FUNDAMENTALS OF NURSING

By: red

Nursing

-refers to the women trained to care for the sick

-act of utilizing the environment that will aid in his recovery (Nightingale)
-assist the individual sick or well in performing activities contributing to health or
its recovery that he can perform unaided if he had the necessary strength or
knowledge to help gain independence. (Henderson)
-Humanistic science (Orem)
-art and a science of caring
-client centered
-Holistic

CBQ

The definition of nursing according to ANA (American Nursing Association)

a. to assist clients sick or well in the performance of activities contributing
to health
b. Nursing is the diagnosis and treatment of human response to actual or
potential health problems
c. Nursing is an interpersonal process, whereby the nurse assist the
individual, family or community to prevent or cope with the experience
of illness.
d. Nursing is separate and distinct from medicine.

History

A. Period of Intuitive nursing

- Illness: caused by evil spirit
- Uses white magic, hypnosis, herbs and charms

B. Period of apprentice nursing

-care delivered by religious order:
St. Claire: Order of Saint Francis
St. Elizabeth of Hungary: Patroness of Nurses
St. Catherine of Siena: First lady with the lamp

C. Dark period of nursing

- women were considered less desirable members of the society

D. Period of educated nursing

- Establishment of first nursing school: St. Thomas Hospital in London
- Published books:
Notes on nursing; Notes on hospital
E. Period of Contemporary Nursing
-establishment of WHO
-constantly assuming the responsibilities of taking care of the patients which
were formerly the sole responsibility of the physician.

Roles of the Professional Nurse

1. Care provider- helping clients promote, restore and maintain dignity within
the holistic person.
 2. Communicator- central role of nurses. As the nurse identify the problems of
the client, the same is endorsed to other members of the health team.
3. Teacher/Educator- role that is involved in all nursing activities since
promotion is the primary concern.
4. Counselor-assuming role that helps client recognize and cope with
psychological and stressful social problems.
5. Client Advocate- Nurse intercedes for or works on behalf of the patient;
explains, interprets and defends the patient’s right.
6. Change agent- Nurses assist client to modify behavior. Also coping with
highly dynamic health care system, health technology and human system
itself.
7. Leader- Nurse influences others to work together towards a mutually
envisioned goal.
8. Manager/Coordinator- Nurse directly manages and coordinates care, delegates
nursing activities and evaluates performance of other nurses & support
workers.
9. Researcher- nurses identify needs and produce scientifically sound
intervention and management through final objective assessment.

NURSE AS AN ADVOCATE
…..BE PRANING
Participation of client in his own care ensured
Rights of client protected, supported
Autonomy of client is safeguarded
Needs of client communicated
Information related to his care
Nurture therapeutic alliance
Given options and choices for decisions

NURSING THEORIES/ CONCEPTUAL FRAMEWORK

A. FLORENCE Environmental Theory

NIGHTINGALE Environmental Factors:
-mother of modern nursing 1. pure air or fresh air
-a hero in Crimean war 2. pure water
referred to as the lady with the 3. efficient drainage
LAMP 4. cleanliness
5. light- direct sunlight

B. VIRGINIA HENDERSON 14 Basic Fundamental Needs

-define nursing : assist the 1. Breathing normally
individual sick or well in 2. Eating and drinking adequately
performing activities contributing to 3. Eliminating body waste
health or its recovery that he can 4. Moving and maintaining a desirable position
perform unaided if he had the 5. Sleeping and resting
necessary strength or knowledge to 6. Selecting suitable clothes
help gain independence. 7. Maintaining body temp within normal range
8. Keeping the body well groomed to protect the
integument
9. Avoiding dangers in the environment and
avoiding injuring others
10. Communicating with others in expressing
emotions, needs, fears or opinions
 11. Worshipping accordingly to ones faith
12. Working in such a way that one feels a sense of
accomplishment
13. playing in various forms of recreation
14. learning discovering or satisfying the curiosity
that leads to normal development and health using
available health facilities

C. FAYE ABDELLAH 21 Nursing Problems

-nursing is a comprehensive -hygiene, S E X, body mechanics, safety, O2,
service that is based on art and nutrition, elimination, F & E, response to disease
science and the use of nursing condition, maintenance of regulatory mechanism &
judgment. function, sensory function, (+, -) expression-feelings-
reaction, interrelatedness of emotions and illness,
communication, interpersonal relationship, personal
spiritual goal, therapeutic environment, self-
awareness, optimum possible goals, use of
community resources, social problems as influencing
factors.
D. DOROTHY JOHNSON Behavioral System Model
-nursing’s primary goal foster Seven subsystem of behaviors:
equilibrium within the individual 1. attachment-affiliative
2. ingestive
3. dependency
4. eliminative
5. sexual
6. achievement
7. aggressive
E. IMOGENE KING Goal Attainment Theory
-nursing is a process of action, 3 dynamic interacting system:
reaction and interaction. 1. Personal System
2. Interpersonal System
3. Social System
F. MADELEINE LEININGER Transcultural Nursing & Ethnonursing
-nursing is a learned humanistic -helps client through cultural values, beliefs and
and scientific profession which is practices to improve or maintain health
focused on human care phenomena.
G. MYRA LEVINE 4 Conservation Principles
1. Conservation of Energy
2. Conservation of Structural Integrity
3. Conservation of Personal Integrity
4. Conservation of Social Integrity
H. BETTY NEWMAN Health Care System Model
-concerned with variables affecting an individual
response to stess: INTRA, INTER, EXTRA
I. DOROTHEA OREM Self Care and Self Care Deficit Theory
-defines three steps of nursing Self care- is the performance or practice of
process as: dx, design and planning, activities that individuals initiate on their behalf to
production and management maintain life health and well-being.
Three Nursing System:
1. Wholly Compensatory
2. Partial Compensatory
3. Supportive Educative
J. HILDEGARD PEPLAU Interpersonal Model
-nursing is a healing art of 4 Phases of Nursing Interaction
human rel. between an ind. who is 1. Orientation
sick/in need of help and the nurse 2. Identification
3. Exploitation
 4. Resolution
K. MARTHA ROGERS Science of Unitary Human Beings
-art and science that is -human beings are more than and different from the
humanistic and humanitarian sum and all the body parts.

L. SISTER CALLISTA ROY ADAPTATION MODEL

-person as an adaptive system functions as a whole
through interdependence of its parts.
M. LYDIA HALL Three Interlocking Circles
CARE-nurturance
CORE-therapeutic use of self
CURE-focus on physicians order

CONCEPT OF MAN AND HIS BASIC HUMAN NEEDS

MAN- biopsychosocial and spiritual being who is in constant contact with the
environment.

Basic Human Needs

-Maslows Hierarchy of Human Needs
• Level 1: physiologic needs
• Level 2: safety and security needs
• Level 3: love and belonging needs
• Level 4: self-esteem needs
• Level 5: self-actualization needs

Characteristic of Basic Human Needs:

1. Needs are universal although some maybe moderated by cultural influences
2. Needs may be met in different ways
3. Needs maybe stimulated by external and internal forces
4. Priorities maybe altered
5. Needs maybe deferred
6. Needs are interrelated

CONCEPT OF HEALTH AND ILLNESS

Health- a state of complete physical, mental and social well being and not merely the
absence of disease or infirmary.

Wellness- an integrated method of functioning which is oriented toward maximizing the

potential of which the individual is capable.

MODELS:

1. JUDITH SMITH MODEL

a. Clinical Model- health is the absence of disease and illness is the
presence of disease or injury.
b. Role Performance Model- Health is the ability of the individual to fulfill
societal roles or work and illness occur when one can’t fulfill such role.
c. Adaptive Model- Health is creative process where an individual cope up
with the daily stressors. Illness is a result of failure in adaptation.
 d. Eudaemonistic model- health is a condition of self actualization or
realization of one’s potential. Illness is a condition that prevents self
actualization.

2. Health Illness Continuum Models

A. Dunn High Level Wellness Grid
- Health will depend on the interaction of health and environment.
- Emergent high level of wellness in an unfavorable environment.
- protected poor health in a favorable environment.
- poor health in an unfavorable environment.

B. Travis Illness-Wellness Grid

-This model illustrates two arrows pointing on the opposite directions and
joint to a neutral point.
-movement to the right indicates increasing level of health and can be
achieve through awareness, education and growth.
-movement to the left indicates progressively decreasing state of health.

3. Health Belief Model (Becker)

- Describes the relationship between a person’s belief and behavior.
- Individual perceptions and modifying factors may influence health
beliefs and preventive health behavior.
a. susceptibility to an illness
b. seriousness of an illness
c. threat of an illness

CONCEPTS RELATED TO HEALTH AND ILLNESS

STRESS- nonspecific response of the body to any demand made upon it.
Concepts:
1. stress is not a nervous energy
2. man, whenever he encounter stress, he tends to adapt to it
3. stress does not always lead to distress
4. stress whenever prolonged may lead to distress

ADAPTATION- adjustments that a person makes in different situations

Types of adaptation:

A. GAS- man whenever he responds to stress, the entire body is involved

Stages:
1. Stage of ALARM
2. Stage of RESISTANCE
3. Stage of EXHAUSTION
B. LAS- may respond through a particular body parts or body organ
INFLAMMATION- mobilization of specific and non specific defense
mechanism in response to tissue injury or infection

Purpose of inflammation:
1. to localize tissue injury
2. to protect tissue from injury
3. to prepare tissue for repair

Stages:
1. Vascular stage-rubor, calor,tumor,dolor
2. cellular stage-neutrophils, monocytes, lymphocytes
3. reparative stage- regeneration and scar tissue formation
 Nursing Management for inflammation:
1. promote rest
2. reduce swelling: position-elevate the affected body part to promote venous
return
3. relieve pain- hot and cold application
4. increase excretion of microorganism by adequate hydration
5. provide adequate nutrition- calories, CHON, Vit. A and C rich foods
6. Pharmacotherapy
7. Surgery

Heat Versus Cold Application

Physiologic effects of heat: Physiologic effects of cold:

1. vasodilation 1. vasoconstriction
2. increase cellular metabolism 2. decrease cellular metabolism
3. promote muscle relaxation 3. numb nerve endings, local anesthetic
4. relieves pain 4. relieves pain
5. provide sedative effect
6. relieves edema

Principles of heat and cold application

1. Cold application is generally safe.
2. Heat application requires doctors order
3. Cold application is done during the first 72 hours, heat post 72 H
4. Heat and cold application is done at a maximum of 30 minutes (rebound effect)
5. Check the area every 15-20 mins.

HEALTH PROMOTION

3 Levels of prevention

 Primary prevention-Use of measures designed to promote positive general health,

development of good health habits and hygiene, proper nutrition, proper attitude
towards sickness, proper and prompt utilization of health and medical facilities.

 Secondary prevention-Consist of early diagnosis and prompt treatment of the disease

in order to arrest and prevent the spread of infection.

 Tertiary prevention-It begins early in the period of recovery from illness. Optimizing
therapeutic effects, moving and positioning to prevent complications of immobility,
active and passive exercise to prevent disability.

Communication in Nursing

Communication- basic component of human relationship

- Is the transmission of thoughts and feelings or more personal and social
interaction between people

Trust- foundation of a positive nurse-client relationship

Verbal- Written or oral use of words in order to convey message

It includes voice intonations, pacing and rhythm

Non verbal- Is the transmission of message without the use of words

 Uses gestures, facial expression, posture, gait, body movements, physical
appearance

Documenting and Reporting

A. Purpose of Client’s Record:

- provides efficient and effective method of sharing information
- it is admissible in the court of law
- valuable data for research
- educational tool for children
- provides data which the entire health team uses to plan care for the client

Charting

Purposes:
1. communication
2. continuation of care
3. audit
4. legal – evidence in court
5. research – study or investigate treatment or nsg. care
6. education
7. statistics – frequency on distribution

Guidelines in Charting:
1. accurate
2. factual
3. complete – not too detailed
4. current
5. legibly
6. use permanent ink
 red ink : PR
 allergies: Nurse’s notes , Kardex

B. Types of Records
1. SOMR- traditional client record
5 components:
1. admission sheet
2. physician’s order sheet
3. medical history sheet
4. nurses notes
5. special records
2. POMR-focused on the clients problem
4 components:
1. database
2. problem list
3. initial list of orders or care
4. progress notes: narrative notes, flow sheets discharge notes

2. Kardex and NCP

Provide concise method of organization and recording data about a
client, making information readily accessible to all members of the health
team.

Characteristics of a good recoding

1. brevity
2. accuracy
 3. appropriateness
4. completeness
5. use of standard terminology
6. signed
7. errors
8. timing
9. confidentiality
10. legal awareness
11 .legible
12.use of common abbreviations

Teaching and learning:

Learning : a change in human diposition over a period of time

: reflected by a change behavior

Teaching: system of activities aimed to produce learning

Principles:
1. meet priority need first
2. make learning relevant
3. keep learning goals realistic
4. relate new information to previous learning
5. include significant others
6. consider individual learning strength and weakness
7. choose appropriate instructional strategies
8. provide time for practice and feedback

Factors faciliating learning: Factors inhibiting learning:

1. motivation 1. emotions
2. readiness 2. physiologic factors
3. active involvement 3. cultural barriers
4. feedback
5. simple to complex
6. repetition
7. timing
8. environment

ABC’s in Nursing
Alternations of respiratory functions:

Hypoxia: insufficient oxygenation tissue

S/S: early: tachycardia, increase rate and depth of respiration, increase systolic BP
Late: bradycardia, dyspnea, decrease systolic BP, cough and hemoptysis

Altered breathing pattern:

Tachypnea: rapid respi rate

Bradypnea: slow respi rate
Apnea: absence of spontaneous breathing

Volume:

Hyperventilation
Hypoventilation
Rhythm:

Cheyne-stokes: very deep and shallow breathing

Kussmaul’s breathing: hyperventilation: increase rate and depth of respi
Met acidosis, renal failure

Apneustic-prolonged inspiration followed by short, usually inefficient respiration

Biot’s: shallow breaths interrupted by apnea
Dyspnea: difficulty or labored breathing
Orthopnea: in ability to breath except in upright position

Maintaining Adequate Respiratory Function

1. Deep Breathing and Coughing Exercise
2. Semi-fowlers or high-fowlers
3. Adequate hydration
4. Avoidance of environmental pollutants, alcohol and smoking
5. Chest physiotherapy - percussion, vibration, postural drainage
6. Bronchodilator
7. Steam Inhalation
8. Medimist Inhalation
9. Use of Oxygen system

Supporting physiologic health patterns:

1. fecal elimination:
Defecation: expulsion of feces from the rectum

Normal characteristics of stools:

Color: yellow or golden brown
Acholic stool: biliary obstrxn
Hematochezia-passage of fresh bright stool
Melena: black tarry stool
Steatorrhea: fatty stool

Fecal elimination problem:

Constipation: dry, hard stools

Mngt: adequate fluid intake, high fiber, establish regular bowel habits
Respond immediately to the urge to defecate, minimize stress, administer
Laxative as ordered

Fecal impaction: hardened like feces in the folds of rectum: hardened fecal mass
Palapated during digital examination
Mngt: manual extraction, increase fluid intake. Adequate activity and exercise

Diarrhea: passage of liquid feces frequently on defecation

Mngt: replace fluid and electrolyte loss. Good perineal hygiene promote rest, low
fiber, BAR{bananna, apple and rice am}, potassium rich foods
Meds: antidiarrheal

Flatuelence: precense of excessive gas

Mngt: avoid gas forming food, provide warm fluid, early ambulation, adequate
activity, limit carbonated beverages, administer cholinergics: prostigmine
Administering enemas:
Purpose: to relieve constipation, to relieve constipation, administer meds, to evacuate
feces

Types:
1. cleansing enema: stimulate peristalsis by irritating the colon and rectum
2. carminative enema:60-180 ml of fld is introduced to expel flatus
3. retention enema: introduce oil into the rectum and sigmoid colon; retention; 1-
2hrs
4. return flow enema: 100-200 ml of fld: introduce into the large colon to stimulate
peristalsis: inflow and out flow process is repeated 5-6 times
5. non retention: solution: tap water, soap suds.NSS, hypertonic solution
ht of soln: 18 inches above the rectum
temp of soln: 115-125 degree F
time of retention: 5-10 mins
6. retention enema: soln: carminative enema, oil
ht of soln: 12 inches above the rectum
time of retention 1-3 hrs

urine examination:

Normal;color;amber/straw;odor:aromatic: ph slightly acidic {4-6-8}; specific gravity:

1.010-1.025

Alternation: hematuria/bacteriuria :UTI

Albumuniria /proteinuria:kidney problems
Glycosuria/ketonuria:DM

Altered urine production: polyuria: excessive amount of urine: more than 100ml/hr
Oliguria: less than 30 ml/hr
Anuria: 0-10 ml/hr
Altered urinary eliminations: frequency: voiding at frequent intervals
Nocturia: increase frequency at night
Urgency: increase feeling to avoid
Dysuria: painful urination
Enuresis: incontinence of urine esp at night
Incontinence: inability to control urination

Hygiene; personal care at which people attend to functions; bathing, toileting, gen
body hygiene and grooming

Skin: largest organ of the body:

Fxns: first line of defense, maintainbody tenmp, secretory organ: sebum {lubricate
hair and skin}. Sensory organ: numerous nerve endings for pain, produce and absorb
vit d.

2 sweat glands: apocrine; axillae anogenital areas: exocrine glands: palms of the
hands, soles of the feet and forehead

Skin problems: abrasion: appears red with localized bleeding, excessive dryness: skin
is scaly and rough, acne: papules, pustules/comedones, erythema: redness maybe
associated with rashes or exposure to sun, hirsutism: excessive growth of hair:
hyperhidrosis: excessive perspiration, bromhidrosis: foul-smelling perspiration,
vitiligo: white patches , hypopigmentation of the melanocytes
Mouth care: brush teeth daily: increase cal intake, vit A, C, D: avoid sweet foods
and drinks: have dental check up every 6 mos.

Mouth problems”
Plaque: tartar: halitosis: glossitis: stomatitis: petridontal dse: cheilosis: dental caries

Hair care: hair shampoo

Problems: dandruff: pruritus: alopecia: pediculosis: scabies: hirsutism

Eye care: cleanse eye from the inner to outer canthus: avoid rubbing the eyes :
maintain adequate lighting when reading: avoid regular use of eye drops

Nose care: clean nasal secretion by blowing the nose gently into soft tissue: both
nares should be open when blowing to prevent torcing debris into the middle ear

Exercise: active: done by the clients: passive: done for the clients: active resistive :
done by the client against a force: active assistive: done by the stronger arm and leg to
the weaker arm and leg: isotonic: with joint movement: isometric; no joint movement

Perineal-genital care:
Purpose; remove normal perineal secretions and odor
To prevent infection
To promote comfort

Female; use forceps to hold cotton balls for cleaning the perenium: anterior to
posterior to prevent contamination to urethral meatus: use one ball for each stroke:
cleanse perineum with soap and antiseptic sol’n.

Males: wash and dry using firm stroke: use circular motion, from the tip of the glans
penis towards the penile shaft: if uncircumsiced: detract the prepuce: wash dry the
scrotum and buttocks

Foot care: wash dry esp the interdigital spaces: use warm water for foot soaks, to
often the nail/loosen debris

Common foot problems: callus: broughtby the pressure from the shoes: npleasant
odor:
Excessive perspiration: plantar warts: painful and makes walking difficult: tinea
pedis: sacaling and cracking of the skin; in grown nail: inward growth of the nail

GRIEF

Grief: total response to the emotional experience of the loss and is manifested in
thoughts, feelings and behavior

Stages:
-kubler-ross
1.deniel
2. anger
3. bargaining
4. depression
5. acceptance

s./s
1. repeated sematic dissterss
2. toughtness in the chest
3. choking or shortness of breath
 4. sighing
5. emoty feelings in the abdomen
6. loss of muscular power
7. intense subjective distress

Management:
1. provide expression of feelings
2. recognize and accept emotions
3. support the nations
4. encourage stablish relationship
5. acknowledge the usefulness of mutual help
6. encourage self care by family members
7. acknowledge the usefulness of councelling
Sign of impending death:
a. loss of muscle tone
b. slowing of the circulation
c. changes in vital signs
d. sensory impairments
e. indications of death
Care of body after death:
a. rigor mortis
b. algor mortis
c. livor mortis

ASSESSING HEALTH

A. VITAL SIGNS: CARDINAL SIGNS

Temperature, pulse, respiration/blood pressure

1. BODY TEMPERATURE
- Balance between the heat produced by the body/ the heat lost from the body
- Normal core body temperature is between 36.7C(98 F)- 37C(98.6F)
- Body heat is produced by metabolism
- Hypothalamus  Heat regulating center
FACTORS AFFECTING BODY’S HEAT PRODUCTION:

a. BMR (Basal metabolic rate)

Younger Person- BMR
Older Person- BMR
b. MUSCLE ACTIVITY (EXERCISE)
- Metabolic Rate
c. THYROXINE OUTPUT
- Cellular Metabolic Rate- Chemical Thermogenesis
d. EPINEPHRINE, NOREPINEPHRINE AND STIMULATION SYMPHATIC
- Cellular Metabolism
e. Increasing Temperature of Body Cells(FEVER)
- Cellular Metabolism

PROCESS INVOLVED IN HEAT LOSS:

1. Radiation
- Transfer of heat from the surface of one object to the surface of another
without contact between two objects.
2. Conduction
- Transfer of heat from one surface to another that requires temperature
Difference between the two
3. Convection
 - Use of air currents
4. Evaporation
- Continuous vaporization of moisture from the skin, oral mucous,
Respiratory tract (insensible heat loss)

FACTORS AFFECTING TEMPERATURE:

a. age
Infant- hypothermia- limited subcutaneous fat
- greatly affected by the change in the environment
Elderly(over 75) – hypothermia (temp. below 36 C or 96.8 F)
- inadequate diet
- loss of subcutaneous fat
- lack of activity
- depleted reserve(thermoregulatory deficiency)

b. Diurnal Variations
- highest temperature -----8 pm-12mn
- lowest temperature---4am—8am
c. Exercise
Strenuous exercise- body temperature (36.3-40C)
d. HORMONES
- progesterone-esp during ovulation-- temperature
- Thyroxine
- Norepinephrine
- Epinephrine
- Estrogen
f. STRESS
- SNS- temperature
- production of epinephrine/norepinephrine-- temp.
e. ENVIROMENT
- Warm environment-- temp
- Cold environment -- temp

Methods:

1. Axillary – 36.5ºC  least accurate; least invasive

2. Oral - 37ºC  most commonly used
 Contraindications:
 Dyspneic
 unconscious
 surgeries
 lesions
 below 6 yrs. old
3. Rectal – 37.5ºC  most accurate; most invasive
 Contraindications:
 diarrhea
 rectal surgeries
 cardiac dse. – vagal nerve  bradycardia
 impaired immune system
 bleeding disorders
Length:
infant: .5
child: 1
adult: 1.5

* Before the onset of the fever, the patient chills  add clothing
Stages:
1. Chill or cold phase
2. Fever or onset
3. Defervescence or fever abatement
 gradual dec. – lysis
 sudden dec. – crisis
Fever Management:
1. Inc. fluid intake – dehydration
 normal: 1200- 1500 ml / day
 Contraindications:
 CHF
 Renal failure
2. turn on electric fan  convection : by air current
3. light, loose clothing  convection
4. cold compresses  conduction : by direct contact
 aforehead, axilla, groin : large blood vessels
5. TSB for 30 minutes  conduction
 Tepid water - 80 to 98ºF
6. turn on aircon  radiation
 by indirect contact or electromagnetic wave

Types of Fever:
1. Intermittent – fluctuations from high to normal or subnormal level
2. Remittent – fluctuates >2ºC without reaching normal temp.
 eg. 40.2  38  39.9
3. Constant – without reching normal temp.
 eg. 40  39.7  39.5  40
4. Relapsing – interspersed with days of no fever
5. Fever spike – sudden inc..of temp. , several hours back to normal

2. Pulse

Classifications of Pulse:
A. Apical – near the heart
 Indications :
a. heart disease
b. 3 years and below
c. abnormal pulse rate and rhythm
 Location:
 3 yrs. and below = 4th ICS, LMCL
 4 yrs. and above = b/w 4th and 5th ICS, LMCL

Assess Apical:
1. rate  60 – 100 bpm
 below 60 = bradycardia
 above 100 = tachycardia
2. Rhythm – pattern of beats / irreg.

B. Peripheral – away from the heart; wrist, foot, neck

1. carotid – adult shock
2. brachial – BP taking; NB shock
3. radial – PR taking; palpatory BP; use 2 fingers
4. Popliteal – leg pressure
Assess:
1. Rate
2. Rhythm
3. Volume or strength (amplitude)
 normal
 full, bounding, strong
 weak, thready, feeble
 dec. blood volume
 Absent – non-palpable pulse; obstruction/ thrombus
4. Equality

*Pulse deficit : difference between cardiac rate and radial pulse.

3. Respiration

Classifications of Respiration:
1. External (ventilation) – lungs and atmosphere
a. expiration – give off CO2
b. inspiration – take in O2
2. Internal – tissue response  cells and blood

*Tissue perfusion : passage of blood in a tissue.

Assess:
1) Rate – 12 to 20
 <12  bradypnea
 >20  tachypnea
2) Depth or Volume
 deep / shallow
3) Rhythm
a) hypoventilation  acidosis; hypopnea: slow, shallow, low RR
 Hypoxia - low O2 in cells
 Hypoxemia – low O2 in blood; dyspnea, cyanosis

Hypo

low O2 high CO2

hypercarbia
hypercapnia

Acute hypoxia:
1. High RR, PR
2. restless
3. change in level of consciousness
4. cough
5. hemoptysis – damage in capillary membrane
6. dyspnea

Chronic Hypoxia:
1. barrel chest
2. clubbed fingers
3. polycythemia : inc Hgb, inc. RBC

Ischemia – low blood in tissues

1. pallor
 2. cyanosis
3. coldness at part
4. weak pulse

Anoxia – absence of O2 in cells

Necrosis – death of cells

b) Hyperventilation or hyperpnea – rapid / deep

RR high, deep
high O2 low CO2

c) Kussmaul’s – rapid, deep

Diabetic - ketoacidosis
d) Cheyne-Stoke – irregular resp. with apnea
e) Biot’s – regular with apnea
f) Apneustic – prolonged inspiration but short expiration  blocked airway -
eg. bronchial asthma

4.) Quality or Character

a. Eupnea – effortless; quiet
b. Dyspnea – difficulty in breathing
c. Orthopnea – dyspnea in supine

IV. Blood Pressure - pressure or force

Components:
1. Systole – high point of pressure; heart contraction
2. Diastole – low points of pressure; heat relaxation
3. Pulse pressure – difference bw systole and diastole
 above 40  wide pulse pressure
 below 30  narrow pulse pressure

Hypertension: systole >140 on 2 succeeding readings

diastole >90 on 2 succeeding readings

Hypotension: systole <100 mmHg

NURSING PROCESS

I. Assessment

Activities:
1. collect data – review of system
 subjective – symptoms, clue
 objective – signs, cues
2. validate data – verify accuracy of data
3. cluster data – groupings of data according to relatedness  systems/functions
4. document data –

Types of Assessment:
1. initial/comprehensive
 1st contact
 upon admission
 Purpose: data base for problem identification, reference and future
comparison, then rapport
  database: all the information about a client; includes the nursing health
history, physical assessment, physician’s history and physical exams,
results of laboratory and diagnostic tests, and material contributed by other
health personnel; past and current data
2. Problem -focused
 Purpose: framework in identifying client’s actual, potential or overlooked
problems.
3. Emergency – life threatening
 physiological crisis
 situational crisis – eg. suicide
4. Time-lapsed
 several days, wks, months after initial assessment
 Purpose: framework comparing present health status with previous health
history

II. Diagnosing  reasoning process; analyzing

Types:
1. medical diagnosis – statement of disease or pathology; judgment or conclusion
 Role: dependent function
2. collaborative – statement of client’s response to a pathology or procedure;
possible complications
 Role: Interdependent – notify doctor
3. Nursing diagnosis – statement of client’s response to a health problem which a
nurse can treat = knowledge, skills, licensed to treat such conditions
 Role: Independent

Types of Nursing Diagnosis:

1. Actual nursing
 problem  present/exist
 signs and symptoms
 Format:
Problem  diagnostic label
Etiology  Etiology
Signs/Symptoms  Defining characteristics
2. Risk nursing diagnosis
 problem not present with risk factor
3. Possible nursing diagnosis
 problem not present; no risk factors; lack evidence
4. Wellness diagnosis – seek increase level of wellness
 “Readiness for Effective ……….….”
5. Syndrome diagnosis – clusters of related diagnosis
 eg. unconscious / immobilized
Risk for Bedsore Risk for
Risk for Disuse Osteoporosis Disuse
Risk for Injury Fracture Symptoms

Purposes of Diagnosis:
1. identify client’s problem
2. guide in planning of goals and nursing care

Acitivities:
1. Organize the data
2. Analyze
 Identify
a. gaps and inconsistencies
b. client’s strengths and weaknesses
c. compare data against standards
 3. Interpret – making a conclusion or judgment
4. Formulating
5. Documentation

III. Planning

Types:
1. Initial – upon admission
2. On going – contact
3. Discharge planning – anticipate future needs of client; admission

Purpose of Planning:
1. guide in implementation of care
2. basis for evaluation of care

Activities:
1. Prioritize problem
2. Set objectives - SMART
3. Set outcome criteria – manifestation of welfare
4. Select appropriate nursing actions
a. initial action
b. last action
c. inappropriate
5. Write a nursing order – complete statement of nursing action
6. Write NCP – blueprint of nursing process

Standardized Care Plan:

1. Standards of care based on nurse’s responsibilities
2. Policies/ Procedures – general guidelines
3. Protocols – specific guidelines
 eg. OB ward vs. NICU ; DR vs. OR
4. Standing order – nurse authorized to perform a part – action but must use
sound judgment or critical thinking

IV. Implementation

Activities:
1. Reassess
2. Implement or modify care plan
3. Document action
Skills:
1. cognitive – knowledge
2. psychomotor – techniques
3. communications
4. interactive – eg. hygiene care  nurse-patient-interaction

IV. Evaluation – process of determining if goals were met or if nsg, actions were
effective

Activities:
1. Assess response
2. Analyze the response
3. Interpret the result
4. Document response
5. Terminate the care plan when goals are met, if not, back assessment of nursing
process  goals half-met or not met