NCM100 Fresh

FUNDAMENTALS OF NURSING
HISTORY OF NURSING
HISTORY OF NURSING
 Early Civilization
 Cause of Disease
 Medicine Man
 Mother Surrogate
 Cause of Disease
 Temples
 Code of Hammurabi: Oldest Sanitation Code

- 1760 BC
- Law codes
- Sanitation
HISTORY OF NURSING
 Early Christian Period

 Deaconesses, Crusaders, Hospitals, Good
Samaritan Law
 Parabolani Brotherhood
 Teutonic Knights
 Knights of St. John of Jerusalem
 Knights of Lazarus
HISTORY OF NURSING
 Throughout history, wars have accentuated the

need for nurses:
 WWI, WWII, American Civil War, Vietnam

War (Recruitment of Nurses)
 Free Education for Nurses
 Crimean War
 Sir Sidney Herbert

 Florence Nightingale
HISTORY OF NURSING
 Florence Nightingale
 1836
 Theodor Fliedner, a German pastor in
Kaiserwerth, opened a hospital with a
training school for nurses
 Training School of Deaconesses
 1847
 Florence Nightingale went to train as a
nurse in Kaiserwerth, Germany
 Where she stayed for 3 months

HISTORY OF NURSING
 1853
 Nightingale trained in the Sisters of Charity
 Paris
 Returning to London, she worked as

administrator and director of nurses at the
Establishment for Gentlewomen During Illness
where she remained
 Until she was called into service during the
Crimean War
HISTORY OF NURSING
 1860
 Nightingale opened the Nightingale Training

School for Nurses
 Served as model for other nursing schools
 Its graduates traveled to other countries

to manage hospitals and nurse training
schools
HISTORY OF NURSING
HISTORY OF NURSING
 Nightingales biggest contributions in

Nursing:
 Sanitation Practices
 Nursing Education
 First Nurse Theorist

 Notes on Nursing: What It Is And
What It Is Not
HISTORY OF NURSING
IN THE PHILIPPINES
 Earliest Hospitals
 Hospital de Real de Manila (1577)
 San Lazaro Hospital (1578)
 San Juan de Dios Hospital (1596)

HISTORY OF NURSING
IN THE PHILIPPINES
 Earliest Nursing Schools
 Iloilo Mission Hospital School of Nursing (1906)
 St. Luke’s Hospital School of Nursing (1907)
 Mary Johnston Hospital and School of Nursing

(1907)
 Philippine General Hospital School of Nursing

(1910)
HISTORY OF NURSING
IN THE PHILIPPINES
 Earliest Nursing Universities
 University of Santo Tomas College of Nursing
 Manila Central University College of Nursing
 University of the Philippines College of Nursing,

Manila
 FEU Institute of Nursing
 UE College of Nursing
HISTORY OF NURSING
IN THE PHILIPPINES
 Nursing Leaders
 Anastacia Giron - Tupaz
- Nurse Chief Superintendent of PNA
- Founder of PNA
HISTORY OF NURSING
IN THE PHILIPPINES
 Nursing Organizations
 Philippine Nurse’s Association (PNA) – National
 First President
 Rosario Delgado
 Current President
 Leah Samaco Pacquiz

NURSE
NURSE
 Came from the Latin word
 “Noutrix”
 Meaning of the word
 “To Nourish”
AS A PROFESSION
 Body of specific and unique knowledge

 Strong service orientation
 Recognized authority by a professional group
 Code of ethics and laws
 Professional organization
 Ongoing research
 Autonomy
 CARE
LEVELS OF NURSES
LEVELS OF NURSES
 5 Levels of Nurses
 Level I
 No experience
 Novice
 Level II
 Has acceptable performance and has
experienced enough situations
 Advanced beginner
LEVELS OF NURSES
 Level III
 Has 2 to 3 years of experience

 Competent
 Employed overseas
 Level IV
 Has 3 to 5 years of experience
 Proficient
LEVELS OF NURSES
 Level V
 Highly proficient
 Does not require guidance and rules
 Expert
 Capable of managing hospital units

FIELDS OF NURSING PRACTICE
 1)Institutional or
Hospital Nursing
 Employment in
hospitals and
health
institutions
 Biggest field of
nursing
practice
 Staff Nurse
 Nurse
Managers
 2) Community /
Public Health
Nursing
 Subdivision:
 School
Nursing
 3) Private Duty
Nursing
 One to one
care
 Total nursing
care or Case
Management
 Home or
hospital based
 5) Military Nursing
 6) Company /
Industrial Nursing
EXPANDED EDUCATIONAL AND
CAREER ROLES
CAREER ROLES
 Clinical Nurse Specialist
 A nurse with an advanced degree,

education, or experience
 Considered to be an expert in a
specialized area of nursing
 Example: Geriatric Nurse, Oncology

Nurse, Maternal and Child Nurse
CAREER ROLES
 Nurse Practitioner
 A nurse with an advanced degree,

certified for a special area or age of
patient care
 Delivers independent practice to

make health assessments and deliver
primary care
 Diagnose
 Prescribe medications
CAREER ROLES
 Nurse Anesthetist
 A nurse who completes a course of study

in an anesthesia school
 Carries out preoperative visits and

assessments
 Administers and monitors anesthesia
during surgery
 Evaluates postoperative status of
patients
CAREER ROLES
 Nurse midwife
 A nurse who completes a program in

midwifery
 Provides prenatal and postnatal care
 Delivers
babies for women with
uncomplicated pregnancies
CAREER ROLES
 Nurse Educator
 A nurse usually with an advanced

degree, who teaches in educational or
clinical settings
CAREER ROLES
 Nurse Administrator
 A nurse who functions at various levels

of management
 Responsible for management and

administration of resources and
personnel involved in giving patient
care
CAREER ROLES
 Nurse Researcher
 A nurse with an advanced degree who

conducts research relevant to the
definition and improvement of nursing
practice and education
CAREER ROLES
 Nurse Entrepreneur
 A nurse, usually with an advance degree

who may manage a clinic or health
related business
NURSING ROLES
NURSING ROLES
 Caregiver
 Primary role of the nurse

 The provision of care
 MOTHER SURROGATE ROLES
 Complete Assistance
 Partial Assistance
 Supportive/Educative
NURSING ROLES
 Communicator
 With Patients
 To establish Therapeutic
Communication
 To identify health problems
 With Health Care Professionals

 Documentation
 Reporting / Endorsements
COMMUNICATION
COMMUNICATION
 It is the
interchange of
information
between two or
more people
 It is the exchange
of ideas or
thoughts
ELEMENTS OF COMMUNICATION
 Sender
 Originator of the information
 Message
 Information being transmitted
 Receiver
 Recipient of information
 Channel
 Mode of communication
 Feedback
 Return response
 Context
 The setting of the communication
LEVELS OF COMMUNICATION
 Intrapersonal
 Occurs when a person communicates
within himself
 Interpersonal
 Takes place within dyads (groups of two
persons) and in small groups.
 Public
 Communication between a person and
several other people
MODES OF COMMUNICATION
 Verbal Communication
 Non-verbal Communication
NON-VERBAL MESSAGES
 They carry more meaning than verbal

messages and involves the following:
 Body movement or kinetics
 Voice quality (pitch and range) and non-

language sounds (sobbing or laughing)
NON-VERBAL MESSAGES
 Proxemics – use of personal or social space
 Intimate Distance – actual contact to 1.5 feet
 Personal Distance – 1.5 to 4 feet or 3 to 4 feet
for interviews
 Social Distance – 4 to 12 feet
 Public Distance – 12 feet and beyond
 Cultural Artifacts – items in contact with interacting

persons that may act as non-verbal stimuli (i.e.,
clothes, cosmetics, jewelry, cars)
THERAPEUTIC RESPONSES IN
COMMUNICATING WITH PATIENTS
THERAPEUTIC RESPONSES
 Identify therapeutic and non-therapeutic

phrases
 Open-ended or Closed-ended question?
 ‘Why’ or ‘What’ questions?
 Avoid false reassurances

THERAPEUTIC RESPONSES
 Use direct questions for suicidal cases
 Avoid the ‘Authoritarian Answer’

 Giving advices
 In initiating conversation
 Use Broad Openings
 In ending conversation
 Summarizing
COMMUNICATING WITH HEALTH
CARE PROFESSIONALS
COMMUNICATING WITH HEALTH CARE
PROFESSIONALS
 Documentation
 Reporting
 Conferring
 Referring
PROFESSIONALS
 Reporting
 Endorsement
 Transferring pertinent information

regarding a patient to a concerned
person
 Outgoing nurse to a incoming nurse
 Staff nurse to physician

PROFESSIONALS
 Conferring
 To verify information
 Rephrasing
 To validate doctor’s orders
 To validate a nurse’s endorsement

PROFESSIONALS
 Referring
 To endorse patient’s special concern to a

higher authority or a specialized
department or personnel
A community nurse referring a client

to a hospital or a doctor
A staff nurse to a dietitian

NURSING ROLES
 Teacher/Educator
 Providing education about a client’s

health and health care procedures they
need to perform to restore or maintain
their health
NURSING ROLES
 Teaching Strategies
 Assess client’s
 Readiness to learn
 Assess the client’s knowledge
 Simple to complex
NURSING ROLES
 Teaching Strategies
 One to One Discussion or Group

Discussion
 Explanation and Description

 Answering Questions
 Visual Assisted Learning Programs
 Demonstration
 Actual performance of an activity

NURSING ROLES
 What is the best method of teaching?

(December 2007 NLE)
 What is the best indicator of client learning?

NURSING ROLES
 Counselor
 Facilitates the patient’s problem solving

and decision – making skills
 By providing information, make

appropriate referrals
NURSING ROLES
 Researcher
 The participation in or conduct of

research
 To increase knowledge in nursing and

improve patient care
NURSING ROLES
 Advocate
 Safeguarding the rights of the patients
 Patients Bill of Rights

THEORIES OF NURSING
THEORIES OF NURSING
 Theory
 A hypothesis or system of ideas that is

proposed to explain a given phenomenon
 Purpose:
 Directs and guide nursing practice

THEORIES OF NURSING
 Nightingale's
 Environmental Theory
 The act of utilizing the

environment of the patient to
assist him in his recovery
 Linked health with 5

environmental factors
 Pure or fresh air
 Pure water
 Efficient drainage
 Cleanliness
 Light
THEORIES OF NURSING
 Nightingale's Environmental Theory
 Addition:
 Education of nurses
 Keeping the client warm
 Maintaining a noise free environment
 Attending to the client’s diet

THEORIES OF NURSING
 Hildegard Peplau’s
 Interpersonal Relations
Model
 Peplau is a
psychiatric nurse
 Focus: Therapeutic
process
 Attained through:
Healthy Nurse
Patient Relationship
THEORIES OF NURSING
 Hildegard Peplau’s Interpersonal Relations

Model
 Four Phases of the Nurse – Patient

Interaction
 Preorientation
 Orientation
 Working / Exploitation
 Termination/Resolution
THEORIES OF NURSING
 Virginia Henderson’s
 14 Fundamental Needs
of a Person
 Assisting sick or
healthy individuals
to gain
independence in
meeting 14
fundamental needs
THEORIES OF NURSING
 Virginia Henderson’s 14 Fundamental Needs
of a Person
 1) Breathing normally
 2) Eating and drinking adequately
 3) Eliminating body waste
 4) Moving and maintaining a desirable
position
 5) Sleeping and resting
 6) Selecting suitable clothes
 7) Maintaining body temperature within
normal range by adjusting clothing and
modifying the environment
THEORIES OF NURSING
 Virginia Henderson’s 14 Fundamental Needs of a
Person
 8) Keeping the body clean and well groomed to

protect the integument
 9) Avoiding dangers in the environment and
avoiding injuring others
 10) Communicating with others in expressing
emotions, needs, fears, or opinions
 11) Worshipping according to one’s faith
 12) Working in a such way that one feels a sense
of accomplishment
 13) Playing or participating in various forms of
recreation
 14) Learning, discovering, or satisfying the
curiosity that leads to normal development and
health, and using available health facilities
THEORIES OF NURSING
 Dorothy Johnson’s
 Seven Subsystems
 Attachment
 Affiliative
 Dependency
 Ingestive
 Eliminative
 Sexual
Achievement
 Aggressive
THEORIES OF NURSING
 Faye Abdellah’s
 21 Nursing Problems
 good hygiene
 optimal activity
 safety
 good body mechanics
 oxygen
THEORIES OF NURSING
 Faye Abdellah’s 21 Nursing Problems
 nutrition
 elimination
 fluid and electrolytes balance
 physiologic response of the body to disease
 regulatory mechanisms
 sensory function.
 positive and negative expressions, feelings and
reactions.
 accept the interrelatedness of emotions and
illness
THEORIES OF NURSING
 Faye Abdellah’s 21 Nursing Problems
 self awareness
 optimum possible goals
 use community resources
 role of social problems

THEORIES OF NURSING
 Martha Roger’s
 Science of Unitary
Human Beings
 Views the person as

a irreducible whole,
the whole being
greater than the
sum of its parts
THEORIES OF NURSING
 Martha Roger’s Science of Unitary Human

Beings
 Man is composed of energy fields, which

are in constant interaction with the
environment
 Seek to promote harmonic interactions

between the two energy fields (Human
and Environmental)
THEORIES OF NURSING
 Dorothea Orem’s
 Self Care and Self Care

Deficit Theory
 Identified three
nursing systems
 Wholly
compensatory
systems
 Partial
compensatory
systems
 Supportive –
Educative
systems
THEORIES OF NURSING
 Imogene King’s
 Goal Attainment Theory
 Patient has THREE (3)

interacting systems
 Individuals /
Personal systems
 Group systems /
Interpersonal
systems
 Social systems
THEORIES OF NURSING
 Betty Neuman’s
 Health Care Systems

Model
 The concern of nursing

is to prevent Stress
Invasion
 Physiological
 Psychological
 Developmental
 Sociocultural
 Spiritual
THEORIES OF NURSING
 Sister Callista Roy’s
 Adaptation Model
 Man is a
Biopsychosocial
Being that requires
a feedback cycle
THEORIES OF NURSING
 Sister Callista Roy’s Adaptation Model
 The goal is to enhance life processes

through adaptation in four adaptive
models
 The Physiologic Mode
 Self Consent Mode
 Role Function Mode
 Interdependence Mode
THEORIES OF NURSING
 Madeline Leininger’s
 Transcultural Nursing
 Emphasizes human caring

varies among cultures
 Culture Care
Preservation and
Maintenance
 Culture Care
Accommodation and
Negotiation
 Culture Care
Restructuring and
Repatterning
CONCEPT OF MAN
CONCEPT OF MAN
 Nurse’s Clients
 Individuals
 Families
 Communities
CONCEPT OF MAN
 BIOLOGIC like ALL other men
 PSYCHOLOGICAL like NO OTHER man
 SOCIAL like SOME OTHER men
 SPIRITUAL like SOME OTHER men

ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 5 Human Needs
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Physiologic needs
 Oxygen
 Fluids
 Nutrition
 Body Temperature
 Elimination
 Rest and Sleep
 Sex
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Safety and security

(Physical and
Psychological)
 Protection
 Security
 Order
 Law
 Limits
 Stability
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Love and
Belongingness
 Family
 Affection
 Relationships
 Work group
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Self-esteem
 Feeling good about one’s
self
 Two factors affecting
Self-esteem
 Yourself
 Sense of
adequacy
 Accomplishment
 Self worth &
respect
 Others
 Appreciation
 Recognition
 Admiration
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Self-actualization –
essence of mental
health
 Personal growth
and fulfillment
 Able to fulfill
needs and
ambitions
 Maximizing one’s
full potential
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Self Actualization
 Judges people correctly

 Superior perception
 Decisive
 Capable of making decisions
 Clear notion as to what is right and

wrong
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Open to new ideas

 Not adopts new ideas
 Not one track mind
 Highly creative and flexible
 Does not need fame
 Problem-centered rather than self-

centered
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Additional needs:
 Need to know and understand
 Aesthetic needs
 Transcendence
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Need to know and understand or Cognitive

needs is supported by Richard Kalish who
says that
 Man needs stimulation

 Needs to explore
 Sex
 Activity
 New things
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Aesthetic needs:
 Beauty
 Balance
 Form
ABRAHAM MASLOW’S
HIERARCHY OF NEEDS
 Transcendence:
 Helping others to self-actualize

ILLNESS, WELLNESS AND HEALTH
DEFINITIONS OF HEALTH
Object 5
 World Health
Organization
 Health is the
complete physical,
mental, social
(totality) well-being
and not merely the
absence of disease
or infirmity
DEFINITIONS OF HEALTH
 Health is individually defined by each

person
 On a personal level, individuals define

health according to
 how they feel
 absence or presence of symptoms of

illness
 and ability to carry out activities
DISEASE
 Objective pathologic process
 Pathologic change in the structure or function

of the mind and body
DISEASE
 Acute
 Rapid onset of symptoms
 Some are life threatening
 Many do not require medical treatment

DISEASE
 Chronic
 Broad term that encompasses many

different physical and mental alterations in
health
 It is a permanent change
 Requires special patient education for

rehabilitation
 Requires long term of care and support

ILLNESS
 Highly subjective
feeling of being sick
or ill
 How the person

feels towards
sickness
 Concerns the Nurse

ELEVEN STAGES OF ILLNESS AND
HEALTH-SEEKING BEHAVIOR BY SUCHMAN
 1. Symptom Experience
 Client realizes there is a problem

 Client responds emotionally
 2. Sick Role Assumption
 Self-medication / Self-treatment
 Communication to others
ELEVEN STAGES OF ILLNESS AND HEALTH-
SEEKING BEHAVIOR BY SUCHMAN
 3. Assuming a Dependent Role
 Accepts the diagnosis

 Follows prescribed treatment
 4. Achieving recovery and rehabilitation
 Gives up the dependent role and assumes

normal activities and responsibilities
CONCEPTS ON DISEASE AND ILLNESS
 Illness without disease

 is possible
 Disease without illness

 is possible
MODELS OF HEALTH AND ILLNESS
DUNN’S HIGH-LEVEL WELLNESS
AND GRID MODEL
 X-axis is HEALTH
 Y-axis is ENVIRONMENT
DUNN’S HIGH-LEVEL WELLNESS
AND GRID MODEL
Quadrant 1 Quadrant 2
- High Level Wellness - Protected Poor Health
in a favorable in a favorable
environment environment
Quadrant 3 Quadrant 4
- Poor health in an - Emergent High Level
unfavorable Wellness in an
environment unfavorable
environment
HEALTH BELIEF MODEL BY
ROSENTOCK
 Concerned with what people perceive about

themselves in relation to their health
 Consider perceptions (influences individuals

motivation toward results)
 Perceived susceptibility
 Perceived seriousness
 Perceived benefit out of the action
FOUR LEVELS OF HEALTH BY SMITH
1. Clinical Model
 Man is viewed as a Physiologic Being
 If there are no signs and symptoms of a

disease, then you are healthy
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
 Failure to adapt is disease

4. Eudaemonistic Model
 This is the BROADEST concept of health
 Because health is viewed in terms of

Actualization
AGENT, HOST, ENVIRONMENT MODEL
BY LEAVELL AND CLARK
 Also known as the Ecologic Model
 Triad is composed of the agent, host and

environment
 Based on the interplay of three components

of the model
NURSING PROCESS
THE NURSING PROCESS
 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

 Actual health problems
 Potential health problems
 To establish plans
 To deliver specific nursing care
 To evaluate nursing care

CHARACTERISTICS OF
THE NURSING PROCESS
 Client-centered
 Cyclical (sequence), dynamic (moving)

rather than static
 Data from each phase provide input to
the next phase
 Interpersonal and collaborative

 Work with patients and relatives
 Work with colleagues and other
members of the health team
CHARACTERISTICS OF
THE NURSING PROCESS
 Adaptation of problem-solving techniques

and decision making principles in all the
phases
 Problem-oriented, flexible, open to new

information
BENEFITS FROM THE NURSING PROCESS
 Improves quality of care
 Ensures continuity and appropriate level

of care
 Long term plans
 Promotes a positive working atmosphere

through collaboration
 Facilitates client participation through

planning with patient
BENEFITS FROM THE NURSING PROCESS
 Feedback allows nurse to evaluate care
 Serves as a framework for accountability

through documentation
PARTS OF THE NURSING PROCESS
 Assessment Phase
 Diagnosing Phase
 Planning Phase
 Intervention Phase
 Evaluation Phase
ASSESSMENT PHASE
ASSESSMENT PHASE
 Is the systematic and continuous collection,
organization, validation, and documentation of
data
 Carried all throughout the nursing process

 Diagnosing
 Planning
 Information in assessment is crucial
 Implementation
 Before performing nursing care
 Evaluation
 Assessing the current status to compare with
previous status
ASSESSMENT PHASE
 What to assess
 Clients perceived needs
 Client’s responses to health problems

 Asthma
 Difficulty of breathing
 Arthritis
 Pain
 Health practices, values, and lifestyles

FOUR TYPES OF ASSESSMENT
 Initial Assessment
 Focus Assessment or On-going

Assessment
 Emergency Assessment
 Time-Lapsed Assessment
 1. Initial Assessment
 When performed:
 At specified time after admission
 Purpose of Initial Assessment:

 To create a data base for problem
identification
 For reference and future comparison
 2. Focus Assessment or On-going

Assessment
 When performed:
 Integrated throughout the nursing process
 Purpose of On-going Assessment:

 To identify problems overlooked earlier
 To determine the status of a health
problem
 Same from database
 Ex before implementation
 3. Emergency Assessment
 When done:
 During acute physiologic and
psychologic crisis
 Where done:
 Emergency Room
 Anywhere
 On site
 Purpose of Emergency Assessment
 To identify life-threatening condition

 4. Time-Lapsed Assessment
 When done:
 Several months after initial
assessment
 Purpose of Time-Lapsed Assessment

 To compare current status of patient
with base line data (initial

assessment)
 Ex
 Diabetic
ASSESSMENT PHASE
 Nursing Activities in the Assessment

Phase
 Data Collection
 Data Organization
 Data Validation
 Data Recording
DATA COLLECTION
DATA COLLECTION
 Is the process of gathering information or

data
 Data gathering
RECORDED DATA
 Types of Data
 Sources of Data
 Methods of Data Collection

TYPES OF 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
 “Mommy I feel hot”

TYPES OF DATA
 2. Objective or Overt Data
 Capable of being observed by use of

senses – sight, touch, smell, hearing
SOURCES OF DATA
SOURCES OF DATA
 1. Primary Source
 Patient himself, except when:
 Patient is unconscious
 Patient is a baby
 Patient is insane
 Significant others become the primary

source of data (from a secondary source)
 Unconscious brought in the ER?
 Whoever brought the patient to the

hospital
SOURCES OF DATA
 2. Secondary Source
 Patient’s record
 Health care members
 Significant others
METHODS OF DATA COLLECTION
METHODS OF DATA COLLECTION
 Observing
 Interviewing
 Examining
METHODS OF DATA COLLECTION:
OBSERVING
 To gather data by using the senses
 Vision
 Overall appearance
 Smell
 Body or breath odors
 Hearing
 Lung, heart, and bowel sounds
 Touch
 Skin temperature, pulse rate
OBSERVING
 Two (2) aspects of observation process:
 Noticing the stimuli using the senses
 Record the observed stimuli

INTERVIEWING
 Is a planned conversation with a purpose
 To get or give information
 Provide health teachings
 Provide support
INTERVIEWING
 Two types of Interview
 Directive Type of Interview
 Non-directive Type of Interview or

Rapport-building Interview
DIRECTIVE TYPE OF INTERVIEW
 Structured
 Uses closed-ended questions calling for

specific data
 Yes or No
 How many
 When
 When used:
 When you need to elicit specific data
 When there is little time available

NON-DIRECTIVE TYPE OR
RAPPORT-BUILDING INTERVIEW
 Uses more open-ended questions
 Advantage is that it allows the patient to

volunteer information
PLANNING THE INTERVIEW SETTING
 Concepts:
 Before the interview, determine what

information you already know
 An interview is a planned conversation

with a purpose
 An interview is a two-way process

PLANNING THE INTERVIEW SETTING
 Concepts:
 When is it done?
 When patient is available
 When patient is comfortable
 Recommended distance from the patient

is three (3) to four (4) feet
 Place
 Seating Arrangement
 Language
STAGES OF THE INTERVIEW
 1. Opening Stage
 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
 Establish rapport
 Orientation
 2. Body of the Interview
 Occurs when patient responds to

questioning
 The most productive stage

 3. Closing Stage
 The nurse terminates the interview when


 Theneeded information has been
obtained and given
 The client can no longer take in

information
 Provided support
STAGES OF THE INTERVIEW STAGES OF
THE INTERVIEW
 3. Closing Stage
 How to close the interview:

 Summarizing Technique
 To verify accuracy
 It reassures the client that the

nurse listened
 Sense of accomplishment
 Offer to answer questions
 Thank the client
 Plan for the next meeting if there is
one
EXAMINING
 The physical examination or assessment
 Use of senses
 Use of inspection, palpation, percussion,

and auscultation
EXAMINING
 Cephalocaudal
 Proximodistal
 IPPA
 IAPP
ORGANIZING DATA
ORGANIZING DATA
 Clustering of data
 Example
 Nursing Health History
 Current health problem
 Past history of illness
 Family history of illness
 Lifestyle
 Body Systems
VALIDATION OF DATA
VALIDATION OF DATA
 Act of double-checking the data
 Purposes of Data Validation
 To ensure the:
 Correctness
 Completeness
DATA RECORDING
DATA RECORDING
 Data Recording COMPLETES the

Assessment Phase
 Complete
 Factual
 Don’t interpret
 Man found lying on the floor
 Brevity
 Short but concise
DOCUMENTATION
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
GUIDELINES ON DOCUMENTATION
 Timing
 Document patient care as soon as possible
 Observe confidentiality
 Observe permanence
 Use non-erasable ink
 Do not use sign pen

 Signature
 Sign full name and append R.N.
 Accuracy
 Ensure that data is correct
 Avoid biases
 Avoid ambiguous terms
 Appropriateness
 Write only appropriate information
 Completeness
 Use standard terminology
 Brevity
 Make it concise yet meaningful
 Legal Awareness
 Cross out erroneous entry
 Write “Error”
 Countersign
TYPES OF RECORDS
 Source-Oriented Clinical Record
 Problem-Oriented Clinical Record

PROBLEM-ORIENTED
CLINICAL RECORD
 Same as Problem Oriented Medical Record

 Entry of data is based on CLIENT’S
PROBLEM
 Example:
 Problem No. 1: constipation
 Increase fluid intake: doctor
 Diatabs: pharmacist
 NPO: dietitian
FOUR BASIC COMPONENTS OF
PROBLEM-ORIENTED CLINICAL RECORD
 1. Baseline Data
 All information gathered from a patient

when he first entered the agency
 Assessment of the physician

 Assessment of the nurse
 2. Problem List
 Contains only ACTIVE problems (and

relevant information about the problem)
 Medical Diagnosis
 Nursing Diagnosis
 3. Initial list of orders or Care Plans

 4. Progress Notes
 Includes:
 Nurses’ narrative notes (SOAPIE)
 Flow sheets
 Discharge Notes and Referral
Summaries
SOURCE-ORIENTED CLINICAL RECORD
 Classification of information is based on

SOURCE
 Each person or department maintains a

different section on chart
COMPONENTS OF A
SOURCE-ORIENTED CLINICAL RECORD
 Admission Sheet
 Nursing Notes
 Medical History and Physical Examination Sheet
 Diagnostic Findings Sheet
 TPR Graphic Sheet
 Doctor’s Treatment and Order Sheet
 Therapeutic Sheet
DIAGNOSING PHASE
DIAGNOSING PHASE
 Nurses use critical thinking skills to

interpret assessment data and identify
client strengths and problems
 Positive or Negative?
DIAGNOSING PHASE
 Diagnostic Process
 Analyze the data
 Identify health problems, risk, and

strengths
 Formulating diagnostic statements

PARTS OF A NURSING DIAGNOSIS
 1. Problem Statement
 Example:
 Fluid Volume Deficit
 2. Presumed Etiology
 Example:
 …related to frequent loss of bowel
movement
 3. Signs and Symptoms

Example:
 …as manifested by decreased skin
turgor
TYPES OF DIAGNOSTIC STATEMENTS
 Basic Two Part Statements (PE)
 Problem and Etiology
 Altered Nutrition Less than Body

Requirements related to difficulty
swallowing
 Basic Three Part Statement (PES)
 Problem
 Etiology
 Signs and Symptoms
 Altered Nutrition Less than Body

Requirements related to difficulty
swallowing as manifested by body
weakness
 One Part Statements
 Problem
 Rape Trauma Syndrome

TYPES OF NURSING DIAGNOSIS
DIFFERENT TYPES OF NURSING
DIAGNOSES DIFFERENT TYPES OF
NURSING DIAGNOSES
 1. Actual Nursing Diagnosis
 Problem present at the time the statement

was made
 Example: Ineffective Airway Clearance

related to excessive and tenacious
secretions
DIAGNOSES
 2. High-Risk Nursing Diagnosis
 A diagnosis that a patient is more

vulnerable or susceptible compared with
others in the same situation
 Example: Risk for Impaired Skin Integrity

related to immobility secondary to
fractured hip.
DIAGNOSES
 3. Possible Nursing Diagnosis
 Not enough evidence about a problem
 Example: Possible Self Care Deficit

related to impaired ability to use left
hand secondary to presence of
intravenous therapy
DIAGNOSES
 4. Wellness Nursing Diagnosis
 A positive statement
 Indicates a healthy response
 Examples:
 Potential for increased compliance

related to increased level of knowledge
 Potential for effective coping related to

adequate support systems
PLANNING PHASE
PLANNING PHASE
 Planning is a deliberative, systematic phase

that involves decision making and problem
solving
 Formulating client goals with the patient
 Designing nursing interventions

ACTIVITIES DURING
THE PLANNING PROCESS
 Set priorities
 Client’s problems
 Set goals and objectives
 Identify alternatives of nursing care
 Select nursing measures
 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
TYPES OF PLANNING
TYPES OF PLANNING
 1. Initial Planning
 Done by the nurse
 When done:
 At specified time upon or after
admission/assessment of the patient

TYPES OF PLANNING
 2. On-going Planning
 Who are involved:

 Done by all nurses who worked with
the patient
 When done:
- Before start of shift
TYPES OF PLANNING
 2. On-going Planning
 Purposes of On-going Planning

 To determine if the client’s health status
has changed
 To decide which problems to focus on
during the shift

 To set priorities for client care during
the shift
TYPES OF PLANNING
 3. Discharge Planning
 Purpose of Discharge Planning
 To ensure continuity of care
 M–E–T–H-O–D-S
CHARACTERISTICS OF
THE PLANNING PROCESS
 S
 Specific
 M
 Measurable
 A
 Attainable
 R
 Realistic
 T
 Time bound
IMPLEMENTING PHASE
IMPLEMENTING PHASE
 Consists of doing and documenting the

nursing care given to the patient
 Putting the care plan into action

IMPLEMENTING PHASE
 Purpose of Implementation
 To carry out planned activities
 To help the client

IMPLEMENTING PHASE
 Requirements for Implementation
 Adequate knowledge
 Technical Skills
 Communication skills
 Therapeutic use of self

IMPLEMENTING PHASE
 Reassess the patient

 Rationale
 To determine if the procedure is still
needed
 Determine the need for nursing assistance
 Understand orders
 Clarify / verify doctors’ orders
NURSING ACTIVITIES DURING THE
IMPLEMENTATION PHASE
 Communicate the procedure

performed by documenting the
procedure
 Encourage patient to participate

actively
GUIDELINES FOR IMPLEMENTATION OF
NURSING STRATEGIES
 It should be based on scientific knowledge,

research, professional standards of practice
(care)
 Rationale:
 This is done to ensure safe nursing care
 It should be adapted to the individual patient

GUIDELINES FOR IMPLEMENTATION OF
NURSING STRATEGIES
 It should always be safe. Do not compromise
 It should be holistic
 It should be accompanied by support,

comfort and teaching
EVALUATION PHASE
EVALUATION PHASE
 Purpose of the Evaluation Phase
 To determine client’s progress
 To determine the effectiveness of the care

plan
 To determine as to what extent the

nursing goals have been met
EVALUATION PHASE
 Importance of doing an Evaluation
 It determines if the care plan will be:
 Continued
 Modified
 Discontinued
EVALUATION PHASE
 Activities during the Evaluation Phase
 Identify the OUTCOME CRITERIA to be

used as measurement (Planning)
 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:
 During or immediately after the
intervention
 Importance:
 Allows the nurse to decide and make
on-the-spot modification/s in an
intervention
TYPES OF EVALUATION
 2. Intermittent Evaluation
 When done:
 At a specified time
 Purpose:
 It shows the extent of progress of the
patient
 Importance:
 Enables the nurse to correct deficiencies
and modify the nursing care plan
TYPES OF EVALUATION
 3. Terminal Evaluation
 When done:
 At or immediately before discharge
 Importance:
 States the status of a health problem at
the time of discharge
 It determines whether the goals are:
 Met
 Partially met
 Unmet
PROMOTING REST AND SLEEP
 Sleep is the altered level of consciousness

in which the individual’s perception of and
reaction to environment are decreased
 What regulates sleep and wakefulness?
 Reticular formation on the Brain Stem
 Ascending nerve fibers

 Reticular Activating System (RAS)
 Sleep Wake Cycle

 Types of Sleep
 NREM
 Non-Rapid Eye Movement Sleep
 REM
 Rapid Eye Movement Sleep
 NREM (Non-Rapid Eye Movement Sleep)
 When the RAS is inhibited

 Sleep
 BODY RESTORATION
 About 75% to 80% of sleep
 Has 4 Stages
 Stage I (Very Light Sleep)
 Lasts only a few minutes

 Drowsy and relaxed
 Eyes roll from side to side
 HR and RR drop slightly
 Readily awakened
 Stage II (Light Sleep)
 Lastsfor 10-15 minutes

 Body processes continue to slow down
 HR and RR decrease furthermore
 Body temperature falls
 Eyes are still

 Stage III
 The HR and RR, as well as other body

processes, slow further
 The sleeper becomes more difficult to
arouse
 The skeletal muscles are very relaxed
 The reflexes are diminished and

snoring may occur
 Stage IV (Delta Sleep or Deep Sleep)
 HR and RR drop 20 – 30% below that

exhibited during waking hours
 Sleeper is very relaxed, rarely moves
and is difficult to arouse

 This stage is thought to restore the
body physically
 REM (Rapid Eye Movement Sleep)
 Occurs about every 90 minutes

 Lasts from 5 to 30 minutes
 “Paradoxical Sleep”
 Resembles wakefulness
 Brain is highly active
 Dreams are usual
 Irregular HR and RR
 May be difficult to arouse or wake up

spontaneously
 For sleep to be normal
 The person must pass through the NREM and

REM
 1 Cycle lasts for 90 to 110 minutes (1 ½ to 2
hours)
 1st 3 Stages of NREM (20-30 minutes)
 Stage IV (30 minutes)
 Back to NREM Stages III and II (20 minutes)
 REM (10 minutes)
 Very brief
 Skipped entirely
 What is/are the longest type or stage of

sleep?
 Stages II and III

 A sleeper who is awakened at any stage

must begin a new cycle
 In a 7 to 8 hours of sleep
 4 – 6 cycles
 To restore the body

 Normal Sleep Requirements
 Newborns
 16 to 18 hours a day
 Infants
 14 to 15 hours
 Toddlers
 12 to 14 hours
 Preschoolers
 11 to 13 hours
 School Aged
 10 to 11 hours
 Adolescents
 9 to 10 hours
 Adults
 7 to 9 hours
 Elders
 7 to 9 hours
 Many sleeping problems
 Tendency toward earlier bedtime

and wake times
 Increase in disturbed sleep
 Medical conditions
 Factors Affecting Sleep
 Illness
 Pain or physical distress

 Arthritis, back pain and ulcers
 Respiratory conditions
 Nasal congestion
 Need to urinate
 Environment
 Noise
 Absence of usual stimuli or the
presence of unfamiliar stimuli

 Namamahay
 Discomfort from environmental
temperature
 Too hot or too cold
 Comfort and size of the bed

 Emotional Stress
 Considered by sleep experts as the

number one cause of short term
sleeping difficulties
 Preoccupied with personal problems

 May be unable to relax sufficiently
to get to sleep
 Stimulants and Alcohol
 Caffeine containing beverages

 Coffee
 Tea
 Chocolate Drinks
 Alcohol
 Speed up the onset of sleep
 BUT disrupts REM

 Smoking
 Nicotinehas a stimulating effect on

the body
 Smoker
 Refrain
from smoking after the
evening meal
COMMON SLEEP DISORDERS
 Insomnia
 Inability to fall asleep or remain asleep
 Acute Insomnia
 Last 1 to several nights
 Caused by personal stressors
 Chronic
 Persists for longer than a month
 Insomnia
 Chronic Intermittent Insomnia
 Difficulty sleeping for a few nights

 Followed by a few nights of adequate
sleep
 Difficulty sleeping returns
 Excessive Daytime Sleepiness
 Hypersomnia
 Narcolepsy
 Hypersomnia
 The affected individual obtains sufficient

sleep at night
 Cannot stay awake during the day
 Caused by
 CNS Damage
 Narcolepsy
 Disorder of excessive daytime sleepiness
 Sleep attacks
 Cataplexy
 Sudden weakness or paralysis
 Fragmented nighttime sleep
 Cause
 Lack of chemical hypocretin
 Sleep Apnea
 Frequent short breathing pauses during

sleep
 10 seconds to 2 minutes
 ObstructiveApnea
 Central Apnea
 Mixed
 Sleep Apnea
 Obstructive Apnea
 Blockage of the flow of air
 Central
 Defect in the respiratory center of the
brain
 Medulla Oblongata
 Mixed
 Parasomnias
 Arousal Disorder
 Sleep
Walking
 Somnambulism
 Parasomnias
 Sleep Wake Transition Disorder
 Sleep talking
 Exhaustion
 Parasomnias
 Associated with REM Sleep
 Nightmares
 Parasomnias
 Others
 Bruxism
NURSING INTERVENTIONS
TO PROMOTE REST AND SLEEP
 Sleep Hygiene
 Referring to interventions to promote

sleep
 Supporting Bedtime Rituals
 Most people are accustomed to bedtime rituals or

pre sleep routines
 Adults
 Hygienic routines
 Washing the face
 Brushing teeth
 Voiding
 Relaxation
 Listening to music
 Reading
 Taking a soothing bath
 Praying
 Children
 Need to be socialized into pre sleep

routine
 Bedtime story
 Holding onto a favorite toy or

blanket
 Kissing everyone goodnight
 Massage
 Warm drink
 Milk
 Tryptophan
 Creating a Restful Environment
 Minimal noise
 Comfortable room temperature
 Appropriate lighting
 Promoting Comfort and Relaxation
 Provide loose fitting nightwear

 Assist clients with hygienic routines
 Assist or encourage the client to void
before bedtime
 Offer to provide a back massage
 Schedule medications
 For clients with pain, administer
analgesics 30 minutes before bedtime
 Promoting Comfort and Relaxation
 Emotional stress interferes with sleep
 Relaxation Techniques
 Deep Breathing
 Muscle Relaxation
 Guided Imagery
 Meditation
PROMOTING NUTRITION
PROMOTING NUTRITION
 Nutrition
 Is the sum of all the interactions

between an organism and the food it
consumes
 Nutrients
 Are organic or inorganic substances

found in foods that are required for body
functioning
PROMOTING NUTRITION
 Essential Nutrients
 The body’s most basic nutrient need is

 Water
 Nutrients that provide fuel to body cells

 Macronutrients
 Carbohydrates
 Proteins
 Fats
 Micronutrients
 Vitamins
 Minerals
MACRONUTRIENTS
CARBOHYDRATES
 CHO
 Two Basic Types
 Simple Sugars
 Complex Carbohydrates
 Starches
 Fibers
MACRONUTRIENTS
CARBOHYDRATES
 Simple sugars
 Water soluble
 Produced
naturally by
plants and
animals
 Monosaccharide
 Glucose
 Fructose
Galactose
MACRONUTRIENTS
CARBOHYDRATES
 Simple sugars
 Disaccharides
 Two Monosaccharide
MACRONUTRIENTS
CARBOHYDRATES
 Food Sources of
Simple Sugars
 Sugarcane
 Table sugar
 Sugar beets
MACRONUTRIENTS
CARBOHYDRATES
 Complex Sugars
 Starches
 Grains
 Legumes
 Potatoes
 Cereals
 Breads
MACRONUTRIENTS
CARBOHYDRATES
 Complex Sugars
 Fibers
 Supplies
roughage or bulk
in the diet
 Outer layer of
grains
 Skin, seeds
and pulp of
many fruits
and
vegetables
MACRONUTRIENTS
CARBOHYDRATES
 Digestion
 In the mouth
 Ptyalin (Salivary Amylase)
 In the small intestines

 Pancreatic amylase
MACRONUTRIENTS
CARBOHYDRATES
 Metabolism
 CHO is Major Source of Body Energy

 GO FOODS
CHON
Glucose
Bloodstream Stored
Glycogen Fats
MACRONUTRIENTS
PROTEINS
 CHON
 Amino acids
 Essential amino acids

 Those that cannot be produced by the
body
 Nonessential amino acids

 Those that can be produced by the
body
MACRONUTRIENTS
PROTEINS
 May be Complete, Partially Complete and

Incomplete
MACRONUTRIENTS
PROTEINS
 Complete Proteins
 Contains all
essential amino
acids plus many non
essential amino
acids
 Derived from
animals
 Meats, poultry,
fish, dairy
products, and
eggs
MACRONUTRIENTS
PROTEINS
 Partially Complete
 Less than the required amount of one or

two essential amino acids
 Gelatin
MACRONUTRIENTS
PROTEINS
 Incomplete
 Lack of one or more

essential amino acids
 Usually derived from

vegetables
 Vegetarians?
 Solution
 Vegetable
combinations
 Corn and beans
 Vegetables with a
small amount of
animal protein
MACRONUTRIENTS
PROTEINS
 Digestion
 In the mouth
 Pepsin
 In the intestines
 Trypsin
MACRONUTRIENTS
PROTEINS
 Storage
 Protein is stored in the body as tissue
 Growth and Development
 GROW FOODS
MACRONUTRIENTS
PROTEINS
 Metabolism
 Anabolism
 Construction
 All body cells manufacture proteins
from amino acids
 Catabolism
 Destruction
 A cell can only accommodate a limited
amount of protein
 Liver
MACRONUTRIENTS
LIPIDS
 Organic substances that are greasy and

insoluble in water
 Fats
 Lipids that are solid at room temperature
 Butter
 Oil
 Lipids that are liquid at room
temperature
 Cooking oil
MACRONUTRIENTS
LIPIDS
 Classified as
 Saturated
 Unsaturated
 Which is healthier?
MACRONUTRIENTS
LIPIDS
 Saturated fats
 coconut oil, and

palm kernel oil
 dairy products
(especially butter, ,
cream, and cheese)
 meat (beef)
 dark meat of
poultry, and poultry
skin
 chocolate
MACRONUTRIENTS
LIPIDS
 Unsaturated
 Avocado
 Nuts
 Vegetable oils
such as soybean,
canola, and olive
oils
MACRONUTRIENTS
LIPIDS
 Digestion
 Starts in the mouth
 Mainly in the stomach

 Bile
 Pancreatic Lipase
MACRONUTRIENTS
LIPIDS
 They become
 Glycerol and Fatty acids

 Energy
 Cholesterol (Lipids plus protein)

 Is Cholesterol needed in the body?
 Important in producing bile
 Excessive
 Atherosclerosis
 GLOW FOODS
TYPES OF LIPOPROTEINS
 1. High Density Lipoproteins (HDL)
 Good cholesterol
 Function of HDLs
 Transportsthe bad cholesterol from

systemic circulation to the liver for
metabolism and eventual elimination
TYPES OF LIPOPROTEINS
 2. Low Density Lipoproteins (LDL)
 Bad cholesterol
 Function of LDLs
 They clog the blood vessels

ENERGY INTAKE
ENERGY INTAKE
 The amount of energy that nutrients or
foods supply to the body is their caloric
value
 CHO
 CHON
 FATS
 * ALCOHOL
 7 Calories/Gram
ENERGY INTAKE
 Recommended Calorie Intake per Day
 Varies
 Generally
 Men
 2000 – 2500 calories
 Women
 1500 – 2000 calories
 Pregnant
 Plus 300 calories
 Lactating
 Plus 500 calories
ENERGY INTAKE
 Compute
 800 grams of CHO

 600 grams of CHON
 400 grams of FATS

MICRONUTRIENTS
MICRONUTRIENTS
 Required in small amounts
 Vitamins
 Minerals
VITAMINS
MICRONUTRIENTS
 Vitamins
 Organic compounds that cannot be

produced by the body
 Water Soluble
 Fat Soluble
WATER SOLUBLE VITAMINS
 Vitamins that cannot be stored by the body

 Excess?
 Vitamin C
 Vitamin B Complex
 Vitamin C
 Ascorbic Acid
 synthesis of collagen
 an important protein used to make skin, scar
tissue, tendons, ligaments, and blood vessels
 essential for the healing of wounds, and for the
repair and maintenance of cartilage, bones, and
teeth
 immune function
 synthesis of the neurotransmitter, norepinephrine
 effective antioxidant
 Vitamin C
 Fruits
 Guava
 Strawberry
 Lemon
 Orange
 Mangoes
 Tomato
 Vegetables
 Bell Peppers
 Broccoli
 Cauliflower
 Green Cabbage
 Vitamin C Deficiency
 Scurvy
 Bruising easily
 hair and tooth loss
 joint pain and swelling
 Related to the weakening of blood

vessels, connective tissue, and bone,
which contain collagen
 Vitamin B Complex
 Vitamin B1
 (thiamine)
 Vitamin B2
 (riboflavin)
 Vitamin B3
 (niacin)
 Vitamin B5
 (pantothenic acid)
 Vitamin B6
 (pyridoxine)
 Vitamin B7
 (biotin)
 Vitamin B9
 (folic acid)
 Vitamin B12
 (cyanocobalamin)
 Vitamins B1, B2, B3

 energy production
 Vitamin B6
 amino acid metabolism
 Vitamin B9
 Vital for the function and maintenance
of the nervous system and red blood
cells
 400 mcg or 0.4 mg (Pregnant)
 fish, milk, eggs,
liver, meat, brown
rice, whole grain
cereals, and
soybeans, poultry
 Folic acid
 Green vegetables
 Liver
 whole grain cereals
 Vitamin B Deficiency
 Vitamin B1 (Thiamine)
 Beriberi
 Wernicke's encephalopathy
 Impaired sensory perception
 Weakening of the limbs
 Irregular heart rate
 Korsakoff's syndrome
 Amnesia and confabulation

 Vitamin B3 (niacin)
 Pellagra
 Aggression
 Insomnia
 Weakness
 mental confusion
 diarrhea
 Vitamin B9 (folic acid)
 In pregnancy
birth defects
 Neural Tube
Defects
 Spina Bifida
 Anencephaly
FAT SOLUBLE VITAMINS
 The body can store these vitamins
 A
 D
 E
 K
 Vitamin A
 Retinol
 Normal Vision
 Maintaining normal skin health
 Deficiency
 Blindness
 Vitamin A sources
 liver (beef, pork,

chicken, turkey,
fish)
 carrots
 Broccoli leaves
 sweet potatoes
 butter
 spinach
 pumpkin
 Vitamin D
 Calciferol
 To maintain normal blood levels of calcium

 Vitamin D aids in the absorption of calcium
 Deficiency
 In children
 Rickets – skeletal deformities
 Calcium
 osteomalacia
 muscular weakness in addition to weak bones
 Vitamin D
 Fish
 Eggs
 fortified milk
 cod liver oil
 The sun
 as little as 10
minutes of
exposure
 Vitamin E
 Tocopherol
 Antioxidant
 Vitamin E sources
 Vegetable oils, nuts,

green leafy
vegetables, and
fortified cereals
 Almonds
 Asparagus
 Avocado
 Nuts
 Olives
 Seeds
 Spinach and other
green leafy vegetables
 Vitamin K
 K
 Koagulation Vitamins
 Clotting factors
 Stops bleeding
 Leafy green
vegetables,
particularly the
dark green ones
such as
 Spinach
 Broccoli
 Malunggay
 Avocado
MINERALS
MINERALS
 Organic or inorganic compounds
 Macrominerals
 Over 100 mg
 Microminerals
 Less than 100 mg
MACROMINERALS
MACROMINERALS
 Calcium
 Sodium
 Potassium
 Phosphorous
 Magnesium
 Chloride
 Sulfur
MACROMINERALS
 Calcium
 Normal growth and maintenance of

bones and teeth
 Deficiency
 Rickets
 Osteoporosis
MACROMINERALS
 Calcium Sources
 Dairy products, such

as milk and cheese
 beans
 oranges
 Okra
 broccoli
 fortified products
such as orange juice
and soy milk
MACROMINERALS
 Sodium
 Regulation of blood and body fluids

 Water Retention
 Transmission of nerve impulses

 Action Potential (Sodium Potassium
Pump)
 2 to 3 grams/day
 Table salts and most condiments
 Preserved foods
MACROMINERALS
 Potassium
 muscle contraction and the

sending of all nerve impulses in
animals through action
potentials
 All meats, poultry and fish are

high in potassium.
 Apricots (fresh more so than
canned)
 Avocado
 Banana
 Cantaloupe
 Milk
 Oranges and orange juice
 Potatoes
MICROMINERALS
MICROMINERALS
 Iron
 Iodine
 Flouride
 Manganese
 Cobalt
 Selenium
MICROMINERALS
 Iron
 Ferrous Sulfate
 Hemoglobin
 Oxygen carriers
 Forms of supplement
 Oral
 Parenteral
MICROMINERALS
 Iron Sources
 Dark Green, Leafy Vegetables

 Dried Beans and Peas
 Dried Fruits
 Eggs
 Enriched Breads
 Iron-Fortified Cereal
 Lean Meats
 Nuts
 Raisins
 Spinach
 Tofu
MICROMINERALS
 Iron
 Oral Form
 Take on an empty stomach

 If with GI distress, take with food
 Use dropper or straw
 Drink with
 Milk or Orange Juice?
 Increase water
 Decrease fiber
MICROMINERALS
 Iron
 Parenteral Form
 Site
 Deep IM
 Z Track
 Don’t massage
 Apply firm pressure for 5 minutes

MICROMINERALS
 Iodine
 As element of the thyroid hormones,

thyroxine (T4) and triiodothyronine (T3)
 Deficiency
 Hypothyroidism
 Goiter
MICROMINERALS
 Iodine Sources
 Sea creatures
 Seaweeds
NUTRITIONAL ASSESSMENT
 Anthropometric Measurements
 Height
 Weight
 (best indicator of nutritional status of
an individual)
 Skin Fold Test (fat folds)
 Mid-upper arm Circumference
Measurement
 Body Mass Index
 Weight
 Weighing Technique
 Ideal Body Weight
 Rule of 5 for Women

 Rule of 6 for Men
 Ideal Body Weight
 Rule of 5 for Women
 100 lbs for 5 ft of height

 Plus 5 lbs for every inch of height
above 5 ft
 Example
 5 feet 1 inch
 Weight = 105 lbs
 5 feet 2 inches
 Weight – 110 lbs
 Ideal Body Weight
 Rule of 6 for Men
 106 lbs for 5 ft of height

 Plus 6 lbs for every inch of height
above 5 ft
 Height = 5 ft 1 inch
 Weight
 112 lbs
 Anthropometric
Measurements
 Skin Fold Test
 Derivedfrom
reserved fat of
the body
 Anthropometric
Measurements
 Mid-upper arm
Circumference
Measurement
 Obtains the
muscle mass of
the body
 This reflects the

protein reserves
of the body
 Body Mass Index
 BMI = weight in kg
(height in meter)2
 BMI
 Height in Meter
 1 Meter = 3.3 feet or 39.6 inches
 1 Kg = 2.2 Lbs
 BMI Results
 Underweight = Less than 18.5

 Normal = 18.5 – 24.9
 Overweight = 25.0 – 29.9
 Obese Type I = 30.0 – 34.9
 Obese Type II = 35.0 – 39.9
 Obese Type III = 40.0 plus

 BMI
 Compute
 Weight = 65 kg
 Height is = 62 inches
 Compute
 Weight = 150 pounds
 Height = 5 feet 3 inches

 Biochemical Data
 Serum Albumin
 Serum Albumin
 Provide an estimate of protein stores
 Albumin
 Serum protein
 Dietary Data
 24 hour food recall
 Food Diary
 Obesity
 Eating Disorders
NUTRITIONAL VARIATIONS
THROUGHOUT THE LIFE CYCLE
 Neonate
 Nutritional requirements are met by

breastmilk or formula milk
 Total daily requirements of the newborn
 80 to 100 ml of milk per kg
 Stomach capacity = 90 ml
 Feedings are required every 2 to 4 hours
 Demand feeding
 Burping
 Infant
 Solid foods are added when?
 4 to 6 months
 Cereals (Rice)
 Fruits
 Vegetables (Yellows before Greens)
 Foods are introduced 1 at a time
 Every 5 to 7 days
 Honey is not given
 May contain small amount of
Clostridium botulinum
 Toddlers
 Toddlers can eat

most foods
 Meals short be
short
 Environmental
distractions must
be eliminated
 Rituals
 Attractive foods
 Avoid sweet
desserts
 Preschooler
 These children eat

at school
 Children at this
stage are very
active and may rush
through meals to
return to playing
 Often require
healthy snacks
 Fruits
 Milk
 Yogurt
 School Aged Child
 Watch out for the

foods the child are
eating at school
 High CHO and High

CHON
 Prolonged physical
and mental effort
 Breakfast is important
 Adolescents
 Growth spurt
 Self Identity and Peer pressure

 Eating disorders
 Young Adults and Middle Adults
 Maintain normal diet of healthy food

options
 Milk
 Elderly
 They have many problems associated with

nutrition
 Difficulty chewing
 Denture
 Chopped and soft foods
 Loss of appetite
 SFF
 Loss of senses of smell and taste
 Favorite foods
 Limited income
 Substitution
 Substitute meat with milk or beans
 Difficulty sleeping at night
 Promote sleep
SPECIAL DIETS
SPECIAL DIETS
 Clear Liquid Diets
 Limited to
 Water
 Tea
 Coffee
 Clear broths
 Strained and
clear juices
 Plain gelatin
 Hard Candy
SPECIAL DIETS
 Clear Liquid Diets
 This provides water and CHO (in the

form of sugar)
 After surgery
SPECIAL DIETS
 Full Liquid Diet
 Foods that are liquids

or foods that turn to
liquid at body
temperature
 All foods in the

Clear Liquid Diet
 Milk
 Puddings and
custards
 Ice cream and
sherbets
 Yogurt
SPECIAL DIETS
 Full Liquid Diet
 For clients who have gastrointestinal

problems and cannot tolerate semi solid
or solid foods
SPECIAL DIETS
 Soft Diet
 All foods in the Clear and Full Liquid Diet

 Meat: Lean, Tender
 Fish, grounded meat
 Vegetables: Mashed or cooked for a very

soft consistency
 Fruits: Cooked or canned
 Breads and oatmeals
 Soft cakes
SPECIAL DIETS
 Diet As Tolerated (DAT)
 When the client’s appetite, ability to eat

and tolerate food
 Gag
 Bowel Sounds
SPECIAL DIETS
 Modification for Disease
 Diabetic Diet
 Hypertensive Diet
SUPPORTING NUTRITION OF THE
PATIENT
ENTERAL AND PARENTERAL

FEEDING
ENTERAL FEEDING
 An alternative feeding method to ensure

adequate nutrition
 Feeding through the gastrointestinal

system
 EN
 TEN
ENTERAL FEEDING
 Nasogastric Tube
 Nasointestinal Tube
 Percutaneous Endoscopic Gastrostomy

(PEG)
 Percutaneous Endoscopic Jejunostomy

(PEJ)
NASOGATRIC TUBE
NASOGATRIC TUBE
 Purpose
 For gastric
gavage (feeding)
and lavage
(irrigation)
 For
administration of
medication
NASOGATRIC TUBE
 Indications
 Clients who are unable to ingest foods
 The upper gastrointestinal tract is

impaired
 Transport of food to the small intestines

is interrupted
NASOGATRIC TUBE
 Single Lumen Tube
 Levin Tube
 Double Lumen
 Salem Sump
Tube
NASOGATRIC TUBE
 Procedure
 Position
 High Fowler’s
 Hyperextension of head
 Explain
 Hand Hygiene
 Measure Depth of Insertion
 NEX
NASOGATRIC TUBE
 Check Nares
 Irritation
 Obstruction
 Put on Gloves
 Lubricate the tip of the tube
 Insert
 Resistance
 Withdraw then lubricate again

NASOGATRIC TUBE
 When the tube reaches the throat

 Ask the client to forward head
 Swallow
 Gag
 Stop
 Give water and encourage to

breath
 Continue insertion
NASOGATRIC TUBE
 Ascertain correct placement of the tube
1 – Radiographic Verification
2 – Acidity of pH of aspirate
 Lithmus Paper
 Blue
 Red
3 – Aspiration of gastric content
4 – Ausculate epigastic region

NASOGATRIC TUBE
 Secure the NGT to the clients gown
 Document
NASOGATRIC TUBE
 Feeding
 Osterized Food
 Average volume of feeding:

 300 ml to 400 ml
 Warmed at room temperature

NASOGATRIC TUBE
 Feeding
 Procedure
 Assist the patient in high fowler’s position

 If tolerated
 If not, Slightly elevated right sided lying
 Checks the formula's expiration date
 Check the patency of the tube

NASOGATRIC TUBE
 Elevate the tip of the tube to 12 inches

above nares
 Connect tube to a 60 cc syringe
 Flush with 30cc of water
 Run the formula through the tubing and

reclamp the tube
 a rate no greater than 50ml/min is
recommended
 Flush with 30cc of water
NASOGATRIC TUBE
 Perform mouth care; brushing teeth, gums

and tongue twice daily
 Apply lip moisturizer or petroleum jelly

unless otherwise ordered
 Discourages mouth breathing and uses
measures to increase salivation such as
chewing gum, sucking on hard candy or ice
if permissible
 Ask the client to remain sitting for
 30 minutes
NASOINTESTINAL TUBE
NASOINTESTINAL TUBE
 Longer than the nasogastric tube
 From one nostril to the small intestines
 Used for clients at risk for aspiration

 Decreased LOC
 Poor cough or gag reflex
 Restlessness and agitation
 Endotracheal intubation
PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY
JEJUNOSTOMY
GASTROSTOMY
 PEG
 To the stomach
 To provide nutrition
to
 Neurologic
disorders such as
a stroke or a
tumor of the
head, neck, or
esophagus
JEJUNOSTOMY
 PEJ
 To the jejunum
GASTROSTOMY/ JEJUNOSTOMY
 Stoma
 Liquid nutritional formulas are put into the

tube and directly into the stomach or
intestines
 Insert a feeding tube to the stoma

 Lubricate tube
 Insert into opening (4 to 6 inches)

 Check patency by getting aspirate
 Administer the feeding
 Hold the barrel of the syringe 3 to 6 in

above opening of the stoma
 Slowly pour solution
 Flush with 30 cc of water

 Remove the syringe and clamp or plug the

tube
 Ensure client comfort and safety

 Remain sitting for 30 minutes
 Assess the stoma
 Washed with soap and water once a
day
 Rotate the tube to avoid sticking in
the stoma
 Petrolatum and other skin protectant
may be applied
 Document
TOTAL PARENTERAL NUTRITION
 Or Intravenous
Hyperalimentation
 Used when the

gastrointestinal
tract is
nonfunctional
 Introduced directly to
the bloodstream
 Tube is inserted via

the:
 Subclavian vein
 Internal jugular vein
of the neck
 Femoral vein
 Brachial vein
 Subclavian Vein
 Internal jugular
vein of the neck
 Nursing Responsibilities:
 Maintain aseptic techniques
 Watch out for signs and symptoms of

embolism
 Pain
 Swelling
 Warmth on the site
 Infection
 Care of Insertion Site
 Application of sterile dressing with anti-

bacterial ointment as ordered by doctor
(PRN)
BLOOD TRANSFUSION
BLOOD TRANSFUSION
 Purposes:
 To administer required blood

component by the patient
 To restore blood volume

 RBC
 WBC
 Platelets
 Plasma Proteins
BLOOD TRANSFUSION
 Human blood is classified into four main

groups
 A
B
 AB
O
BLOOD TRANSFUSION
 Antigens
 Number of proteins in the red blood cell
surface
 Most important in determining blood type
(Blood Type Compatibility)
 Blood type A, Antigen A

 Blood type B, Antigen B
 Blood type AB, Antigen A and B
 Blood type O, No antigen
 Universal Donor
BLOOD TRANSFUSION
 Antibodies
 Preformed antibodies are present in the

plasma
 Blood Incompatibility
 Blood Type A, Antibody B

 Blood Type B, Antibody A
 Blood Type AB, Antibody None
 Universal Recipient
 Blood Type O, A and B

BLOOD TRANSFUSION
 Rh Factor
 The Rh factor antigen is present

 Rh+
 When the Rh factor antigen is not

present
 Rh –
 Filipinos
BLOOD TRANSFUSION
 Procedure:
1. Verify doctor’s order. Inform client and

explain the purpose of the procedure
2. Check for cross matching and blood

typing. To ensure compatibility
3. Obtain and record baseline VS

BLOOD TRANSFUSION
4. Practice safe asepsis
5. At least 2 nurses check the label of the

blood transfusion
> Check the following:
- Serial number
- Blood component
- Blood type
- Rh factor
- Expiration data
- Screening tests (VDRL for sexually
transmitted diseases, HBsAg for
hepatitis B; malarial smear for
malaria)
BLOOD TRANSFUSION
6. Warm blood at room temperature before

transfusion. To prevent chills
7. Identify client properly. Two nurses

check the client’s identification
8. Use needle gauge 18 or 19. This allows

easy flow of blood
9. Use BT (blood transfusion) set with filter.

To prevent administration of blood clots
and other particulates
BLOOD TRANSFUSION
10. Start infusion slowly at 10 gtts/minute. Remain

at bedside for 15 to 30 minutes. Adverse reaction
usually occurs during the first 15 to 20 minutes
11. Monitor VS. Altered VS indicates adverse

reaction
12. Do not mix medications with blood transfusion.

To prevent adverse effects
- Do not incorporate medication into the blood
transfusion
- Do not use the blood transfusion line for IV
push of medication
13. Administer 0.9% NaCl before, during or after

BT. Never administer IV fluids with dextrose.
Dextrose cause hemolysis.
BLOOD TRANSFUSION
 Complications:
- Allergic Reaction (flushing, rash, hives, pruritus,

laryngeal edema, DOB)
- Febrile, Non Hemolytic (sudden chills and fever,

flushing, headache, anxiety)
- Sepsis (rapid onset of chills, vomiting, marked

hypotension, high fever)
BLOOD TRANSFUSION
- Circulatory Overload (rise in venous pressure,

dyspnea, crackles or rales, distended neck vein,
cough, elevated BP)
- Hemolytic (low back pain, chills, feeling of

fullness, tachycardia, flushing, tachypnea,
hypotension, bleeding)
BLOOD TRANSFUSION
 Nursing Interventions When Complication

Occurs in Blood Transfusion
1. Stop blood transfusion immediately
2. Start an IV line (0.9% NaCl)

THANK YOU FOR LISTENING 

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FUNDAMENTALS OF NURSING

 Code of Hammurabi: Oldest Sanitation Code

 Early Christian Period

 Knights of St. John of Jerusalem

 Throughout history, wars have accentuated the

 WWI, WWII, American Civil War, Vietnam

 Free Education for Nurses

 Sir Sidney Herbert

 Training School of Deaconesses

 Where she stayed for 3 months

 Returning to London, she worked as

 Nightingale opened the Nightingale Training

 Served as model for other nursing schools

 Its graduates traveled to other countries

 Nightingales biggest contributions in

 First Nurse Theorist

 Hospital de Real de Manila (1577)

 San Lazaro Hospital (1578)

 San Juan de Dios Hospital (1596)

 Earliest Nursing Schools

 Iloilo Mission Hospital School of Nursing (1906)

 St. Luke’s Hospital School of Nursing (1907)

 Mary Johnston Hospital and School of Nursing

 Philippine General Hospital School of Nursing

 University of Santo Tomas College of Nursing

 Manila Central University College of Nursing

 University of the Philippines College of Nursing,

 FEU Institute of Nursing

 Anastacia Giron - Tupaz

- Nurse Chief Superintendent of PNA

 Philippine Nurse’s Association (PNA) – National

 Leah Samaco Pacquiz

 Came from the Latin word

 Meaning of the word

 Body of specific and unique knowledge

 Has 2 to 3 years of experience

 Does not require guidance and rules

 Capable of managing hospital units

 Clinical Nurse Specialist

 A nurse with an advanced degree,

 Example: Geriatric Nurse, Oncology

 A nurse with an advanced degree,

 Delivers independent practice to

 A nurse who completes a course of study

 Carries out preoperative visits and

 A nurse who completes a program in

 Provides prenatal and postnatal care

 A nurse usually with an advanced

 A nurse who functions at various levels

 Responsible for management and

 A nurse with an advanced degree who

 A nurse, usually with an advance degree

 Primary role of the nurse

 MOTHER SURROGATE ROLES

 With Health Care Professionals

 They carry more meaning than verbal

 Body movement or kinetics

 Voice quality (pitch and range) and non-

 Public Distance – 12 feet and beyond

 Cultural Artifacts – items in contact with interacting

 Identify therapeutic and non-therapeutic

 Open-ended or Closed-ended question?

 ‘Why’ or ‘What’ questions?