awakening

Concepts!
 REM sleep is NOT AS RESTFUL as NON-REM sleep
 However, REM sleep is NEEDED
 Dreaming is a psychological outlet of pent up emotions

Nursing Alert!
 Deprivation of REM sleep results to:
o Irritability
o Restlessness
o Poor concentration

2. Non-Rapid Eye Movement Sleep (Non-REM Sleep)

 Deep restful sleep
 Benefit is that it restores the body physically and psychologically
(especially for post-operative patients)

Concept!
 Deprivation of Non-REM sleep causes:
o Physical exhaustion
o Decreased resistance against infection

Wellness Teachings to Enhance or Promote Sleep

 Establish a regular routine
 Have adequate exercise at daytime
o Avoid stimulating activity by bedtime
 Avoid all types of stimulants
o Caffeine-containing foods
 Coffee
 Cocoa
 Chocolate
 Tea
 Cola
o Nicotine
o Alcohol

38
  Prolongs the REM stage of sleep
 It excites the patient like an anesthetic
 Not a stimulant
 Avoid shabu
 Use the bed mainly for sleep
 If unable to sleep, get up and pursue satisfying activity
 Drink something warm or hot (except stimulants)
o Milk contains L-tryptophan
o L-tryptophan is an amino acid with a natural sedative effect that
induces one to sleep
 Do something HOT!
o Twice-a-week masturbation is ideal
o Facilitates release of tension of the day
 Side-to-side turning every two hours with back tapping
 Support bedtime rituals
 Remove all music in order to sleep

PROMOTING NUTRITION

Proteins
 Macromolecules composed of
o Carbon
o Hydrogen
o Oxygen
o Nitrogen

Basic Body Needs:

 Carbohydrates
 Proteins
 Fats

Concepts:
 Glucose is a ready source of energy for metabolic processes

Carbohydrates
 When eaten are metabolized to glucose for energy
 Excess carbohydrates are converted to glycogen and stored in the liver
 Other excess carbohydrates go to the fat cells

Key Concept!
 During starvation, stored glycogen is converted to glucose via a process
called glycogenolysis

39
  If glycogen is used up, fat resources are converted to glucose via a
process called gluconeogenesis

Nursing Alert!
 Fat conversion to glucose produces waste products called KETONE
BODIES
 These give rise to metabolic acidosis as in Diabetic Ketoacidosis

Additional concepts!
 During starvation protein reserves are converted to glucose via process
called gluconeogenesis

Gluconeogenesis
 Production of glucose out of non-carbohydrate products

Lipoproteins
 Substances composed of fats and proteins

Types of Lipoproteins
1. High Density Lipoproteins (HDL)
 High-grade lipoprotein
 Good grade lipoprotein
 Good cholesterol
 Function of HDLs
o Transports the bad cholesterol from systemic circulation to the liver
for metabolism and eventual elimination

2. Low Density Lipoproteins (LDL)

 Low-grade lipoprotein
 Bad cholesterol
 Function of LDLs
 They clog the blood vessels

3. Very Low Density Lipoproteins (VLDL)

 Very bad cholesterol

Functions of Fats
 Insulation
 Heat Conservation
 Source of Energy

Proteins
Two (2) types in terms of needs of the body:
1. Essential Proteins
 Proteins that cannot be produced by the body itself

40
  To be sourced out from food eaten
 Animal protein is complete protein
 Plant protein is considered as incomplete protein

2. Non-essential Proteins
 Proteins that can be produced by the body

Functions of Protein
 Main element of our cells.
o Building blocks of the cells are proteins
 Resistance against infection
o Formation of Immunoglobulins (globular proteins)
 Maintenance of normal intravascular fluid volume
o Works with glucose and sodium
o Albumin
 Main protein of blood
 Acts as a colloid
 Attracts water around it

Concepts!!!
 If protein levels are decreased, sodium and glucose will not be enough to
hold plasma inside blood vessel resulting into edema

 In liver cirrhosis, hypoalbuminemia results to edema

VITAMINS

Two (2) types of Vitamins

 Fat Soluble Vitamins
 Water Soluble Vitamins

Fat Soluble Vitamins

1. Vitamin A
 Essential for normal vision
 For transmission of light stimulus via the optic nerve

2. Vitamin D
 Source is food
 Precursor is in the skin
 Sunlight is needed for Vitamin D to be converted to its active form
 Function:
o Influences calcium metabolism
o To metabolize calcium

41
Concept!
 Without Vitamin D, there would be decreased calcium levels

 Increased levels of Vitamin D leads to increased calcium levels

Vitamin E
 Anti-oxidant
 Promotes cell membrane integrity (like Vitamin C)
 Vitamin for the heart and skin
 Sources are meats and in vegetables
 Deficiency results to Vitamin E deficiency hemolytic anemia

Vitamin K
 Synthesis of clotting factors
 Synthesis of prothrombin

Concept!
 Decreased levels of Vitamin K leads to prothrombin deficiency

 Deficiency in prothrombin leads to bleeding

MICRONUTRIENTS
Ferrous sulfate (FeSO4)
 Forms:
o Tablet
o Liquid
o Injectable
 Oral (tablet and liquid forms)
o Take on an empty stomach
o If there is GI distress (i.e. diarrhea), take with food
o If GI distress subsides, take on an empty stomach
 Toxic effects:
o Constipation (first option)
 Oral Liquid Iron
o Use dropper and apply at the back of the tongue or use a straw

o Rationale:
 To avoid staining the teeth
 Health Teaching!!!
o To enhance iron absorption, advice taking orange juice
o Vitamin C in orange juice enhances iron absorption
o Do not take milk
o Milk inhibits absorption of iron

42
 o Too much fiber prevents absorption of iron
o Thus, do not take oats when taking iron.
 Injectable Iron
o Route is deep I.M.
o Use Z-track technique
o Gauge of Needle is at least 18
o Length of Needle is 1.5” to 2.0”
o Site of administration is the GLUTEAL MUSCLE ONLY!!!
o Rationale:
 To avoid staining the skin
 Concept:
o Use an airlock
o Place 0.5 ml of air in syringe so that medication would not leak into
the subcutaneous tissues
 Nursing Alert!
o Apply firm pressure for at least five (5) minutes after injection
 Do NOT massage

SPECIAL DIETS
1. Light Diet
 Given for post-operative patients
 Plainly cooked
 No spices
 Large amounts of FAT omitted
 Avoid bran and high fiber

2. Soft Diet
 For people with difficulty with swallowing and chewing
 Generally low residue diet
 Nursing Alert!
o Avoid the following:
 Nuts
 Seeds (tomato, guava, berry)
 Raw fruits and vegetables
 Fried Foods
 Whole grains and cereals

3. Pureed Diet
 Osteorized diet

4. Full Liquid Diet

 Foods that melt or liquefy at body temperature

43
5. Clear Liquid Diet
 Given to surgical patients
 Limited to:
o Water
o Coffee
o Tea
o Cola
o Clear stained broth
o Gelatin
o Hard candies
 Nursing Alert!
o Dairy products are avoided

6. High Fiber Diet

 For patients at risk for constipation

7. Candidiasis Diet
 Free of the following:
o Fruits
o Sugar
o Yeast
o Fermented foods

8. Low Residue Diet

 Reduced fiber
 To decrease GI irritation
 For patients with bowel inflammatory diseases:
o Chron’s disease
o Ulcerative colitis

Acid-Ash Diet
 To alkalinize urine
 To soothe an irritated bladder and urethra
 Give citrus fruits
 Give vegetables
 Exceptions are:
o Prune Juice
o Cranberry Juice
o Both produce ACIDIC URINE

Ash-Acid Diet
 Given to acidify urine
 To minimize or help control Urinary Tract Infections
 Give the following:

44
 o Protein
o Meat
o Poultry

ASSESSMENT OF NUTRITIONAL STATUS

Anthropometric Measurements

Skin Fold Test

 Derived from reserved fat of the body

Mid-upper arm Circumference Measurement

 Obtains the muscle mass of the body
 This reflects the protein reserves of the body
 Laboratory diagnostic procedure for albumin

SUPPORTING NUTRITION OF PATIENT: ENTERAL AND PARENTERAL

FEEDING

ENTERAL FEEDING
1. NASOGASTRIC TUBE FEEDING (NGT)
 Purpose of NGT insertion
o For gastric gavage and lavage
o For administration of food and medication
o To keep the stomach empty
o To prevent aspiration from regurgitation of gastric contents
o For gastric decompression
 How to Insert NGT
o Depth of Insertion
 Measure length from the tip of the nose to the ears to the tip
of the xiphoid process
 Insertion:
o Position the patient in semi-Fowler’s or Fowler’s position
o While inserting to NASOPHARYNX
 Position the head in a hyperextended manner
o When glottis, epiglottis are approached
 Flex the head
o Rationale:
 To prevent entry of the tube into the trachea
 Nursing Alert!
o Watch for signs and symptoms of RESPIRATORY DIFFICULTY
o If there are signs, WITHDRAW TUBE
o While inserting tube, observe for coughing or difficulty of breathing

45
  After inserting, ascertain proper placement on the stomach
 Concept!
o Most accurate method to test for proper placement of the NGT is
via X-RAY
 Other ways to test proper placement:
o 1. Let patient hum
 If positive for humming, tube is in the esophagus and
stomach
 If negative for humming, tube is in the trachea
 Nursing Alert!
o Small-bore tube allows patient to hum
o Therefore, this method is NOT RELIABLE
o 2. Determine the pH of the aspirate
 Use litmus paper
 Change of color from BLUE to RED indicates that the
aspirate is acidic and, therefore, from stomach contents
 Change of color from RED to BLUE indicates that the
aspirate is basic and, therefore, from lung contents
 IMPORTANT CONCEPTS!!!
o To insure safety of the patient prior to feeding, CHECK THE
FOLLOWING:
 Placement of the tube
• For patient safety
• To prevent LUNG aspiration of food
 Patency of the tube
• To insure successful introduction or administration of food
o 3. By auscultating the epigastric region while insufflating 50 ml of
air
 Hear gurgling sound
TUBE FEEDING
 Never try to submerge the free end of the NGT to water
o This is potentially dangerous
o If in trachea and submerging of free end to water coincides with
inspiration, it will suck the water and lead to pulmonary aspiration
 Position during feeding:
o Fowler’s Position
 Measure gastric residual volume
o Subtract this from total feeding to introduce
o If aspirate is greater than 50 ml for adult or 10 ml for infant, then
WITHHOLD FEEDING for 2 – 3 hours.
o Rationale:
 Patient is not yet ready for next feeding.
o If same occurs after 2 – 3 hours, NOTIFY DOCTOR.
 There is a problem with gastric emptying

46
  Watch out for COUGHING
o Leakage to trachea
 If with DIFFICULTY OF BREATHING
o Stop the procedure
 Flush with water after feeding to avoid clogging of the tube
 After the procedure
o Do not place the patient on bed before 30 minutes have lapsed
o Rationale:
 To prevent aspiration and regurgitation
 Average volume of feeding:
o 300 ml to 400 ml

TOTAL PARENTERAL NUTRITION

 Introduced directly to the bloodstream
 Tube is inserted via the:
o Subclavian vein
o Internal jugular vein of the neck
o External jugular vein of the neck
 Important Concept!!!
o Tube must reach two (2) centimeters before or above the RIGHT
ATRIUM
 Nursing Responsibilities:
o Watch out for signs and symptoms of embolism
 Care of Insertion Site
o Application of sterile dressing with anti-bacterial ointment as
ordered by doctor (prn)

GASTROSTOMY TUBE FEEDING (Enteral)

 No auscultation needed
 Assess for the patency of the tube
 Use water to do this

PROMOTING OXYGENATION

DEEP BREATHING
Two (2) types of Deep Breathing:
1. APICAL DEEP BREATHING
 Done to expand the upper portion of the lungs
 Let the patient place palms on the upper chest
 Concentrate on that area
 Take a slow deep breath at a count of 1,2,3
 Release it slowly through the nose or a pursed lip at a count of 4,5,6,7
 Therefore, expiration is longer than inspiration
 Rationale:

47
 o To prevent respiratory alkalosis
 Taught to patients who will undergo:
o Upper abdominal surgery
o Cholecystectomy
 Incision site on diaphragm
 Patient does not want to breathe
 Predisposed to hypostatic pneumonia

2. BASAL DEEP BREATHING

 Same procedure
 Area of concentration is the lower ribcage
 When to teach patient:
o Before surgery
o Before pain is present
 Rationale:
o If pain is already present, it would be difficult for patient to follow
 When done:
o Done q2 hours together with turning

COUGHING EXERCISES
 Purpose
o To expand the lungs
o To facilitate expectoration of secretions
 How often done:
o At least every two (2) hours
 Procedure
o Teach the patient to inhale and exhale
o Tell the patient to inhale and exhale a second time
o Tell the patient to inhale and cough out
 NURSING ALERT!!!
o Coughing is contraindicated in the following patients:
 With increased intracranial pressure (ICP)
 With increased intraoptical pressure (IOP)
 With cardiac arrhythmias (but are allowed to do deep
breathing)

Concepts!!!
 Deep Breathing and Coughing
o Purpose is to stimulate surfactant production
 Yawning and sneezing also stimulate surfactant production

OXYGEN INHALATION AND ADMINISTRATION

48
Practical Application Concept!
 When administering oxygen, be sure to open the valve of the oxygen tank
first.
 Be certain that the valve on the regulator is closed so that the flow meter
would not break!

Concept!
 Humidifier moistens the oxygen administered
 Purpose
o To avoid drying and irritation of the mucosal lining
o Also traps particulates from the tank
 Iron oxide may be present in the tank (iron plus oxygen
produces iron oxide or rust)

Concept!
 Fire Precaution
o Place ‘NO SMOKING’ sign at the door or at the head part of the
patient
 Tank and oxygen do not explode
 They merely support combustion

Other Concepts!
 Do not use volatile substances
 Acetone and alcohol can react with oxygen and lead to toxicity of patient
 Do not use oil based or grease on any part of the oxygen set
 Do not allow the patient to use an electric razor as sparks may trigger
combustion

Nursing Alert!
 Retrolental Fibroplasia occurs if there is excess oxygen administration in
infants. Excess oxygen leads to destruction of the retina and blindness

Modes of Administration
1. Low Flow Administration
 Utilizes nasal cannula or nasal prongs or nasal catheters
 Given to COPD patients

2. High Flow Administration

 Uses a venturi mask

NEBULIZATION
 With sodium chloride and salbutamol
 A physiologic solution
 Water liquefies secretions

49
  Sodium chloride stimulates coughing
 Salbutamol is a bronchodilator
 Purpose:
o For expectoration of secretions

Nursing Pre-therapy Assessment Prior to Nebulization

 Have baseline data of patient’s breath sounds
 Assess again after nebulization to assess effectiveness of the procedure

SPIROMETRY
 Purpose is to expand the lungs
 Done when inhaling
 Instruction to the patient:
o Inhale from the spirometer and NOT blow to the spirometer
 Procedure:
o Inhale – exhale
o Inhale – exhale fully
o Place mouthpiece between teeth
o Hold breath for four (4) seconds
o Then inhale, fully rising the ball
 Upon inhalation, the ball rises

CHEST PHYSIOTHERAPY
 This is a dependent procedure
 There are no absolute contraindications to this procedure
 Contraindicated for the following patients with:
o Pacemakers
o Lung abscess
o Hemoptysis
o Dangerous Arrhythmias
o Active PTB (which goes to the other lobe)
o Lung CA (malignancy goes to other lung)

Three components of Chest Physiotherapy

 Vibration
 Percussion
 Postural Drainage

Vibration
 Palms of your hand are placed on chest or back of patient giving quivering
motions
 Palms remain in contact with the chest or back
Percussion
 Use cupped hands

50
  Hands alternate in rising and coming into contact with chest or back of
patient

Postural Drainage
 Drain secretions by gravity
 Change positions
 IMPORTANT CONCEPT!!!
o Rule out contraindications before performing chest physiotherapy

Pre-therapy Assessment for Vibration and Percussion

 Assess breath sounds to know which lung fields have secretions
 Then assess again after procedure to check effectiveness of the
procedure.

Concepts!!!
 Vibration and percussion are done to mechanically dislodge secretions
 Nebulization is done to liquefy secretions
 Suctioning is done to clear secretions
 Postural Drainage is done to drain secretions using gravity

Postural Drainage
 When done:
o Before meals
o Two (2) hours after meals
 Before doing the procedure, the following baseline data are needed:
o Breath sounds
o Vital signs
o Continuous ECG monitoring
 During the procedure:
o Ensure the comfort of the patient
o Provide a kidney basin and tissue paper
 Nursing Alert!
o Watch out for signs of symptoms which may require stopping of the
procedure:
 Sudden dyspnea
 Cyanosis
 Extreme diaphoresis
 Sudden alteration of blood pressure, respiratory rate, pulse
rate
 Appearance of arrhythmias
 Hemoptysis
 General intolerance of the procedure

Important Concept!

51
  If any of the above occurs, STOP THE PROCEDURE and inform the
physician

Concepts!
 After the procedure assess the following:
o Breath sounds
o Vital signs
o Quantity and quality of sputum
o Overall response of the patient to the procedure
 Give oral hygiene
o Rationale:
 To eliminate phlegm from the mouth

Important Concept!!!
 Patients with cystic fibrosis benefit much from postural drainage

SUCTIONING
 Purpose is to seek out secretions

Concepts!!!
 Question:
o If you have only one (1) suction catheter, which will you suction
first, the nose or the mouth?
 Answer:
o If the patient is an infant or a newborn:
 Start on the mouth then proceed to the nose
 Rationale:
o If you start on the nose, you will trigger the sneezing reflex and this
would result into aspiration
 Answer:
o If the patient is an adult, suction the mouth first, then proceed to the
nose
 Rationale:
o This is done for aesthetic reasons

TYPES OF SUCTIONING
Type of Position of Depth Duration Interval Total
Suctioning the Patient with Time
while each
Suctioning Pass of

52
 Suction
Oropharyngeal
Suctioning

If patient is Fowler’s (high 10 – 15 Not more 20 – 30 Not

conscious or moderate); centimeters than 10 – seconds more
Head turned to 15 than 5
one side seconds minutes
(towards the
nurse)

If the patient is Place on one 10 – 15 Not more 20 – 30 Not

unconscious side (facing the centimeters than 10 – seconds more
nurse); 15 than 5
Tilt neck to seconds minutes
move head
slightly forward
towards the
basin to avoid
aspiration
during
suctioning
Nasopharyngeal
Suctioning

If the patient is Neck should be From tip of Not more 20 – 30 Not

conscious hyperextended; the nose to than 10 – seconds more
Fowler’s tip of the 15 than 5
position earlobe seconds minutes

If the patient is Flat on bed From tip of Not more 20 – 30 Not

unconscious with head the nose to than 10 – seconds more
turned to the the tip of 15 than 5
nurse the earlobe seconds minutes
Lateral position
may be
assumed

TYPES OF SUCTIONING
Type of Position of Depth Duration Interval Total
Suctioning the Patient with each Time
while Pass of
Suctioning Suction

53
Orotracheal
Suctioning

If patient is Low to Measure Not more 20 – 30 Not more

conscious semi- from mouth than 10 seconds than 5
fowler’s to mid- seconds minutes
position sternum

If the patient Flat on Measure Not more 20 – 30 Not more

is bed; from mouth than 10 seconds than 5
unconscious Suction to mid- seconds minutes
trachea sternum
through the
mouth
Nasotracheal
Suctioning

If the patient Low to From tip of Not more 20 – 30 Not more

is conscious semi- the nose to than 10 seconds than 5
fowler’s earlobe to seconds minutes
position dominating
side of
neck to the
thyroid
cartilage

If the patient Flat on From tip of Not more 20 – 30 Not more

is bed; the nose to than 10 – seconds than 5
unconscious Suction earlobe to 15 minutes
trachea dominating seconds
through the side of
nose neck to the
thyroid
cartilage

TYPES OF SUCTIONING

54
 Type of Position of Depth Duration Interval Total
Suctioning the Patient with Time
while each
Suctioning Pass of
Suction
Endotracheal Semi-Fowler’s 12.5 5 – 10 2 – 3 Not
Tube if not centimeters seconds minutes more
Suctioning contraindicated or 6 inches; than 5
Insert as minutes
far as it
goes until
you meet
resistance
or until
patient
coughs

Tracheostomy Semi-Fowler’s Insert as 5 – 10 2 – 3 Not

Tube if not far as it seconds minutes more
Suctioning contraindicated gets until than 5
you meet minutes
resistance
or until the
patient
coughs

55
Important Concepts!!!
 For Endotracheal Suctioning
o NO TUBE IS USED HERE
o This is suctioning of the trachea through the mouth or through the
nose
 Two (2) types of Endotracheal Suctioning
o Orotracheal Suctioning
 Oral approach
o Nasotracheal Suctioning
 Nasal approach

General Conditions for Suctioning

 For Endotracheal and Tracheostomy (Naso and Oral and Tube)
o Before suctioning, HYPEROXYGENATE the patient
o During intervals, HYPEROXYGENATE the patient
 For ET, Tracheostomy, ET Tube
o Nursing Alert!
 During insertion, if you encounter resistance, withdraw the
catheter about one centimeter (1 cm) before applying suction
o Rationale:
 To avoid trauma on the mucous membrane
o Do suctioning intermittently
o Suctioning should not be continuous
o Rotate the catheter (between the thumb and the index finger) as
you withdraw
o Apply suction only when you are ready to withdraw (i.e. keep finger
away from suction port if you are still not ready)

How to Hyperoxygenate the Patient

 Give two (2) to three (3) blows by ambubag
 Increase flow rate and concentration of oxygen
 Nursing Alert!
o If the patient has thick, tenacious secretions, DO NOT USE AN
AMBUBAG
o Use an OXYGEN INSUFFLATION SUCTION CATHETER
instead!!!
o This is a two-lumen catheter (one lumen brings oxygen to the
patient, the other lumen brings out secretions from the patient)
 In the event of encrustations, PERFORM TRACHEAL LAVAGE
o Instill 2.5 ml to 5.0 ml Normal Saline Solution for adults to liquefy
the mucous plug
o Instill 2.0 ml Normal Saline Solution for children to liquefy the
mucous plug

56
  Instill 0.5 ml to 1.0 ml Normal Saline Solution for infants to liquefy the
mucous plug

VITAL SIGNS

TEMPERATURE
 Oral
 Axillary
 Rectal

Oral Method
 Most convenient
 Most accessible
 Nursing Alert!
o Applicability is for children aged six (6) years and above
o Not applicable for children below six (6) years old
 Contraindicated in patients with:
o Oral surgery
o Mouth breathers
o History of convulsive seizures
o Unconscious
o Incoherent
o Irrational
o Mentally disrupted
o Insane
 Procedure
o Nothing Per Orem for about thirty (30) minutes before taking
temperature
o No food intake
o No drinks
o No smoking
o No chewing gum
o No whistling
o No gargling
 Rationale:
o Any of the above would alter the result
 Placement:
o Under the tongue, beside the frenulum (right or left)
 Total Time:
o Two (2) to three (3) minutes

Axillary Method
 Least realiable
 Safest method

57
  Nursing Alert!
o During application, be sure that axilla is dry
o Dry using a patting motion
 Nursing Alert!
o Do NOT RUB!!!
 Rationale:
o This increases heat due to friction
o Rubbing increases blood supply to the area
o Therefore, there will be increase in temperature reading
o Rubbing provides a false-positive elevation of temperature reading
 Duration:
o In adults – nine (9) minutes
o In children – five (5) minutes

Rectal Method
 Most reliable (except for tympanic thermometer)
 Most accurate (except for tympanic thermometer)
 Concept!
o If tympanic method is used using a tympanic thermometer, the
rectal method is only second most reliable and second most
accurate
 Disadvantage:
o Placement on a different site yields a different reading
o Therefore, ensure that the bulb of the rectal thermometer rests on
the mucous membrane
 Contraindications:
o Hemorrhoids
o Rectal Surgery
o Certain Cardiac ailments due to stimulation of the vagus nerve;
valsalva maneuver leads to arrhythmias
 Position of Patient when taking the reading:
o Sim’s left position
o Sim’s right position
o For Newborn, lift up ankles to keep buttocks up
o In Toddlers, set on prone position on adult’s lap
 Duration:
o Two (2) minutes

Conversion of Centigrade to Fahrenheit

 Centigrade = (5/9)F – 32
 Centigrade = (F/1.8) – 32

Conversion of Fahrenheit to Centigrade

 Fahrenheit = (9/5)C + 32

58
  Fahrenheit = (1.8)C + 32

Concepts!!!
 Peak body temperature occurs at 12NN to 3PM or 4PM
 Lowest body temperature occurs in the early morning hours of the day

FEVER
 Normally, the hypothalamus is able to adjust body temperatures between
37°C to 40°C
 But due to the presence of pyrogenic materials like the following:
o Pathogenic microorganisms
o Toxins
o Foreign substances
o Any substance capable of increasing body temperature
 Creates a deficiency of -3°C, making a person enter the FIRST STAGE
OF FEVER

First Stage of Fever

 Typical signs and symptoms indicate the body’s compliance mechanism to
increase and conserve heat:
o Chills
o Shivering
o Gooseflesh
 Contraction of arectores pilorum or pilo arecti muscles
o Vasoconstriction
 Decreases blood supply to the skin
 Pallid Skin
o Cyanotic nail beds
 Key Concept!!!
o Patient complains of feeling cold
o Sweating will stop because body will minimizes heat loss
 Also called:
o Onset Stage
o Chill Stage
o Cold Stage
 This stage is characterized by low febrile temperatures
 Nursing Management
o Key Concept
 Aim is to minimize heat loss
o Key Concept
 Do NOT apply TEPID SPONGE BATH because this would
make patient progress to SHOCK
 Provide additional clothing as necessary
 Provide additional blankets as necessary

59
  Provide something warm to drink
 These measures would result to a gradual increase in body temperature
 Question:
o When will you start application of TSB?
 Answer:
o If there is a 1°C to 2°C increase in body temperature

Second Stage of Fever

 Also called:
o Coarse Stage of Fever
o Peak Stage of Fever
 Key Concept!
o Patient does not feel hot or cold
o Skin is warm to touch
o Skin is flushed
o Fever blisters are present
 Herpetic lesions
o Absence of shivering
o Possible dehydration
 Important Concept!!!
o For every increase of temperature, there is a corresponding
increase in pulse rate
 Rationale:
o Increase in temperature results in an increase in pulse rate due to
increased metabolic rate
o Increased metabolic rate increases oxygen demand
o Due to increased oxygen demand of susceptible brain cells,
CONVULSIVE SEIZURES may occur. These may also be due to
irritation of nerve cells – FEBRILE CONVULSIONS
 Increased oxygen demand also leads to an increase in respiratory rate
 Patient complains of:
o Loss of appetite
o Myalgia or muscle pains due to increased catabolism
 Nursing Management
o Tepid Sponge Bath
o Cooling Bed Bath

Tepid Sponge Bath

 Temperature of water is 32°C
o This temperature is maintained throughout the procedure
 How to apply:
o Done by patting
 Rationale:
o To avoid friction, which increases temperature

60
  Important Concept!
o Do NOT use ALCOHOL when applying TSB
 Rationale:
o Alcohol dries the skin and leads to irritation
 Key Concept!
o TSB should not be done hurriedly
 Rationale:
o When done hurriedly, TSB will stimulate shivering
o Shivering would lead to increased muscle activity
o Increased muscle activity would lead to increased temperature

Cooling Bed Bath

 Water temperature will start at 32°C
 Procedure will go on with gradual decrease in water temperature until it
is maintained at 18°C
 Therefore, to achieve this drop in temperature, utilize ice
 Same procedure of application as in Tepid Sponge Bath
Types of Fever
1. Intermittent Fever
 A fever that is alternated at regular intervals by periods of normal and
subnormal temperature

2. Remittent Fever
 Fever alternated by wide range of fluctuations in temperature, all of
them are ABOVE NORMAL.
 Duration is within a 24-hour period

3. Relapsing Fever
 Short periods of febrile episodes alternated by one (1) to two (2) days
of normal temperature

4. Constant Fever
 Minimal fluctuations of temperature, all of which are ABOVE NORMAL

5. Staircase or Spiking Fever

 Common in patients with TYPHOID FEVER

PULSE ASSESSMENT

Concepts!
 If pulse is regular, count or monitor pulse for thirty (30) seconds and
multiply by two (2). This is legal!

 If pulse is irregular, count or monitor the pulse for one (1) FULL minute

61
Assessment of the Pulse Deficit
 This is the most accurate method
 Involves two nurses using one watch
 Starts at the same time
 Ends at the same time
 Comparison of results ensues
 Count is done for one (1) full minute

Scale in Pulse Assessment

 0 - Absent or cannot be felt
 1+ - Weak or thready
 2+ - Normal
 3+ - Grounding

BLOOD PRESURE

Systolic
 Produced by ventricular contraction
 Pressure on blood vessels during depolarization or ventricular contraction

Diastolic
 Pressure that remains in the walls of the blood vessels during relaxation or
repolarization or resting

Broadly two (2) types:

 Direct
o By insertion of a catheter
 Indirect Method
o Auscultatory method
o Palpatory method
o Flush Method

Auscultatory Method
 Uses Korotkoff sound
o A popping sound
o NOT the heart beat
o It is a phenomenon – an unknown phenomenon!

Determining Amount of Inflation

 Using auscultatory method
o Ask patient what is his last BP reading and then add 30 – 40 mmHg
from last systolic reading.
o Deflate gradually – rate is approximately 2 – 3 mmHg per second
 Alternative auscultatory method

62
 o Auscultate for the last sound as you go up. Then add 30 – 40
mmHg
o Then deflate

Tripartite Blood Pressure

 Done if patient is an adult.
 Example:
 140 mmHg systolic – first loudest sound
 100 mmHg 1st diastolic – muffling
 70 mmHg 2nd diastolic – last sound
o Therefore, the tripartite blood pressure is 140 / 100 / 70
 If there is no muffling, an example would be:
o 160 / no muffling / 110

Concepts!!!
 Take systolic on loudest sound if patient is an adult
 If patient is pediatric or up to ten (10) years old, take the first sound,
whether it is faint or loud
 If, for example, first sound is at 190 mmHg and there is silence up to 140
mmHg and then there is a sound at 130 mmHg down to 80 mmHg then…
 Use the PALPATORY METHOD in combination with the
AUSCULTATORY METHOD because there is an auscultatory gap

Repeat using:
 Auscultatory method
 Palpatory method

How to do the Palpatory Method

 Inflate
o Determine up to what point to inflate
o Palpate pulse
o If pulse is absent, add 30 – 40 mmHg
 Deflate
o First palpable pulse is true systolic pressure
 For diastolic pressure, proceed using the auscultatory method

Flush Method
 Represents the mean blood pressure
 Represents the average of the systolic and diastolic pressures
 When done:
o When you have a BP apparatus without a stethoscope
o Used for pediatric patients
 How done:
o Inflate up to the point where extremity becomes pale

63
 o Deflate slowly and look for a REBOUND FLUSH – when extremity
becomes red again
 This is the true reading!!
 Note that there is only ONE reading!!!

SKIN INTEGRITY
 Decubitus ulcers are caused by:
o Unrelieved, sustained pressure
o Localized ischemia
o Shearing force
o Pressure plus friction
 Predisposing Factors:
o Unconsciousness
o Incontinence
o Loss of Sensation
o Hypoproteinemia
 Decreased lean muscle mass
 Increase in fluid shifting leads to edema
 Dependent position is the skin attached to or facing the bed
o Emaciation

Stages of Decubitus Ulcer Formation

Stage 1
 Involves the epidermis
 Manifestation
o Non-blanchable erythema of INTACT SKIN
o This is the first heralding sign of decubitus ulceration

Stage 2
 Partial Thickness Skin Loss
 Involves epidermis and dermis
 Manifestation
o Blister formation
o Shallow craters
o Shallow abrasion and ulceration

Stage 3
Full Thickness Skin Loss Ulceration
 There is skin loss already
 Involves necrosis of the skin and subcutaneous tissues EXTENDING TO
but NOT THROUGH the underlying fascia

Stage 4

64
  Formations and manifestations of Stage 3 plus…
o Involvement of bones, supporting structures (tendons), joint
capsules
o Massive damage

Tools to Assess Risk of Ulceration

 Norton’s Pressure Area Risk Assessment Form
 Shannon’s Scoring System
 Branden Scale of Predicting Ulceration
 Waterlow Risk Assessment Cards
o Most important tool
o Most common tool
o Most often used tool

EDEMA
 Caused by shifting of fluid into the interstitial tissues

Management of Edema
1. Elevation of the edematous part
Nursing Alert!
 If edema is due to Congestive Heart Failure (Right Sided), NEVER
ELEVATE THE LOWER EXTREMITIES
Rationale:
 This increases the workload of the right side of the heart

Concept!
 If edema is due to prolonged standing, DO THE ELEVATION

2. Wear elastic stockings

3. Use warm compress alternated with cold compress

Rationale:
 Vasoconstriction and vasodilation causes re-circulation of fluid

Concept!
 This is contraindicated if there is inflammation

Assessment of Edema
Induration
 1+ - 1 cm induration
 2+ - 2 cm induration
 3+ - 3 cm induration
 4+ - 4 cm induration
 5+ - 5 cm induration

65
PAIN MANAGEMENT

Pain
 A noxious stimulation of actual or threatened / potential tissue damage

Categories of Pain according to Origin

 Cutaneous
o Skin
 Deep Somatic
o Tendons, ligaments
o Bones
o Blood Vessels
 Visceral Pain
o Organs of the body

Categories of Pain based on Cause

 Acute
o Due to trauma or surgery
o Persists for less than six (6) months
 Chronic Malignant Pain
o Related to cancer
o On and off
o Persists for more than six (6) months
 Chronic Non-malignant Pain
o Persists for more than six (6) months

Categories of Pain according to Where It Is Experienced

 Radiating Pain
o Felt on the source and is extending to nearby tissues
 Referred Pain
o Felt on other parts detached from the source
o Example:
o Pain on a lacerated liver may be felt on the right shoulder and not
on the right upper quadrant
 Intractable Pain
o Highly resistant to pain-relief methods
 Phantom Pain
o Pain that is felt on a MISSING BODY PART or a PART THAT IS
PARALYZED by SPINAL CORD INJURY.

Pain Threshold
 Amount of pain stimulation that is required in order to feel pain

Pain Tolerance

66
  Maximum amount of pain and duration that a person is willing to endure

Gate Control Theory

Concept!
 This is the most widely used theory in pain management

Concepts!
 At the dorsal horn of the spinal cord is a gate.
 This gate is called the SUBSTANCIA GELATINOSA
 A series of nerves pass through this gate
 Small diameter nerve fibers pass through the substancia gelatinosa
o Pain signals are carried to the spinal cord by the small diameter
nerve fibers
 Large diameter nerve fibers also pass through the substancia gelatinosa
o Large diameter nerve fibers close the gate – prevents the
transmission of impulses through the spinal cord
o Therefore, when LARGE DIAMETER NERVE FIBERS ARE
STIMULATED, THE GATE IS CLOSED
 Pain management operates on the principle of how to stimulate the Large
Diameter Nerve Fibers to close the gate.

Pain Management Strategies

Pharmacologic Methods
 Narcotics
 NSAIDs
 Adjuvants or Co-analgesics

Non-Pharmacologic Methods
 Physical Interventions
 Cognitive / Behavioral Interventions

Non-Pharmacologic Physical Interventions

1. Cutaneous Stimulation
 Massage
o Effleurage
o Soft massage
o Gentle stroking
 Petrissage
o Hard massage
o Large and quick pinches
o Also done by striking
 Application of Counter-Irritant
o Bengay

67
 o Menthol
o Omega Pain Killer
o Flax Seeds
o Poultices
 Heat and Cold Application
o Nursing Alert!
o Rebound Phenomenon
 When you apply heat (usually done for 20 minutes),
vasodilation is produced
 If heat is applied for more than 20 minutes, there is
vasoconstriction
 This is an inherent defense mechanism from burning of
tissues
 Cold Application
o Maximum vasoconstriction is reached when skin reaches 15°C
o If there is further drom in temperature, there is vasodilation (skin
becomes reddish)
o This is the inherent defense mechanism from being frozen
 Accupressure
o Pressure on certain points of the body
o Stimulates release of endorphins, which have natural analgesic
effects
o This started in Ancient China
 Accupuncture
o Insertion of long slender needles on certain chemical pathways
o Origin is also Ancient china
 Contralateral Stimulation
o Example: Injury on left side and massage is done on the right side
o Useful when patient cannot be accessed:
 For patients in a cast
 For patients with burns
 For patients with phantom pain

2. Immobilization
 Application of splints

3.Transcutaneous Electrical Nerve Stimulation

 Composed of electrodes
 Operated by battery
 Electrodes are applied on painful site or over the spinal cord

4.Administration of a Placebo
 Relieves pain because of its intent and not because of physical or
chemical properties

68
Cognitive or Behavioral Non-Pharmacologic Interventions
 Purpose:
o To alter pain perception
o To alter pain behavior
o To provide client with a greater sense of control over the pain

Specific Interventions
1.Distraction
 Purpose is to divert attention from pain
 Slow Rhythmic Breathing
o Stare at a certain object
o Take deep breath slowly
o Release or exhale slowly
o Concentrate on breathing
o Picture a peaceful scene
o Establish a rhythmic pattern

2.Massage and Slow Rhythmic Breathing

3.Rhythmic Singing and Tapping

 Key Concept!
o Faster beat music is more preferable

4.Guided Imagery
 Imagine that you are walking along a peaceful shore
 Eyes are closed and suggestions are given

5.Hypnosis
 The success of hypnosis depends on the ability of the patient to
concentrate and the capacity of the hypnotist to suggest
 Based on suggestion
 Progressive relaxation

URINARY ELIMINATION

Oliguria
 Renal output of less than 500 ml per day

Anuria
 Renal output of less than 100 ml per day

Retention
 Positive for distended bladder
 May also occur in the absence of bladder distention

69
Altered Urinary Elimination

Enuresis
 Common among pediatric patients
 Age 4 – 5 years old child has adequate bladder control
 Primary Enuresis
o Never had a dry period
 Secondary Enuresis
o Acquired enuresis
o At age 7, bladder control is present for at least one year
o Then, enuresis comes back
o Urinating could NOT be controlled again

Incontinence
 Involuntary passage of urine

Types of Incontinence

1.Functional Incontinence
 Involuntary passage
 Unpredictable time

2.Reflex Incontinence
 Occurs at somewhat predictable times when specific bladder volume is
reached
 No awareness of bladder filling
 No urge to void
 It may be related to neurologic impairment

3.Stress Incontinence
 Loss of urine is less than 50 ml occurring with increased intra-abdominal
pressure
o Occurs when laughing
o Occurs when sneezing
o Occurs when smiling
Total Incontinence
 Continuous flow of urine
 No bladder distention
 No bladder spasm
 No awareness of bladder filling

Urge Incontinence

70
  Urine flows as soon as a strong sense of feeling to void occurs
 Strong bladder spasm

Management of Incontinence

1.Kegel’s Exercises
 Also called:
o Pubococcygeal Muscle Exercises
o Pelvic Floor Muscle Exercises
 Applicable for:
o Functional Incontinence
o Stress Incontinence
 How done:
o Advise patient to stand with legs slightly apart
o Concentrate on perineum
o Draw perineum upward slowly
 Alternative way:
o When urinating, try to stop in the middle of flow or try to stop
diarrhea from flowing
o Advantage of Kegel’s Exercises
o Increases muscle tone of the pelvis
o Increases muscle control

2.Clean Intermittent Self Catheterization

 Applicable for Reflex Incontinence
 How done:
o Use a mirror for:
 Obese male patients
 Female patients
 Concept!
o Possible Board Question:
 Is your Clean Intermittent Self Catheterization procedure a
sterile procedure?
o Answer:
 No, it is just a clean procedure. Therefore, you can just
wash the catheter for the next use.

3.Crede’s Maneuver
 Application of a steady but gentle pressure on the supra-pubic region to
force urine out of the bladder
 Nursing Alert!
o Do not use if there is OBSTRUCTION (i.e. renal obstruction in the
form of renal stones)

71
 o This is done only for patients who are no longer expected to regain
control (Reflex incontinence and retention)

4.Prompted Voiding or Scheduled Toileting

 For Reflex Incontinence

5.Application of Adult Catheter and External Condom Catheter

 For elderly with Total Incontinence

6.Catheterization

MIDSTREAM CLEAN CATCH URINE SPECIMEN

How is this done?
 If patient is a Male…
o Clean the penis
o Do this from the meatus down to the shaft
o Let the patient urinate
o Discard the first or the initial urine
o Collect midstream urine
o Purpose is to attain sterile specimen for urine culture and sensitivity
testing
 If patient is a Female…
o Let patient wash genitals
o Dry the genitals
o Get to bed
 Place patient in semi-Fowler’s position when she is ready to void
 Clean and spread labia with two fingers
 Remain holding labia
 Then let patient urinate
 Let go of first flow
 Collect next flow

CATHETERIZATION

 Coude Catheter
o Elbowed catheter for Benign Prostatic Hypertrophy patients
 Robinson Catheter
o Straight catheter
 Multi-Lumen Retention Catheter
o Foley catheter
 One lumen is for inflation
 One lumen is for drainage of urine
 One lumen is for irrigation
 A three-way catheter

72
  Aspirate using syringe and needle
 This is made with a self-sealing rubber

Concepts!!!
 See to it that penis is perpendicular to body to straighten up the urethra to
bladder
 While inserting the catheter, ask the patient to breathe through the mouth
 Cleanse the penis before insertion
 Grasp penis firmly to avoid stimulating erections
 Where to tape catheter
o Tape it upward on the abdomen
 Rationale:
o To avoid scrotal excoriation
o Tape on the inner thigh (with penis sideways either on left or right
and follow the normal contour of the penis
 Length of Catheter
o 40 centimeters
 Depth of Insertion
o While inserting, the point at which urine starts to flow, insert further
by five (5) centimeters and then inflate the balloon – KOZIER
o Insert up to a the Y-point, retract after inflating (this method is more
prone to infection
 For females
o Insert at female Urethra
 Length of Catheter
o 22 centimeters
 Depth of Insertion
o Point at which urine starts to flow, insert further by five (5)
centimeter before inflating balloon

GIT – FECAL ELIMINATION

Wellness Teachings
 Fluid intake of at least 2,000 ml per day
 Regular exercise
 High fiber diet
 Avoid ignoring the urge to defecate
 Do not abuse laxatives

Concepts!
 For Flatulence
o Avoid carbonated drinks
o Do not use straw
o Avoid chewing gum

73
 o Avoid gas-forming foods:
 Camote
 Cabbage
 Cauliflower
 Onions

For Constipation:
 Increase fluid intake
 Prune juice
 Papaya
 Increase fiber in the diet
 Use METAMUCIL (natural fiber) instead of laxatives

Special Laboratory Procedures

1.Guiac Test
 To determine the presence of occult blood
 Concepts!!!
o Have a meat-less diet three (3) days before examination
o Withhold oral iron supplements
o Injectible iron is allowed
o Avoid any food that discolors the stool.

2.GI SERIES
Upper GI Series – Barium Swallow
 Nursing Considerations:
o Elimination of contrast medium
 How:
o Increase fluid intake
o Increase fiber in the diet
 Rationale:
o To offset the risk of constipation
o Inform patient that the color of the stool will be WHITE

Lower GI Series – Barium Enema

 Done at the radiology department
 Nursing Concern:
o Elimination of Barium
 How:
o Cleansing enema may be needed after barium enema

Different Types of Enema

1. Cleansing Enema

74
  Soap suds enema
 Alkaline solution
 Nursing Alert!
o Contraindicated in patients with liver cirrhosis and with increased
ammonia in the blood
 Rationale:
o Alkaline solution facilitates transfer of ammonia from the GI tract to
the bloodstream
 Therefore, use lemon juice or dilute vinegar instead!!!
 Nursing Alert!
o Also contraindicated in possible appendicitis or appendicitis
patients
 Rationale:
o Can lead to rupture of the appendix

2. Carminative Enema
 Used to expel out flatus
 Burned sugar
 Now commercially available

3. Oil Retention Enema

 Purpose:
o To lubricate the colon and to soften the feces
o Retention time is one (1) to three (3) hours

4. Retention Flow Enema

 Also called Harish Flush Enema
 Solution is continually administered until what comes out of the body is
clear.

Positions in Enema
 Cleansing Enema
 High Cleansing Enema
o Clean as much of the colon as possible
o On introduction, Sim’s Left position facilitates flow of enema to
sigmoid colon
o Then, assume Dorsal Recumbent position to facilitate flow of
enema to transverse colon
o Then, Right Side-Lying position to facilitate flow of enema to the
descending colon
 Low Cleansing Enema
o For cleaning of rectum and colon only

SEXUALITY

75
Human Sexual Response

Excitement / Physical Stimulation

 Erotic stimuli causes sexual stimulation
 Lasts for a few minutes to several hours

Types of Stimulation
Physical Stimulation
 Oral stimulation
o Fellatio
 Oral stimulation of the penis using the mouth
o Cunningulus
 Oral stimulation of the vagina
o Anningulus
 Oral stimulation of the anus
 In homosexual male, typhoid fever may be obtained from
anningulus
 Male and Female oral sex is called SOIXANTE NEUF

Physiological Sexual Stimulation

 Stimulation by:
o Smell
o Sight
o Hearing
o Fantasy
o Spoken words
o Mental imagery

During stimulation or Period of Excitement

 Males
o Erection of the penis
 Females
o Redness near the ear
o Nipples, breasts move up
o Fourchette retracts
o Clitoris becomes visible
o Increased vaginal secretion
o If female is unaroused, there is backpain as penis hits the cervix
 If the female is well-stimulated, the cervix rises

Plateau Stage
 Lasts thirty (30) seconds to three (3) minutes
 In males:

76
 o Scrotum rises upward
o Shaft of penis increases in length and width
 In females:
o Cervix rises
 In both sexes:
o There is increased muscle tone
o Myotonia

Orgasmic Phase or Orgasmic Stage

 Climax of sexual tension
 Peak of sexual experience
 Lasts three (3) to ten (10) seconds

Resolution Stage
 Key Concepts!
o Females have longer resolution phase
o Males have shorter resolution phase

PERIOPERATIVE NURSING

Stages of Perioperative Nursing

 Pre-operative Phase
 Intra-operative Phase
 Post-operative Phase

Pre-operative Phase
 Begins upon decision of patient to undergo the operation
 Ends when patient is placed on the operating table

Intra-operative Phase
 Begins when patient is placed on the operating table
 Ends when client is admitted to the Post-Anesthesia Care Unit or PACU

Post-operative Phase
 Begins upon admission to the PACU
 Ends upon the discharge of the patient

Skin Preparation
 Purpose:
o To reduce post-operative infection by:
 Removing soil and transient microbes
 Reducing microbial count to subpathological level in a short
period of time with minimal skin irritation.
 Concepts!

77
  Hair on the skin should not be shaved if it does not interfere with the
procedure
 If hair needs to be removed, the best method would be through the use of:
o Clippers
o Depilatory cream
 Shaving is NOT ADVISED. This is the last choice
 Where is shaving done?
o Not at the Operating Room!

TYPES OF WOUNDS

1. Clean Wound
 Uninfected
 No inflammation
 Respiratory, Alimentary and Urinary tracts are not entered

2. Clean Contaminated Wound

 A surgical wound
 No evidence of infection
 Respiratory, GI, Urinary tracts are entered

3. Contaminated Wound
 Involves large spillage of content from the GI, Urinary and Respiratory
tracts
 Positive for inflammation
 Positive for infection
 Dirty Infected Wound
 Old wounds
 Necrotic, gangrenous wound

Modes of Applying Gauze Dressing

1. Dry to Dry
 A wide mesh of cotton applied to the surface of the wound
 A second layer is applied over it

2. Wet to Dry
 Inner layer is saturated with NSS or anti-microbial agent
 On top is a moist absorbent material

3. Wet to Damp
 A variation of wet to dry

78
  It is removed before it is completely dried

4. Wet to Wet
 Inner layer is saturated with NSS or anti-microbial solution
 Second layer is a wide mesh
 It is kept moist with a wetting agent

79