Fundamentals of Nursing p1

Far Eastern University-Institute of Nursing
In-House Nursing Review Hand-out
FUNDAMENTALS OF NURSING
OVERVIEW
I.
THEORETICAL FRAMEWORK of NURSING PRACTICE

A.
B.
C.
D.
E.
F.
G.
Nursing
Concepts of Health and Illness
Concepts of Stress
Homeostasis
Adaptation
Adaptation to Stress Physiological Response (Hans Selye)
Physiologic Indicators of Stress
II.
COPING STRATGIES (COPING MECHANISMS)

A. 2 Types of Coping Strategies
B. Relaxation Techniques
III.
PSYCHOLOGICAL RESPONSE
A. Task Oriented Behaviors
B. Defense Mechanisms
C. Common Defense Mechanisms
IV.
TYPES of NURSING DIAGNOSES

A. Formulating the Nursing Diagnosis
B. Collaborative Problems
V.
METHODS USED for ASSESSMENT

A. Collection of Data: Objective and Subjective
VI.
DOCUMENTING and REPORTING

A. Guidelines for Good Documentation and Reporting
B. Documentation
C. Documentation Systems
D. Nursing Care Plan (NCP)
E. KARDEX
F. Nursing Discharge / Referral Summaries
VII.
PHYSICAL EXAMINATION
A. Purposes
B. Preparation of Examination
C. Order of Examination
D. Skills in Physical Assessment
E. Examples of Adventitious Breath Sounds
VIII.
THE COMMUNICATION PROCESS

A. Modes of Communication
B. Verbal Communication
C. Nonverbal Communication
D. Factors Influencing the Communication Process
E. Therapeutic Communication Technique
F. Barriers to Communication
G. Phases of the Helping Relationship
PRINCIPLES and PRACTICE of NURSING CARE
IX.
PRINCIPLES of ASEPSIS and INFECTION CONTROL

A.
B.
C.
D.
E.
F.
G.
H.
X.
Chain of Infection
Modes of Transmission
Course of Infection
Inflammation
Immune Response
Nosocomial Infection
Factors Increasing Susceptibility to Infection
Diagnostic Tests Used to Screen for Infection
THEORIES OF PAIN
A. Specific Theory
B. Pattern Theory
C. Gate Control Theory
D. Current Developments in Pain Theory

XI.
TYPES OF PAIN
A.
B.
XII.
Acute Pain
Chronic Pain
PAIN ASSESSMENT
A. TOOLS/INSTRUMENTS USED
B. A B C D E method of pain assessment
C. P Q R S T assessment for pain perception
D. Pain History
ADMINISTRATION OF MEDICATIONS
XIII.
DRUG NOMENCLATURE and FORMS

A. Names
B. Classification
C. Forms
D. Types of Drug Actions
E. Principles in Administering Medications
XIV.
BASIC HUMAN NEEDS

A. Abraham Maslow
B. Maslows Characteristics of a SelfActualized Person
XV.
MEETING OXYGENATION NEEDS

A. Oxygenation
B. Cardiovascular Physiology
C. Structure and Function
D. Steps in the Process of Oxygenation
E.
MEETING NUTRITIONAL NEEDS
A. Principles of Nutrition
B. Nutrients
XVI.
XVII.
MEETING URINARY ELIMINATION NEEDS

A. Normal Urinary Function
B. Common Assessment Findings
XVIII.
URINARY CATHETERIZATION
A. Purposes
B. Necessary Equipment for Catheterization
C. Preparation of the Patient
D. Retention or Indwelling Catheter (Foley)
E. Procedure for Insertion
F. Caring for the Patient with an Indwelling Catheter
G. Removing the Indwelling Catheter and Aftercare of the Patient
XIX.
MEETING BOWEL ELIMINATION NEEDS

A. Factors that Influence Bowel Elimination
B. Characteristics of Normal Stool
C. Common Bowel Elimination Problems
XX.
TYPES of ENEMAS
A. Cleansing
B. Oil-Retention
C. Carminative
D. Astringent
XXI.
NASOGASTRIC and INTESTINAL TUBES

A. Nasogastric Tubes
B. Intestinal Tubes
XXII.
LOSS AND GRIEF

A. Loss
B. Grieving Process (Theories of Grief, Dying, and Mourning)
C. Anticipatory Grief
D. Complications of Bereavement
E. Symptoms of Normal Grief
F. Nursing Health Promotion (to facilitate mourning)
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1. THEORETICAL FRAMEWORK of NURSING PRACTICE

A. Nursing
As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia
Henderson: The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health. Its recovery, or to a peaceful death that
the client would perform unaided if he had the necessary strength, will or knowledge.
Help the client gain independence as rapidly as possible.
1. CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE
Theorist
FLORENCE
NIGHTINGALE
Description
Developed the first theory of nursing.
Focused on changing and manipulating the environment in order to

put the patient in the best possible conditions for nature to act.
HILDEGARD PEPLAU
Introduced the Interpersonal Model.
She defined nursing as a therapeutic, interpersonal process which

strives to develop a nurse-patient relationship in which the nurse
serves as a resource person, counselor and surrogate.
FAYE ABDELLAH
Defined nursing as having a problem-solving approach, with key

nursing problems related to health needs of people; developed list 21
nursing problem areas
IDA JEAN ORLANDO
Developed the three elements client behavior, nurse reaction and

nurse action compose the nursing situation. She observed that the
nurse provide direct assistance to meet an immediate need for help in
order to avoid or to alleviate distress or helplessness.
MYRA LEVINE
Described the Four Conservation Principles.

1. conservation of energy
2. conservation of structured integrity
3. conservation of personal integrity
4. conservation of social integrity
DOROTHY JOHNSON
Developed the Behavioral System Model.

1. Patients behavior as a system that is a whole with interacting
parts
2. how the client adapts to illness
3. goal of nursing is to reduce so that the client can move more
easily through recovery.
MARTHA ROGERS
Conceptualized the Science of Unitary Human Beings. She asserted

that human beings are more than different from the sum of their parts; the
distinctive properties of the whole are significantly different from those of
its parts.
DOROTHEA OREM
Emphasizes the clients self care needs; nursing care becomes

necessary when client is unable to fulfill biological, psychological,
developmental or social needs.
IMOGENE KING
Nursing process is defined as dynamic interpersonal process between

nurse, client and health care system.
BETTY NEUMAN
Stress reduction is a goal of system model of nursing practice. Nursing

actions are in primary, secondary or tertiary level of prevention
SISTER CALLISTA
ROY
Presented the Adaptation Model. She viewed each person as a unified

bio-psychosocial system in constant interaction with a changing
environment. The goal of nursing is to help the person adapt to changes
in physiological needs, self-concept, role function and interdependent
relations during health and illness.

LYDIA HALL
Introduced the notion that nursing centers around three components:

person(core), pathologic state and treatment(cure) and body(care).
JEAN WATSON
Conceptualized the Human Caring Model. She emphasized that nursing

is the application of the art and human science through transpersonal
caring transactions to help persons achieve mind-body-soul harmony,
which generates self-knowledge, self-control, self-care and self-healing.
ROSEMARIE RIZZO
PARSE
Introduced the Theory of Human Becoming. She emphasized free

choice of personal meaning in relating to value priorities, co-creating of
rhythmical patterns, in exchange with the environment and
contranscending in many dimensions as possibilities unfold.
MADELEINE
LENINGER
Developed the Transcultural Nursing Model. She advocated that

nursing is a humanistic and scientific mode of helping a client through
specific cultural caring processes (cultural values, beliefs and practices)
to improve or maintain a health condition
2.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
ROLES AND FUNCTION OF A NURSE

Caregiver the caregiver role has traditionally included those activities that assist the
client physically and psychologically while preserving the clients dignity.
Caregiving encompasses the physical, psychosocial, developmental, cultural and
spiritual levels.
Communicator communication is an integral to all nursing roles. Nurses communicate
with the client, support persons, other health professionals, and people in the
community. In the role of communicator, nurses identify client problems and then
communicate these verbally or in writing to other members of the health team. The
quality of a nurses communication is an important factor in nursing care.
Teacher as a teacher, the nurse helps clients learn about their health and the health care
procedures they need to perform to restore or maintain their health. The nurse
assesses the clients learning needs and readiness to learn, sets specific learning
goals in conjunction with the client, enacts teaching strategies and measures
learning.
Client advocate a client advocate acts to protect the client. In this role the nurse may
represent the clients needs and wishes to other health professionals, such as
relaying the clients wishes for information to the physician. They also assist clients
in exercising their rights and help them speak up for themselves.
Counselor counseling is a process of helping a client to recognize and cope with
stressful psychologic or social problems, to developed improved interpersonal
relationships, and to promote personal growth. It involves providing emotional,
intellectual, and psychologic support.
Change agent the nurse acts as a change agent when assisting others, that is, clients, to
make modifications in their own behavior. Nurses also often act to make changes
in a system such as clinical care, if it is not helping a client return to health.
Leader a leader influences others to work together to accomplish a specific goal. The
leader role can be employed at different levels; individual client, family, groups of
clients, colleagues, or the community. Effective leadership is a learned process
requiring an understanding of the needs and goals that motivate people, the
knowledge to apply the leadership skills, and the interpersonal skills to influence
others.
Manager the nurse manages the nursing care of individuals, families, and communities.
The nurse-manager also delegates nursing activities to ancillary workers and other
nurses, and supervises and evaluates their performance.
Case manager nurse case managers work with the multidisciplinary health care team to
measure the effectiveness of the case management plan and to monitor outcomes.
Research consumer nurses often use research to improve client care. In a clinical area
nurses need to:
Have some awareness of the process and language of research
Be sensitive to issues related to protecting the rights of human subjects
Participate in identification of significant researchable problems
Be a discriminating consumer of research findings
B. Concepts of Health and Illness

I.
Health As defined by the World Health Organization (WHO): state of complete

physical, mental and social well-being, not merely the absence of disease or infirmity.
a. Characteristics
i.
A concern for the individual as a total system
ii.
A view of health that identifies internal and external environment
iii.
An acknowledgment of the importance of an individuals role in life
A dynamic state in which the individual adapts to
changes in internal and external environment to maintain a state of well being
b. Models of Health and Illness
i.
Health-Illness Continuum (Neuman) Degree of client wellness that exist at

any point in time, ranging from an optimal wellness condition, with available
energy at its maximum, to death which represents total energy depletion.
ii. High Level Wellness Model (Halbert Dunn) It is oriented toward maximizing
the health potential of an individual. This model requires the individual to
maintain a continuum of balance and purposeful direction within the
environment.
iii. Agent Host environment Model (Leavell) The level of health of an
individual or group depends on the dynamic relationship of the agent, host and
environment
Agent any internal or external factor that disease or illness.
Host the person or persons who may be susceptible to a

particular illness or disease
Environment consists of all factors outside of the host

iv. Health Belief Model Addresses the relationship between a persons belief
and behaviors. It provides a way of understanding and predicting how clients
will behave in relation to their health and how they will comply with health care
therapies.
Four Components
The individual is perception of susceptibility to an illness
The individuals perception of the seriousness of the illness
The perceived threat of a disease
The perceived benefits of taking the necessary preventive

measures
v.
Evolutionary Based Model Illness and death serves as a evolutionary

function. Evolutionary viability reflects the extent to which individuals function
to promote survival and well-being. The model interrelates the following
elements:
Life events
Life style determinants
Evolutionary viability within the social context
Control perceptions
Viability emotions
Health outcomes
vi. Health Promotion Model A complimentary counterpart models of health

protection. Directed at increasing a clients level of well being. Explain the
reason for clients participation health-promotion behaviors. The model focuses
on three functions:
It identifies factors (demographic and socially) enhance or

decrease the participation in health promotion
It organizes cues into pattern to explain likelihood of a clients

participation health-promotion behaviors
It explains the reasons that individuals engage in health activities

II. Illness State in which a persons physical, emotional, intellectual, social
developmental or spiritual functioning is diminished or impaired. It is a condition
characterized by a deviation from a normal, healthy state.
a. 3 Stages of Illness
i.
Stage of Denial Refusal to acknowledge illness; anxiety, fear,
irritability and aggressiveness.
ii.
Stage of Acceptance Turns to professional help for assistance

iii.
Stage of Recovery (Rehabilitation or Convalescence) The patient

goes through of resolving loss or impairment of function
b. Rehabilitation
i.
A dynamic, health oriented process that assists individual who is ill or
disabled to achieve his greatest possible level of physical, mental,
spiritual, social and economical functioning.
ii.
Abilities not disabilities, are emphasized.
iii.
Begins during initial contact with the patient
iv.
Emphasis is on restoring the patient to independence or regain his preillness/predisability level of function as short a time as possible
v.
Patient must be an active participant in the rehabilitation goal setting
an din rehabilitation process.
c.
Focuses of Rehabilitation
i.
Coping pattern
ii.
Functional ability focuses on self-care: activities of daily living (ADL);
feeding, bathing/hygiene, dressing/grooming, toileting and mobility
iii.
Mobility
iv.
Integrity of skin
v.
Control of bowel and bladder function
C. Concepts of Stress
I. Stress
(Theory by Hans Selye)
a. Non specific response of the body to nay demand made upon it
b. Any situation in which a non specific demand requires an individual to respond or
take action
II. Characteristics of Stress
a. Stress is not nervous energy. Emotional reactions are common stressors
b. Stress is not always the result of damage to the body
c.
Stress does not always result in feelings of distress (harmful or unpleasant stress)
d. Stress is a necessary part of life and is essential for normal growth and
development
e. Stress involves the entire body acting as a whole and is an integrated manner
f.
Stress response is natural, productive and adaptive
III. Stressors Factor or agent producing stress, maybe: physiological, psychological,

social, environmental, developmental, spiritual or cultural and represent an unmet
needs
a. Classification of Stressors
i.
Internal Stressors originate from within the body. E.g. fever,
pregnancy, menopause, emotion such as guilt
ii.
External Stressors originate outside a person. E.g. change in

family or social role, peer pressure, marked change in
environmental temperature
b. Factors influencing response to stressors

i.
Physiological functioning
ii.
Personality
iii.
Behavioral characteristics
iv.
Nature of the stressor: integrity, scope, duration, number, and
nature of other stressors
D. Homeostasis Process of maintaining uniformity, stability and constancy with in the living
organisms. (from Greek word homotos like, and stasis position)
E. Adaptation Bodys adjustment to different circumstances and conditions. Process by the
physiological or psychological dimensions change in response to stress; attempt to maintain
optimal functioning

F. Adaptation to Stress-Physiological Response (Hans Selye)

I. Local Adaptation Syndrome (LAS) Response of a body tissue, organ or part to the
stress of trauma, illness or other physiological change
a.
Characteristics
i.
The response is localized, it does not involve entire body systems
ii.
The response is adaptive, meaning that a stressor is necessary to stimulate it
iii.
The response is short term. It does not persist indefinitely
iv.
The response is restorative, meaning that the LAS assists in restoring
homeostasis to the body region or part
b.
Two Localized Responses

i.
Reflex Pain Response is a localized response of the central
nervous system to pain. It is an adaptive response and protects tissue from
further damage. The response involves a sensory receptor, a sensory nerve
from the spinal cord, and an effector muscle. An example would be the
unconscious, reflex removal of the hand from a hot surface.
ii.
c.
Inflammatory Response is stimulated by trauma or infection. This response

localizes the inflammation, thus revenging its spread and promotes healing.
The inflammatory response may produce localized pain, swelling, heat,
redness and changes in functioning.
Three Phases of Inflammatory Response

i. First Phase Narrowing of blood vessels occurs at the injury to control bleeding.
Then histamine is released at the injury, increasing the number of white blood
cells to combat infection.
ii.
Second Phase It is characterized by release of exudates from the wound
iii. Third Phase The last phase is repair of tissue by regeneration or scar
formation. Regeneration replaces damaged cells with identical or similar cells.
The three stages of adaptation to stress: the alarm reaction, the

stage of resistance and the stage of exhaustion.
II. General Adaptation Syndrome (GAS) or Stress Syndrome characterized by a

chain or pattern of physiologic events.
a. 3 Stages
i.
Alarm Reaction initial reaction of the body which alerts the bodys
defenses. SELYE divided this stage into 2 parts:
The SHOCK PHASE
The COUNTERSHOCK PHASE
ii.
Stage of Resistance occurs when the bodys adaptation takes
place; the body attempts to adjust with the stressor and to limit the
stressor to the smallest area of the body that can deal with it.
iii.
Stage of Exhaustion the adaptation that the body made during
the second stage cannot be maintained; the ways used to cope
with the stressors have been exhausted
Stressor
Shock Phase
Epinephrine
Tachycardia
Myocardial contractility
Blood clotting
Metabolism
Norepinephrine
Blood to kidney
Renin
Cotisone
Protein catablism
Gluconeogenesis
Stage of Resistance
Adaptation
Stage of Exhaustion

b. STRESSORS stimulate the sympathetic nervous system, which in turn

stimulates the hypothalamus. The HYPOTHALAMUS releases corticotrophin
releasing hormone (CRH). During times of stress, the ADRENAL MEDULLA
secretes EPINEPHRINE & NOREPINEPHRINE in response to sympathetic
stimulation. Significant body responses to epinephrine include the following:
i.
Increased myocardial contractility, which increases cardiac output
& blood flow to active muscles
ii.
Bronchial dilation, which allows increased oxygen intake
iii.
Increased blood clotting
iv.
Increased cellular metabolism
v.
Increased fat mobilization to make energy available & to
synthesize other compounds needed by the body.
G. Physiologic Indicators of Stress
a.
Pupils dilate to increase visual perception when serious threats to the body arise.
b.
Sweat production (diaphoresis) increases to control elevated body heat due to

increased metabolism.
c.
The heart rate & cardiac output increase to transport nutrients and by-products of
metabolism more efficiently.
d.
Skin is pallid because of constriction of peripheral vessels, an effect of norepinephrine.
e.
Sodium & water retention increase due to release of mineralocorticoids, which results
in increased blood volume.
f.
The rate & depth of respirations increase because of dilation of the bronchioles,
promoting hyperventilation.
g.
Urinary output may increase or decreases.
h.
The mouth may be dry.
i.
Peristalsis of the intestines decreases, resulting in possible constipation and flatus.
j.
For serious threats, mental alertness improves.
k.
Muscle tension increases to prepare for rapid motor activity or defense.
l.
Blood sugar increases because of release of glucocorticoids & gluconeogenesis.
H. Psychologic Indicators psychologic manifestations of stress include anxiety, fear, anger,

depression & unconscious ego defense mechanisms.
a. Anxiety a common reaction to stress. It is a state of mental uneasiness, apprehension,
dread, or foreboding or a feeling of helplessness related to an impending or
anticipated unidentified threat to self or significant relationships. It can be
experienced, subcutaneous or unconscious level. Can be manifested on 4
LEVELS:
b. Fear an emotion or feeling of apprehension aroused by impending or seeming danger,
or other perceived threat. The object of fear may or may not be based in reality.
c. Anger an emotional state consisting of a subjective feeling of animosity or strong
displeasure. People may feel guilty when they feel anger because they have been
taught that to feel angry is wrong.
d. Depression common reaction to events that seem overwhelming or negative. It is an
extreme feeling of sadness, despair, dejection, lack of worth or emptiness.
Emotional symptoms can include: Feelings of tiredness, sadness, emptiness, or numbness
Behavioral signs include: Irritability, inability to concentrate, difficulty making decisions, loss of
sexual desire, crying, sleep disturbance and social withdrawal.
Physical signs include: Loss of appetite, weight loss, constipation, headache and dizziness
I.
Cognitive Indicators are thinking responses that include problem-solving, structuring,

self-control or self-discipline, suppression and fantasy

a.
Problem solving involves thinking through the threatening situation, using a

specific steps to arrive at a solution
b.
Structuring arrangement or manipulation of a situation so that threatening

events do not occur.
c.
Self-Control (discipline) assuming a manner of facial expression that convey

a sense of being in control or in change.
d.
Suppression consciously and willfully putting a thought or feeling out of mind
e.
Fantasy (daydreaming) likened to make believe. Unfulfilled wishes &

desires are imagined as fulfilled, or a threatening experience is reworked or
replayed so that it ends differently from reality.
2. COPING STRATEGIES (COPING MECHANISMS)
Coping dealing with problems & situations or contending with them successfully.
Coping Strategy innate or acquired way of responding to a changing environment or specific
problem or situation.
According to Folkman and Lazarus, coping is the cognitive & behavioral effort to manage specific
external and/ or internal demands that are appraised as taxing or exceeding the resources of the
person.
A. Coping Strategies: 2 Types
I. Problem-focused coping efforts to improve a situation by making changes or taking
some action
II. Emotion-focused coping does not improve the situation, but the person often feels
better.
Coping strategies are also viewed as:
a. Long-term coping strategies can be constructive & realistic
b. Short-term coping strategies can reduce stress to a tolerable limit temporarily
but are in the end od ineffective ways to deal with reality.
Coping can be adaptive or maladaptive:
B. Adaptive Coping helps the person to deal effectively with stressful events &
minimizes distress associated with them.
C. Maladaptive Coping can result in unnecessary distress for the person &
others associated with the person or stressful event.
*Effective coping results in adaptation; ineffective coping results in maladaptation.
The effectiveness of an
individuals coping is influenced by a number of factors:
The number, duration & intensity of the stressors
Past experiences of the individual
Support systems available to the individual
Personal qualities of the person
*If the duration of the stressors is extended beyond the coping powers of the
individual, that person becomes exhausted and may develop increased
susceptibility to health problems.
*Reaction to long term stress is seen in family members who undertake the care of
a person in the home for a long period. This stress is called caregiver burden &
produces responses such as chronic fatigue, sleeping difficulties & high BP.
*Prolonged stress can also result in mental illness.
D. Relaxation Techniques used to quiet the mind, release tension & counteract the fight or
flight responses of General Adaptation Syndrome (GAS).
I. Breathing Exercises
II. Massage
III. Progressive Relaxation
IV. Imagery

V. Biofeedback
VI. Yoga
VII. Meditation
VIII.Therapeutic Touch
IX. Music Therapy
X. Humor & Laughter
3. PSYCHOLOGICAL RESPONSE
Exposure to a stressor results in psychological and physiological and physiological adaptive
responses. As people are exposed a stressors, their ability to meet their basic needs is threatened.
This threat whether actual or perceived, produces frustration, anxiety and tension. Psychological
adaptive behaviors assist the persons ability to cope with stressors. These behaviors are directed
at stress management and are acquired through learning and experience as a person identifies
acceptable and successful behaviors.
Psychological adaptive behaviors are also related to as COPING MECHANISMS. It involves:
A. Task Oriented Behaviors Involve using cognitive abilities to reduce stress, solve problems,
resolve conflicts and gratify needs. It enables a person to cope realistically with the demands of
a stressor.
Three General Types
I. Attack Behavior Is acting to remove or overcome a stressor or to satisfy a need
II. Withdrawal Behavior Is removing the self physically or emotionally from the
stressor
III. Compromise Behavior Is changing the usual method of operating, substituting
goals or omitting the satisfaction of needs to meet other needs or to avoid stress.
B. Defense Mechanisms Unconscious behaviors that offer psychological protection from a
stressful event. They are used by everyone and help protect against feelings of worthlessness
and anxiety. Frequently activated by short-term stressors and usually do not result in psychiatric
disorders.
4. TYPES OF NURSING DIAGNOSES
A. Formulating the Nursing Diagnosis
I. Actual
a. Clients demonstrates defining characteristics of a problem
b. Nurse intervenes to resolve or help client cope with the problem
II. High-risk
a. A problem is likely to develop based on assessment of risk factors
b. Nurse intervenes to reduce risk factors or increase protective factors
c. Example: encourage smoking cessation
III. Wellness
a. Client is presently healthy but wishes to achieve a higher level of function
b. Nurse intervenes to promote growth or maintenance of the healthy response
B. Collaborative Problems
I. Definition: a potential problem the nurse manages using both independent and
interdependent interventions
II. Example: potential complication of head injury: loss of consciousness, epidural or
subdural hematoma, seizures
III. Usually occurs when a disease is present or a treatment is prescribed
IV. Clients with similar disease or treatment will have the same potential for
complications, which must be managed collaboratively; however, their responses to
the condition will vary, so a broad range of nursing diagnoses will apply.
a. Example: a client with asthma will always be at risk for lowered oxygen
saturation; however, the clients response to this condition will be unique based
on his/her developmental level, past experiences and family configuration
b. Refer to Table for examples of collaborative problems
Example:
10

Disease/Situation
Potential complication
of childbirth
Potential complication
of diuretic therapy
Complication
Hemorrhage
Related to
Related to
Dysrhythmia
Related to
Etiology
1.Uterine atony
2. Retained placental
fragment
3. Bladder distention
Low serum potassium
5. METHODS USED for ASSESSMENT

A. Collaboration of Data: Objective & Subjective
I.
Review of clinical record

a. Client records contain information collected by many members of the
healthcare team, such as demographics, past medical history, diagnostic test
results and consultations
b. Reviewing the clients record before beginning an assessment prevents the
nurse from repeating questions that the client has already been asked and
identifies information that needs clarification.
II. Interview
a. The purpose of an interview is to gather and provide information, identify
problems of concerns, and provide teaching and support.
b. The goals of an interview are to develop a rapport with the client and to collect
data
c. An interview has 3 major stages
i.
Opening: purpose is to establish rapport by creating goodwill and
trust; this is often achieved through a self introduction, nonverbal
gestures (a handshake), and small talk about the weather, local
sports team, or recent current event; the purpose of the interview
is also explained to the client at this time.
ii.
Body: during this phase, the client responds to open and closedended questions asked by the nurse.
iii.
Closing: either the client or the nurse may terminate the interview,
it is important fro the nurse to try to maintain the rapport and trust
that was developed thus far during the interview process.
d. Types of questions
i.
Closed questions used in directive interview
Re____ short factual answers; e.g. Do you have pain?
Answers usually reveal limited amounts of information
Useful with clients who are highly stressed and/or have
difficulty communicating
ii.
Open-ended questions used in nondirective interview

Encourage clients to express and clarify their thoughts and
feelings; e.g. How have you been sleeping lately?
Specify the broad area to be discussed and invite longer
answers
Useful at the start of an interview or to change the subject
iii.
Leading questions
Direct the clients answer; e.g. You dont have any questions
about your medications, do you?
Suggests what answer is expected
Can result in client giving inaccurate data to please the nurse
Can limit client choice of topic for discussion
III. Nursing History

a. Collection of information about the effect of the clients illness on daily
functioning and ability to cope with the stressor (the human response)
11

b. Subjective data
i.
May be called covert data
ii.
Not measurable or observable
iii.
Obtained from client (primary source), significant others, or health
professionals (secondary sources).
iv.
For example, the client states, I have a headache
c.
Objective data
i.
May be called overt data
ii.
Can be detected by someone other than the client
iii.
Includes measurable and observable client behavior
iv.
For example, a blood pressure reading of 190/110 mmHg.
IV. Physical assessment

a. Systematic collection of information about the body systems through the use of
observation, inspection, auscultation, palpation and percussion
b. A body system format for physical assessment is found below:
General assessement
Integumentary system
Head, ears, eyes, nose, throat
Breast and axillae
Thorax and lungs
Cardiovascular system
Nervous system
Abdomen and gastrointestinal system
Anus and rectum
Genitourinary system
Reproductive system
Musculoskeletal system
V. Psychosocial assessment
a. Helpful framework for organizing data
b. A suggested format for psychosocial assessment is found below:
c.
Vocation/education/financial
Home and Family
Social, leisure, spiritual and cultural
Sexual
Activities of daily living
Health Habits
Psychological
The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may

also be helpful for guiding data collection
VI. Consultation
a. The nurse collects data from multiple sources: primary (client) and secondary
(family members, support persons, healthcare professionals and records)
b. Consultation with individuals who can contribute to the clients database is
helpful in achieving the most complete and accurate information about a client
c. Supplemental information from secondary sources (any source other then the
client) can help verify information, provide information for a client who cannot
do so, and convey information about the clients status prior to admission
VII. Review of literature
a. A professional nurse engages in continued education to maintain knowledge of
current information related to health care
b. Reviewing professional journals and textbooks can help provide additional data
to support or help analyze the client database
6.
DOCUMENTING and REPORTING
A. Guidelines for Good Documentation and Reporting
12

I.
II.
III.
IV.
V.
VI.
Fact information about clients and their care must be factual. A record should contain
descriptive, objective information about what a nurse sees, hears, feels and smells
Accuracy information must be accurate so that health team members have confidence
in it
Completeness the information within a record or a report should be complete,
containing concise and thorough information about a clients care. Concise data are
easy to understand
Currentness ongoing decisions about care must be based on currently reported
information. At the time of occurrence include the following:
a.
Vital signs
b.
Administration of medications and treatments
c.
Preparation of diagnostic tests or surgery
d.
Change in status
e.
Admission, transfer, discharge or death of a client
f.
Treatment fro a sudden change in status
Organization the nurse communicate in a logical format or order
Confidentiality a confidential communication is information given by one person to
another with trust and confidence that such information will not be disclosed
B. Documentation anything written or printed that is relied on as a record of proof fro

authorized persons.
Purposes of Records:
I. Communication
II. Planning Client Care
III. Auditing Health Agencies
IV. Research
V. Education
VI. Reimbursement
VII. Legal Documentation
VIII.Health Care Analysis
C. Documentation Systems
I. Source Oriented Record
a. The traditional client record
b. Each person or department makes notations in a separate section or sections
of the clients chart
c. It is convenient because care providers from each discipline can easily locate
the forms on which to record data and it is easy to trace the information
d. Example: the admissions department has an admission sheet; the physician
has a physicians order sheet, a physicians history sheet & progress notes
e. NARRATIVE CHARTING is a traditional part of the source-oriented record
II. Problem Oriented Medical Record (POMR)
a. Established by Lawrence Weed
b. The data are arranged according to the problems the client has rather than the
source of the information.
The four (4) basic components:
i.
Database consists of all information known about the client when
the client first enters the health care agency. It includes the
nursing assessment, the physicians history, social & family data
ii.
Problem List derived from the database. Usually kept at the front
of the chart & serves as an index to the numbered entries in the
progress notes. Problems are listed in the order in which they are
identified & the list is continually updated as new problems are
identified & others resolved
iii.
Plan of Care care plans are generated by the person who lists
the problems. Physicians write physicians orders or medical care
plans; nurses write nursing orders or nursing care plans
iv.
Progress Notes chart entry made by all health professionals
involved in a clients care; they all use the same type of sheet fro
notes. Numbered to correspond to the problems on the problem
list and may be lettered for the type of data
Example: SOAP Format Or SOAPIE and SOAPIER
S Subjective data
O Objective data
A Assessment
13

P Plan
I Intervention
E Evaluation
R- Revision
Advantages of POMR:
It encourages collaboration
Problem list in the front of the chart alerts caregivers to the
clients needs & makes it easier to track the status of each
problem.
Disadvantages of POMR:
Caregivers differ in their ability to use the required charting
format
Takes constant vigilance to maintain an up-to-date problem list
Somewhat inefficient because assessments & interventions
that apply to more than one problem must be repeated.
III. PIE (Problems, Interventions, and Evaluation)
a. Groups information in to three (3) categories
b. This system consists of a client care assessment floe sheet & progress notes
c. FLOW SHEET uses specific assessment criteria in a particular format, such
as human needs or functional health patterns
d. Eliminate the traditional care plan & incorporate an ongoing care plan into the
progress notes
IV. Focus Charting
a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns fro recording are usually used: date & time, focus &
progress notes
V. Charting by Exception
a. Documentation system in which only abnormal or significant findings or
exceptions to norms are recorded
b. Incorporates three (3) key elements:
i.
Flow sheets
ii.
Standards of nursing care
iii.
Bedside access to chart forms
VI. Computerized Documentation
a. Developed as a way to manage the huge volume of information required in
contemporary health care
b. Nurses use computers to store the clients database, add new data, create &
revise care plans & document client progress.
VII. Case Management
a. Emphasizes quality, cost-effective care delivered within an established length
of stay
b. Uses a multidisciplinary approach to planning & documenting client care, using
critical pathways.
D. Nursing Care Plan (NCP)
Two Types:
I. Traditional Care Plan written fro each client; it has 3 columns: nursing diagnoses,
expected outcomes & nursing interventions.
II. Standardized Care Plan based on an institutions standards of practice; thereby
helping to provide a high quality of nursing care
E. KARDEX widely used, concise method of organizing & recording data about a client, making
information quickly accessible to all health professionals. Consists of a series of cards kept in a
portable index file or on computer generated forms. Information may be organized into
sections:
I. Pertinent information about the client
II. List of medications
III. List of IVF
IV. List of daily treatments & procedures
V. List of Diagnostic procedures
14

VI. Allergies
VII. Specific data on how the clients physical needs are to be met
VIII.A problem list, stated goals & list of nursing approaches to meet the goals
F. Nursing Discharge / Referral Summaries completed when the client is being discharged &
transferred to another institution or to a home setting where a visit by a community health nurse
is required. Regardless of format, it include some or all of the following:
I. Description of clients physical, mental & emotional state
II. Resolved health problems
III. Unresolved continuing health problems
IV. Treatments that can be continued (e.g. wound care, oxygen therapy)
V. Current medications
VI. Restrictions that relate to activity, diet & bathing
VII. Functional/self-care abilities
VIII.Comfort level
IX. Support networks
X. Client education provided in relation to disease process
XI. Discharge destination
XII. Referral Services (e.g. social worker, home health nurse)
7. PHYSICAL EXAMINATION
A. Purposes
The nurse uses physical assessment for the following reasons:
I. To gather baseline data about the clients health
II. To supplement, confirm or refute data obtained in the nursing history
III. To confirm and identify nursing diagnoses
IV. To make clinical judgments about a clients changing health status and management
B. Preparation of Examination
I. Environment A physical examination requires privacy. An examination room that is
well equipped for all necessary procedures is preferable
II. Equipment Hand washing is done before equipment preparation and the
examination. Hand washing reduces the transmission of microorganisms
III. Client
a. Psychological Preparation clients are easily embarrassed when forced to
answer sensitive questions about bodily functions or when body parts are
exposed and examined. The possibility that the examination will find something
abnormal also creates anxiety so reduction of this anxiety may be the nurses
highest priority before the examination
b. Physical Preparation the clients physical comfort is vital to the success of the
examination. Before starting, the nurse asks if the client needs to use the toilet.
c. Positioning during the examination, the nurse asks the clients to assume
proper positions so that body parts are accessible and clients stay comfortable.
Clients abilities to assume positions will depend on their physical strength and
degree of wellness.
C. Order of Examination
I. General Survey includes observation of general appearance and behavior, vital
signs, height and weight measurement
II. Review of systems
III. Head to toe examination
D. Skills in Physical Examination
I. Inspection to detect normal characteristics or significant physical signs. To inspect
body parts accurately the nurse observes the following principles:
a. Make sure good lighting is available
b. Position and expose body parts so that all surface can be viewed
c. Inspect each areas fro size, shape, color, symmetry, position and abnormalities
d. If possible, compare each area inspected with the same area of the opposite
side of the body
e. Use additional light (for example, a penlight) to inspect body cavities
II. Palpation the hands can make delicate and sensitive measurements of specific
physical signs, so palpation is used to examine all accessible parts of the body. The
nurse uses different parts of the hand to detect characteristics such as texture,
temperature and the perception of movement.
15

III. Percussion examination by striking the bodys surface with a finger, vibration and
sound are produced. This vibration is transmitted through the body tissues and the
character of the sound depends on the density of the underlying tissue
IV. Auscultation is listening to sound created in body organs to detect variations from
normal. Some sounds can be heard with the unassisted ear, although most sounds
can be heard only through a stethoscope.
a. Bowel sounds
b. Breath sounds
i.
Vesicular
ii.
Bronchovesicular
iii.
Bronchial
E. Examples of Adventitious Breath Sounds
I. Crackles (previously called rales)
II. Rhonchi
III. Wheeze
IV. Friction rub
Therapeutic Communication Techniques
1. Using silence
2. Providing general leads
3. Being specific & tentative
4. Using open-ended questions
5. Using touch
6. Restating to paraphrasing
7. Seeking clarification
8. Perception checking or seeking consensual validation
9. Offering self
10. Giving information
11. Acknowledging
12. Clarifying time or sequence
13. Presenting reality
14. Focusing
15. Reflecting
16. Summarizing & planning
B. Barriers to Communication
1. Stereotyping
2. Agreeing & disagreeing
3. Being defensive
4. Challenging
5. Probing
6. Testing
7. Rejecting
8. Changing topics & subjects
9. Unwarranted reassurance
10. Passing judgment
11. Giving common advice
Phases of the Helping Relationship
12. Pre-interaction Phase
13. Introductory Phase
a. Opening the relationship
b. Clarifying the problem
c. Structuring & formulating the contract
14. Working Phase
a. Exploring & understanding thoughts or feelings
b. Facilitating & taking action
15. Termination Phase
8. PRINCIPLES of ASEPSIS and INFECTION CONTROL
A. Chain of Infection
I. The chain of infection refers to those elements that must be present to cause an
infection from a microorganism
16

II. Basic to the principle of infection is to interrupt this chain so that an infection from a
microorganism does not occur in clients
III. Infectious agent; microorganisms capable of causing infections are referred to as an
infectious agent or pathogen.
IV. Modes of transmission: the microorganism must have a means of transmission to
get from one location to another, called direct and indirect
V. Susceptible host describes a host (human or animal) not possessing enough
resistance against a particular pathogen to prevent disease or infection from
occurring when exposed to the pathogen; in humans this may occur if the persons
resistance is low because of poor nutrition, lack of exercise of a coexisting illness that
weakens the host.
VI. Portal of entry: the means of a pathogen entering a host: the means of entry can be
the same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary
tract).
VII. Reservoir: the environment in which the microorganism lives to ensure survival; it
can be a person, animal, arthropod, plant, oil or a combination of these things;
reservoirs that support organism that are pathogenic to humans are inanimate
objects food and water, and other humans.
VIII.Portal of exit: the means in which the pathogen escapes from the reservoir and can
cause disease; there is usually a common escape route for each type of
microorganism; on humans, common escape routes are the gastrointestinal,
respiratory and the genitourinary tract.
Modes of Transmission
1. Direct contact: describes the way in which microorganisms are transferred
from person to person through biting, touching, kissing, or sexual
intercourse; droplet spread is also a form of direct contact but can occur
only if the source and the host are within 3 feet from each other;
transmission by droplet can occur when a person coughs, sneezes, spits,
or talks.
2. Indirect contact: can occur through fomites (inanimate objects or materials)
or through vectors (animal or insect, flying or crawling); the fomites or
vectors act as vehicle for transmission
3. Air: airborne transmission involves droplets or dust; droplet nuclei can
remain in the air for long periods and dust particles containing infectious
agents can become airborne infecting a susceptible host generally through
the respiratory tract
B. Course of Infection
I.
Incubation: the time between initial contact with an infectious agent until the first
signs of symptoms - - > the incubation period varies from different
pathogens; microorganisms are growing and multiplying during this stage
II. Prodromal Stage: the time period from the onset of nonspecific symptoms to the
appearance of specific symptoms related to the causative pathogen
- - > symptoms range from being fatigued to having a low-grade fever with
malaise; during this phase it is still possible to transmit the pathogen to
another host
III. Full Stage: manifestations of specific signs & symptoms of infectious agent;
referred to as the acute stage; during this stage, it may be possible to transmit the
infectious agent to another, depending on the virulence of the infectious agent
IV. Convalescence: time period that the host takes to return to the pre-illness stage;
also called the recovery period; - - >the host defense mechanisms have responded
to the infectious agent and the signs and symptoms of the disease disappear; the
host, however, is more vulnerable to other pathogens at this time; an appropriate
nursing diagnostic label related to this process would be Risk for Infection
17

C. Inflammation The protective response of the tissues of the body to injury or infection; the
physiological reaction to injury or infection is the inflammatory response; it may be acute or
chronic
Bodys response
I. The inflammatory response begins with vasoconstriction that is followed by a brief
increase in vascular permeability; the blood vessels dilate allowing plasma to escape
into the injured tissue
II. WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and
attack and ingest the invaders (phagocytosis); this process is responsible for the
signs of inflammation
III. Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as
a result of the heat from the increased blood in the area, swelling occurs from fluid
accumulation; the pain occurs from pressure or injury to the local nerves.
D. Immune Response
I. The immune response involves specific reactions in the body to antigens or foreign
material
II. This specific response is the bodys attempt to protect itself, the body protects itself
by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes
III. Cell mediated immunity: T-lymphocytes are responsible for cellular immunity
a. When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they
enter the circulation from lymph tissue and seek out the antigen
b. Once theantigen is found they produce proteins (lymphokines) that increase
the migration of phagocytes to the area and keep them there to kill the antigen
c. After the antigen is gone, the lymphokines disappear
d. Some T-lymphocytes remain and keep a memory of the antigen and are
reactivated if the antigen appears again.
IV. Humoral response: the ability of the body to develop a specific antibody to a specific
antigen (antigen-antibody response)
a. B-lymphocytes provide humoral immunity by producing antibodies that convey
specific resistance to many bacterial and viral infections
b. Active immunity is produced when the immune system is activated either
naturally or artificially.
i.
Natural immunity involves acquisition of immunity through
developing the disease
ii.
Active immunity can also be produced through vaccination by
introducing into the body a weakened or killed antigen (artificially
acquired immunity)
iii.
Passive immunity does not require a host to develop antibodies,
rather it is transferred to the individual, passive immunity occurs
when a mother passes antibodies to a newborn or when a person
is given antibodies from an animal or person who has had the
disease in the form of immune globulins; this type of immunity only
offers temporary protection from the antigen.
E. Nosocomial Infection
I. Nosocomial Infections: are those that are acquired as a result of a healthcare
delivery system
II. Iatrogenic infection: these nosocomial infections are directly related to the clients
treatment or diagnostic procedures; an example of an iatrogenic infection would be a
bacterial infection that results from an intravascular line or Pseudomonas aeruginosa
pneumonia as a result of respiratory suctioning
III. Exogenous Infection: are a result of the healthcare facility environment or personnel;
an example would be an upper respiratory infection resulting from contact with a
caregiver who has an upper respiratory infection
IV. Endogenous Infection: can occur from clients themselves or as a reactivation of a
previous dormant organism such as tuberculosis; an example of endogenous
infection would be a yeast infection arising in a woman receiving antibiotic therapy;
18

the yeast organisms are always present in the vagina, but with the elimination of the
normal bacterial flora, the yeast flourish.
F. Factors Increasing Susceptibility to Infection
I. Age: young infants & older adults are at greater risk of infection because of reduced
defense mechanisms
a. Young infants have reduced defenses related to immature immune systems
b. In elderly people, physiological changes occur in the body that make them
more susceptible to infectious disease; some of these changes are:
i.
Altered immune function (specifically, decreased phagocytosis by
the neutrophils and by the macrophages)
ii.
Decreased bladder muscle tone resulting in urinary retention
iii.
Diminished cough reflex, loss of elastic recoil by the lungs leading
to inability to evacuate normal secretions
iv.
Gastrointestinal changes resulting in decreased swallowing ability
and delayed gastric emptying.
II. Heredity: some people have a genetic predisposition or susceptibility to some
infectious diseases
III. Cultural practices: healthcare beliefs and practices, as well as nutritional and hygiene
practices, can influence a persons susceptibility to infectious diseases
IV. Nutrition: inadequate nutrition can make a person more susceptible to infectious
diseases; nutritional practices that do not supply the body with the basic components
necessary to synthesized proteins affect the way the bodys immune system can
respond to pathogens
V. Stress: stressors, both physical and emotional, affect the bodys ability to protect
against invading pathogens; stressors affect the body by elevating blood cortisone
levels; if elevation of serum cortisone is prolonged, it decreases the anti-inflammatory
response and depletes energy stores, thus increasing the risk of infection
VI. Rest, exercise and personal health habits: altered rest and exercise patterns
decrease the bodys protective, mechanisms and may cause physical stress to the
body resulting in an increased risk of infection; personal health habits such as poor
nutrition and unhealthy lifestyle habits increase the risk of infectious over time by
altering the bodys response to pathogens
VII. Inadequate defenses: any physiological abnormality or lifestyle habit can influence
normal defense mechanisms in the body, making the client more susceptible to
infection; the immune system functions throughout the body and depends on the
following:
a. Intact skin and mucous membranes
b. Adequate blood cell production and differentiation
c. A functional lymphatic system and spleen
d. An ability to differentiate foreign tissue and pathogens from normal body tissue
and flora; in autoimmune disease, the body has a problem with recognizing its
own tissue and cells; people with autoimmune disease are at increased risk of
infection related to their immune system deficiencies.
VIII.Environmental: an environment that exposes individuals to an increased number of
toxins or pathogens also increases the risk of infection; pathogens grow well in warm
moist areas with oxygen (aerobic) or without oxygen (anaerobic) depending on the
microorganism, an environment that increases exposure to toxic substances also
increases risk
IX. Immunization history: inadequately immunized people have an increased risk of
infection specifically for those diseases for which vaccines have been developed.
X. Medications and medical therapies: examples of therapies and medications that
increase clients risk for infection includes radiation treatment, anti-neo-plastic drugs,
anti inflammatory drugs and surgery
G. Diagnostic Tests Used to Screen for Infection
I. Signs and symptoms related to infections are associated with the area infected; for
instance, symptoms of a local infection on the skin or mucous membranes are
localized swelling, redness, pain and warmth
19

II. Symptoms related to systemic infections include fever, increased pulse &
respirations, lethargy, anorexia, and enlarged lymph nodes
III. Certain diagnostic tests are ordered to confirm the presence of an infection.
9. THEORIES OF PAIN
A. Specific Theory
I. Proposes that bodys neurons & pathways for pain transmission are specific, similar
to other senses like taste
II. Free nerve endings in the skin act as pain receptors, accept input & transmit
impulses along highly specific nerve fibers
III. Does not account for differences in pain perception or psychologic variables among
individuals.
B. Pattern Theory
I. Identifies 2 major types of pain fibers; rapidly & slowly conducting
II. Stimulation of these fibers forms a pattern; impulses ascend to the brain to be
interpreted as painful
III. Does not account for differences in pain perception or psychologic variables among
individuals.
C. Gate Control Theory
I. Pain impulses can be modulated by a transmission blocking action within the CNS.
II. Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or scratching
an area) and may inhibit smaller diameter fibers to prevent transmission of the
impulse (close the gate).
D. Current Developments in Pain Theory Indicate that pain mechanisms & responses are far
more complex than believed to be in the past.
I. Pain may modulated at different points in the nervous system.
a. First-order neurons at the tissue level
b. Second-order neurons in the spinal cord that process nociceptor information
c. Third-order tracts & pathways in the spinal cord & brain that relay/process this
information
II. The role of the pain experience in the development of new nociceptors and/or
reducing the threshold of current nociceptor is also being investigate
10. TYPES OF PAIN
A. Acute Pain
I. Usually temporary, sudden in onset, localized, lasts for 6 months; results from tissue
injury associated with trauma, surgery, or inflammation.
Types of Acute Pain
a. Somatic: arises from nerve receptors in the skin or close to bodys surface;
may be sharp & well-localized or dull & diffuse; often accompanied by nausea
& vomiting
b. Visceral: arises from bodys organs; dull & poorly localized because of minimal
noriceptors; accompanied by nausea & vomiting, hypotension & restlessness
c.
Referred pain: pain that is perceived in an area distant from the site of stimuli
(e.g. pain in a shoulder following abdominal laparoscopic procedure).
II. Acute pain initiates the fight-or-flight response of the Autonomic Nervous System
and is characterized by the following symptoms:
a. Tachycardia
b. Rapid, shallow respirations
c. Increased BP
d. Sweating
e. Pallor
f. Dilated pupils
g. Fear & Anxiety
20

B. Chronic Pain
I. Prolonged, lasting longer than 6 months, often not attributed to a definite cause, often
unresponsive to medical treatment.
Types of Chronic Pain
a. Neuropathic: painfuil condition that results from damage to peripheral nerves
caused by infection or disease; post-therapeutic neuralgia (shingles) is an
example
b. Phantom: pain syndrome that occurs following surgical or traumatic amputation
of a limb.
i.
The client is aware that the body part is missing
ii.
Pain may result of stimulation of severed nerves at the site of
amputation
iii.
Sensation may be experienced as an itching, pressure, or as
stabbing or burning in nature
iv.
It can be triggered by stressors (fatigue, illness, emotions,
weather)
v.
This experience is limited for most clients because the brain
adapts to amputated limb; however, some clients experience
abnormal sensation or pain over longer periods
vi.
This type of pain requires treatment just as any other type of pain
does.
c.
Psychogenic: pain that is experienced in the absence of a diagnosed

physiologic cause or event; the clients emotional needs may prompt pain
sensation.
II. Depression is a common associated symptom for the client experiencing chronic
pain; feelings of despair & hopelessness along with fatigue are expected findings.
11. PAIN ASSESSMENT
A. TOOLS/INTRUMENTS USED
I. A VERBAL REPORT using an intensity scale is a fast, easy & reliable method
allowing the client to state pain intensity & in turn, promotes consisted
communication among the nurse, client & other healthcare professionals about the
clients pain status; the 2 most common scales used are 0 to 5 or 0 to 10. With 0
specifying no pain & the highest number specifying the worst pain
II. A VISUAL ANALOG SCALE is a horizontal pain-intensity scale with word modifiers at
both ends of the scale, such as no pain at one end and worst pain at the other,
clients are asked to point or mark along the line to convey the degree of pain being
experienced
III. A GRAPHIC RATING SCALE is similar to the visual analog scale but adds a
numerical scale with the word modifiers, usually the numbers 0 to 10 are added to
the scale.
IV. FACES PAIN SCALE children, clients who do not speak English & clients with
communication impairments may have difficulty using a numerical pain intensity
scale; the FACES pain scale may be used for children as young as 3 years old; this
scale provides facial expressions (happy face reflects no pain, crying face represents
worst pain)
V. PHYSIOLOGIC INDICATORS OF PAIN may be the only means a nurse can use to
assess pain for a non-communicating client, facial & vocal expression may be the
initial manifestations of pain; expressions may include rapid eye blinking, biting of the
lip, moaning, crying, screaming, either closed or clenched eyes, or stiff unmoving
body position
B. A B C D E method of pain assessment
I. This acronym was developed for cancer pain; however, it is very appropriate for
clients with any type of pain, regardless of the underlying disease.
II. A = Ask about pain
III. B = Believe the client & family reports pain
21

IV. C = Choose pain control options appropriate for the client

V. D = Deliver interventions in a timely, logical &coordinated fashion
VI. E = Empower clients & families
C. P Q R S T assessment for pain reception
I. This method is especially helpful when approaching a new pain problem
II. P = What precipitated the pain?
III. Q = What are the quality & quantity of the pain?
IV. R = What is the region of the pain?
V. S = What is the severity of the pain?
VI. T = What is the timing of the pain?
D. Pain History
I. Location when clients report pain all over, this generally refers to total pain or
existential distress (unless there is an underlying physiologic reason for pain all over
the body, such as myalgias); assess the clients emotional state for depression, fear,
anxiety or hopelessness.
II. Intensity It is important to quantify pain using a standard pain intensity scale. When
clients cannot conceptualize pain using a number, simple word categorizes can be
useful (e.g. no pain, mild, moderate, severe).
III. Quality
a. Nociceptive pain are usually related to damage to bones, soft tissues, or
internal organs; nociceptive pain includes somatic & visceral pains.
i.
Somatic pain is aching, throbbing pain; example arthritis
ii.
Visceral pain is squeezing, cramping pain; example: pain
associated with ulcerative colitis
IV. Pattern pain may be always present for a client; this is often termed baseline pain.
Additional pain may occur intermittently that is of rapid onset & greater intensity than
the baseline pain; known as breakthrough pain. People at end-of-life often have both
types of pain. Cultural beliefs regarding the meaning of pain should be examined
ADMINISTRATION OF MEDICATIONS
12. DRUG NOMENCLATURE and FORMS
A. Names
I.
Chemical Name provides an exact description of the drugs composition. An

example of chemical name acetylsalicylic known common as Aspirin
II. Generic Name is given by the manufacturer who first develops the drug before it
receives official approval. Protected by law, the generic name is given before a drug
receives official publications.
III. Official Name is the name under which drug is listed in official publication
IV. Trade, Brand or Propriety Name is the name under which a manufacturer markets.
B. Classification Nurses categorized medications with similar characteristics by their class.
Drug classification indicates the effects on a body system, the symptoms relieved or the
desired effect. Each class contains drugs prescribed for similar types of health problems. The
physical and chemical composition of drugs within a class is not necessarily the same. A drug
may also belong to more than one class. For example, aspirin is an analgesic and antipyretic
and an anti-inflammatory drug.
C. Forms Drugs are available in a variety of forms preparations. The form of the drug
determines its route o administration. For example, a capsule is taken orally and a solution may
be given intravenously. The composition drug is designed to enhance its absorption and
metabolism within the body. Many drugs are available in several forms such as tablets,
capsules, elixirs and suppositories. When administering a medication, the nurse must be
certain to give the metabolism in the proper form.
D. Principles in Administering Medications
I. Observe the 7 RIGHTS of Drug Administration:
a. Right Drug
b. Right Dose
c. Right Time
d. Right Route
22

e. Right Patient
f. Right Recording
g. Right Approach
II. Practice asepsis
III. Nurses who administer medications are responsible for their own actions. Question
any order that you can consider incorrect.
IV. Be knowledgeable about medications that you administer
V. Keep narcotics & barbiturates in locked place
VI. Use only medications that are in clearly labeled containers
VII. Return liquid that are cloudy or have changed in color to the pharmacy
VIII.Before administering a medication, identify the client correctly
IX. Do not leave the medication at the bedside
X.
If the client vomits after taking an oral medication, report this to the nurse in charge
and/or physician
XI. Preoperative medications are usually discontinued during the post operative period
unless ordered to be continued
XII. When a medication is omitted for any reason, record the fact together with the
reason
XIII. When a medication error is made, report immediately to the nurse in charge and/or
physician
13. BASIC HUMAN NEEDS
A. Abraham Maslow developed the five (5) levels of human needs:
I.
II.
III.
IV.
V.
Physiologic Needs needs such as air, food, water, shelter, rest, sleep, activity and
temperature maintenance are crucial for survival
Safety and Security Needs the need for safety has both physical and physiologic
aspects
Love and Belonging Needs the third level of needs includes giving and receiving
affection, attaining a place in a group and maintaining the feeling of belonging
Self-Esteem Needs the individual needs both self-esteem and esteem from others
Self-Actualization when the need for self-esteem is satisfied, the individual strives
for self-actualization, the innate need to develop ones maximum potential and realize
ones abilities and qualities
B. Maslows Characteristics of a Self-Actualized Person

I. Is realistic, sees life clearly and is objective about his or her observations
II. Judges people correctly
III. Has superior perception, is more decisive
IV. Has a clear notion of right or wrong
V. Is usually accurate in predicting future events
VI. Understands art, music, politics and philosophy
VII. Possesses humility, listens to others carefully
VIII.Is dedicated to some work, task, duty or vocation
IX. Is highly creative, flexible, spontaneous, courageous,
and willing to make mistakes
X. Is open to new ideas
XI.
Is self-confident and has self-respect
XII.
Has low degree of self-conflict; personality is integrated
XIII.
Respect self, does not need fame, possesses a feeling of self-control
XIV.Is highly independent, desires privacy
XV.
Can appear remote or detached
XVI.
is friendly, loving and governed more by inner directives than by society
XVII.
Can make decisions contrary to popular opinion
XVIII.
Is problem centered rather than self-centered
XIX.
Accepts the world for what it is
23

14. MEETING OXYGENATION NEEDS

A. Oxygenation a basic human need & is required to sustain life.
B. Cardiovascular Physiology the function of the cardiac system is to
deliver oxygen, nutrients, & other substances to the tissues and to remove the waste products
of cellular metabolism
C. Structure and Function the heart pumps blood through the pulmonary circulation by way of
the right ventricle and to the systemic circulation by way of the left ventricle
I. Myocardial Pump the pumping action of the heart is essential to maintain oxygen
delivery
II. Myocardial Blood Flow to maintain adequate blood flow to the pulmonary and
systemic circulations, myocardial blood flow must sufficiently supply oxygen and
nutrients to the myocardium itself
III. Coronary Artery Circulation blood flow to the atria and ventricles does not supply
oxygen and nutrients to the myocardium itself. It is the branch of the systemic
circulation that supplies oxygen and nutrients and removal of waste from the
myocardium
IV. Systemic Circulation the arteries and veins of the systemic circulation deliver
nutrients and oxygen and remove wastes from the tissues. Oxygenated blood flows
from the left ventricle by way of of the aorta and into the large systemic arteries
V. Regulation of Blood Flow the amount of blood ejected from the left ventricle each
minute is the cardiac output. The circulating volume of blood changes according to
the oxygen and metabolic needs of the body. For example, during exercise,
pregnancy and fever, the cardiac output increases but during sleep, the cardiac
output decreases.
D. Steps in the Process of Oxygenation
I. Ventilation process by which gases are moved into and out of the lungs. Adequate
ventilation requires coordination of the muscular and elastic properties of the lung
and thorax and intact innervation. The major inspiratory muscle is the diaphragm
which is innervated by the phrenic nerve.
II. Perfusion the primary function of pulmonary circulation is to move blood to and
from the alveolar-capillary membrane so that gas exchange can occur
III. Exchange of Respiratory Gases respiratory gases are exchanged in the alveoli of
the lungs and the capillaries of the body tissues
a. Diffusion movement of molecules from an area of higher concentration to an
area of lower concentration
b. Oxygen Transport delivery depends on the amount of oxygen entering the
lungs (ventilation), blood flow to the lungs & tissues (perfusion), adequacy of
diffusion & capacity of the blood to carry oxygen.
c. Carbon Dioxide Transport carbon dioxide diffuses into RBCs and I rapidly
hydrated into carbonic acid because of the presence of carbonic hydrase
15. MEETING NUTRITIONAL NEEDS
A. Principles of Nutrition
I. Digestion process by which food substances are changed into forms that can be
absorbed through cell membranes
II. Absorption the taking in of substance by cells or membranes
III. Metabolism sum of all physical and chemical processes by which a living organism
is formed and maintained and by which energy is made available
IV. Storage some nutrients are stored when not used to provide energy; e.g.
carbohydrates are stored either as glycogen or as fat
V. Elimination process of discarding unnecessary substances through evaporation,
excretion
B. Nutrients
24

I.
Carbohydrates the primary sources are plant foods

Types of Carbohydrates
a. Simple (sugars) such as glucose, galactose, and fructose
b. Complex such as starches (which are polysaccharides) and fibers (supplies
bulk or roughage to the diet)
II. Proteins organic substances made up of amino acids

III. Lipids organic substances that are insoluble in water but soluble in alcohol and
ether.
a. Fatty acids the basic structural units of all lipids and are either saturated (all
the carbon atoms are filled with hydrogen) or unsaturated (could accommodate
more hydrogen than it presently contains)
b. Food sources of lipids are animal products (milk, egg yolks and meat) and
plants and plant products (seeds, nuts, oils)
IV. Vitamins organic compounds not manufactured in the body and needed in small
quantities to catalyze metabolic processes
a. Water-soluble vitamins include C and B-complex vitamins
b. Fat-soluble vitamins include A, D, E, and K and these can be stored in limited
amounts in the body
V. Minerals compounds that work with other nutrients in maintaining structure and
function of the body
a. Macronutrients calcium, phosphate, sodium, potassium, chloride, magnesium
and sulfur
b. Micronutrients (trace elements) iron, iodine, copper, zinc, manganese and
fluoride
The best sources are vegetables, legumes, milk and some meats
VI. Water the bodys most basic nutrient need; it serves as a medium for metabolic
reactions within cells and a transporter fro nutrients, waste products and other
substances
16. MEETING URINARY ELIMINATION NEEDS
A. Normal Urinary Function
I. Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr to ensure
continued normal kidney function
II. Urine normally consists of 96% water
III. Solutes found in urine include:
a. Organic solutes: urea, ammonia, uric acid and creatinine
b. Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium &
phosphorus
B. Common Assessment Findings
I. Urgency strong desire to void my be caused by inflammations or infections in the
bladder or urethra
II. Dysuria painful or difficult voiding
III. Frequency voiding that occurs more than usual when compared with the persons
regular pattern or the generally accepted norm of voiding once every 3 to 6 hours
IV. Hesitancy undue delay and difficulty in initiating voiding
V. Polyuria a large volume of urine or output voided at any given time
VI. Oliguria a small volume of urine or output between 100 to 500 mL/24 hr
VII. Nocturia excessive urination at night interrupting sleep
VIII.Hematuria RBCs in the urine
17. URINARY CATHETERIZATION

Is the introduction of a catheter through the urethra into the bladder for the purpose of
withdrawing urine.
A. Purposes
I. To relieve urinary retention
II. To obtain a sterile urine specimen from a woman
III. To measure the amount of residual urine in the bladder
IV. To obtain a urine specimen when a specimen cannot secure satisfactory by other
means
V. To empty bladder before and during surgery and before certain diagnostic
examinations
25

***Several BASIC FACTS about the lower urinary tract system should be borne in mind when
considering catheterization.
B. Necessary Equipment for Catheterization
Catheters are graded on the French scale according to the size of the lumen. For the
female adult, No. 14 and No. 16 French catheters are usually used. Small catheters are
generally not necessary and the size of the lumen is also so small that it increases the
length of time necessary for emptying the bladder. Larger catheter distends the urethra
and tends to increase the discomfort of the procedure. For male adult, No.18 and No.
20 French catheters usually used, but if this appears to be too large, smaller catheter
should be used. No. 8 and No. 10 French catheters are commonly used for children.
C. Preparation of the Patient
I. Adequate exploration
II. Position dorsal recumbent for the female and supine for the male using a firm
mattress or treatment table, Sims or lateral position can be an alternate for the
female patient
III. Provision for privacy
D. Retention or Indwelling Catheter (Foley) A catheter to remain in place for the following
purposes:
I. The gradual decompression of an over distended bladder
II. For intermittent bladder drainage
III. For continuous bladder drainage
An indwelling catheter has a balloon which is inflated after the catheter is inserted into the
bladder. Because the inflated balloon is larger than the opening to the urethra, the catheter is
retained in the bladder.
E. Procedure for Insertion
I. Inflate the balloon with the prefilled syringe before inserting the catheter to check for
balloon patency. Aspirate the fluid back into the syringe when it is determined that the
balloon is patent.
II. Hold the catheter with one hand and inflate the balloon according to the
manufacturers instructions, as soon as the catheter is in the bladder and urine has
begun to drain from the bladder. Usually 5 ml to 10 ml of sterile water is used
III. If the patient complains of pain after the balloon is inflated, allow it to empty and
replace the catheter with another one. The balloon is probably located in the urethra
and is causing discomfort owing to distention of the urethra
IV. Exert slight tension on the catheter after the balloon is inflated to assure its proper
placement in the bladder
V. Connect the catheter to the drainage tubing and drainage bag if not already
connected
VI. Tape the catheter along the interior aspect of the thigh fro a female patient. Be sure
there is no tension on the catheter when it is taped to the patient
VII. Hang the drainage bag on the frame of the bed below the level of the bladder
F. Caring for the Patient with an Indwelling Catheter
I. Be sure to wash hands before and after caring for a patient with an indwelling
catheter
II. Clean the perineal area thoroughly, especially around the meatus, twice a day and
after each bowel movement. This helps prevent organisms for entering the bladder
III. Use soap or detergent and water to clean the perineal area and rinse the area well
IV. Make sure that the patient maintains a generous fluid intake. This helps prevent
infection and irrigates the catheter naturally by increasing urinary output
V. Encourage the patient to be up and about as ordered
VI. Record the patients intake and output
VII. Note the volume and character of urine and record observations carefully
VIII.Teach the patient the importance of personal hygiene, especially the importance of
careful cleaning after having bowel movement and thorough washing of hands
frequently
IX. Report any signs of infection promptly. These include a burning sensation and
irritation at the meatus, cloudy urine, a strong odor to the urine, an elevated
temperature and chills
X. Plan to change indwelling catheters only as necessary. The usual length of time
between catheter changes varies and can be anywhere from 5 days to 2 weeks. The
less often a catheter is changed, the less the likelihood than an infection will develop
26

G. Removing the Indwelling Catheter and Aftercare of the Patient

I. Be sure the balloon is deflated before attempting to remove the catheter. This may be
done by inserting a syringe into the balloon valve or by cutting the balloon valve
II. Have the patient take several deep breaths to help him relax while gently removing
the catheter. Wrap the catheter in a towel or disposable, waterproof drape
III. Clean the area at the meatus thoroughly with antiseptic swabs after the catheter is
removed
IV. See to it that the patients fluid intake is generous and record the patients intake and
output. Instruct the patient to void into the bedpan or urinal
V. Observe the urine carefully for any signs of abnormality
VI. Record and report any usual signs such as discomfort, a burning sensation when
voiding, bleeding and changes in vital signs, especially the patients temperature. Be
alert to any signs of infection and report them promptly
18. MEETING BOWEL ELIMINATION NEEDS
A. Factors that influence Bowel Elimination
I. Age
II. Diet
III. Position
IV. Pregnancy
V. Fluid Intake
VI. Activity
VII. Psychological
VIII.Personal Habits
IX. Pain
X. Medications
XI. Surgery/Anesthesia
B. Characteristics of Normal Stool
I. Color varies from light to dark brown foods & medications may affect color
II. Odor aromatic, affected by ingested food and persons bacterial flora
III. Consistency formed, soft, semi-solid; moist
IV. Frequency varies with diet (about 100 to 400 g/day)
V. Constituents small amount of undigested roughage, sloughed dead bacteria and
epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments);
inorganic matter (calcium, phosphates)
C. Common Bowel Elimination Problems
I. Constipation abnormal frequency of defecation and abnormal hardening of stools
II. Impaction accumulated mass of dry feces that cannot be expelled
III. Diarrhea increased frequency of bowel movements (more than 3 times a day) as
well as liquid consistency and increased amount; accompanied by urgency,
discomfort and possibly incontinence
IV. Incontinence involuntary elimination of feces
V. Flatulence expulsion of gas from the rectum
VI. Hemorrhoids dilated portions of veins in the anal canal causing itching and pain
and bright red bleeding upon defecation.
19. TYPES OF ENEMAS
A. Cleansing Enemas: Stimulate peristalsis through irrigation of colon and rectum and by
distention
I. Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of
castile soap in 1000 ml of water
II. Tap water: Give caution o infants or to adults with altered cardiac and renal reserve
III. Saline: For normal saline enemas, use smaller volume of solution
IV. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate
and does not require further preparation
B. Oil-Retention Enemas: Lubricates the rectum and colon; the feces absorb the oil and become
softer and easier to pass
C. Carminative Enema: Provides relief from gaseous distention
D. Astringent Enema: Contracts tissue to control bleeding
Key Points: Administering Enema
I. Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for
children, 250 cc or less fro an infant), 99 degrees F to 102 degrees F. Solutions that
27

are too hot or too cold, or solutions that are instilled too quickly, can cause cramping
and damage to rectal tissues
II. Allow solution to run through the tubing so that air is removed
III. Place client on left side in Sims position
IV. Lubricate the tip of the tubing with water-soluble lubricant
V. Gently insert tubing into clients rectum (3 to 4 inches for adult, 1 inch for infants, 2 to
3 inches for children), past the external and internal sphincters
VI. Raise the water container no more than 12 to 18 inches above the client
VII. Allow solution to flow slowly. If the flow is slow, the client will experience fewer
cramps. The client will also be able to tolerate and retain a greater volume of solution
VIII.After you have instilled the solution, instruct client to hold solution for about 10 to 15
minutes
IX. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are
retained 10 to 15 minutes.
20. NASOGASTRIC and INTESTINAL TUBES
A. Nasogastric Tubes
I.
Levin Tube single lumen

a.Suctioning gastric contents
b.Administering tube feedings
II. Salem Sump Tube double lumen (smaller blue lumen vents the tube & prevents suction
on the gastric mucosa, maintains intermittent suction regardless of suction source)
a. Suctioning gastric contents
b. Maintaining gastric decompression
Key Points:
a. Prior to insertion, position the client in High-Fowlers position if possible.
b. Use a water-soluble lubricant to facilitate insertion
c. Measure the tube from the tip of the clients nose to the earlobe and from
the nose to the xiphoid process to determine the approximate amount of
tube to insert to reach the stomach
d. Flex the clients head slightly forward; this will decrease the chance of entry
into the trachea
e. Insert the tube through the nose into the nasopharyngel area; ask the client
to swallow, and as the swallow occurs, progress the tube past the area of
the trachea and into the esophagus and stomach. Withdraw tube
immediately if client experiences respiratory distress
f. Secure the tube to the nose; do not allow the tube to exert pressure on the
upper inner portion of the nares
g. Validating placement of tube.
Aspirate gastric contents via a syringe to the end of the tube
Measure ph of aspirate fluid
Place the stethoscope over the gastric area and inject a small amount
of air through the NGT. A characteristic sound of air entering the
stomach from the tube should be heard
h. Characteristics of nasogastric drainage:
Normally is greenish-yellowish, with strands of mucous
Coffee-ground drainage old blood that has been broken down
in the stomach
Bright red blood bleeding from the esophagus, the stomach or
swallowed from the lungs
Foul-smelling (fecal odor) occurs with reverse peristalsis in
bowel obstruction; increase in amount of drainage with
obstruction
B. Intestinal Tubes provide intestinal decompression proximal to a bowel obstruction.
Prevent/decrease intestinal distention. Placement of a tube containing a mercury weight and
allowing normal peristalsis to propel tube through the stomach into the intestine to the point of
obstruction where decompression will occur
I.
Types of Intestinal Tubes

a. Cantor and Harris Tubes
28

i.
ii.
iii.
Approximately 6-10 feet long

Single lumen
Mercury placed in rubber bag prior to tube insertion
b. Miller-Abbot Tubes
i.
Approximately 10 feet long
ii.
Double lumen
iii.
One lumen utilized for aspiration of intestinal contents
iv.
Second lumen utilized to instill mercury into the rubber bag after
the tube has been inserted into the stomach
II. Nursing Implications
a. Maintain client on strict NPO
b. Initial insertion usually done by physician and progression of the tube may be
monitored via an X-ray
c. After the tube has been placed in the stomach, position client on the right side
to facilitae passage through the pyloric valve
d. Advance the tube 2 to 4 inches at regular intervals as indicated by the
physician
e. Encourage activity, to facilitate movement of the tube through the intestine
f. Evaluate the type of gastric secretions being aspirated
g. Do not tape or secure the tube until it has reached the desired position
h. Tubes may attached to suction and left in place for several days
i. Offer the client frequent oral hygiene, if possible offer hard candy or gum to
reduce thirst
j. Removal of the tube depends on the relief of the intestinal obstruction
i.
May be removed by gradual pulling back (4-6 inches per hour) and
eventual removal via the nose or mouth
ii.
May be allowed to progress through the intestines and expelled via
the rectum.
21. LOSS AND GRIEF
A. Loss absence of an object, person, body part, emotion, idea
or function that was valued
I. Actual loss is identified and verified by others
II. Perceived Loss cannot be verified by others
III. Maturational Loss occurs in normal development
IV. Situational Loss occurs without expectations
V. Ultimate Loss (Death) results in a lost for a dying person
as well as for those left behind, can be viewed as a time of growth for all who
experienced it
B. Grieving Process (Theories of Grief, Dying and Mourning)
I.
3 Phases of Grief
a. Protest: lack of acceptance, concerning the loss, characterized by anger,
ambivalence and crying
b. Despair: denial and acceptance occurs simultaneously causing disorganized
behavior, characterized by crying and sadness
c. Detachment: loss is realized; characterized by hopelessness, accurately
defining the relationship with the lost individual and energy to move forward in
life.
II. Kubler-5 Stages of Grieving

a. Denial characterized by shock and disbelief, serves as a buffer to mobilize
defense mechanism
b. Anger: resistance of the loss occurs, anger is typically directed toward others
c. Bargaining = deals are sought with God or other higher power in an effort to
postpone the loss
d. Depression: loss is realized; may talk openly or withdraw.
e. Acceptance: recognition of the loss occurs, disinterest may occur; future
thinking may occur.
III. Wordens 4 Tasks of Mourning
a. Accept the reality of the loss, the loss is accepted
b. Experience the pain of grief, healthy behaviors are accomplished to assist in
the grieving process.
29

c.
Adjust to the environment without the deceased, task are accomplished to

reorient the environment, i.e. removing the clothes of the deceased from the
closet.
d. Emotionally relocate the deceased and move forward with life, correctly align
the past, the present & look towards the future
C. Anticipatory Grief expression of the symptoms of grief prior to the actual loss, grief period
following the lost may be shortened and the intensity lessened because of the previous of grief;
for example, a child told that a family move is expected may grieve about losing friends prior to
actually living
D. Complications of Bereavement
I. Chronic Grief symptoms of grief occur beyond the expected time frame and the
severity of symptoms is greater; depression may result.
II. Delayed Grief when symptoms of grief are not expressed and are suppressed, a
delayed reaction of grief occurs, the nurse should discuss the normal process of
grieving with the client and give permission to express these symptoms
E. Symptoms of Normal Grief
I. Feelings include sadness, exhaustion, numbness, helplessness, loneliness, and
disorganization, preoccupation with the lost object or person, anxiety, depression.
II. Thought patterns include fear, guilt, denial, ambivalence, anger
III. Physical sensations include nausea, vomiting, anorexia, weight loss or gain,
constipation or diarrhea, Diminished hearing or sight, chest pain, shortness of breath,
tachycardia
IV. Behaviors include crying, difficulty carrying out activities of daily living and insomia
F. Nursing Health Promotion (to facilitate mourning)
1.Help client accept that the loss is real by providing sensitive, factual information concerning
the loss
2.Encourage the expression of feelings to support people; this build relationships and
enhances the grief process
3.Support efforts to live without the diseased person or in the face of disability; this promotes
a clients sense of control as well as a healthy vision of the future
4.Encourage establishment with new relationships to facilitate healing.
5.Allow time to grief, the work of grief may take longer for some; observe for a healthy
progression of symptoms.
6.Interpret normal behavior by teaching thoughts, feelings, and behaviors that can be
expected in the grief process
7.Provide continuing support in the form of the presence for therapeutic communication and
resource information.
8.Be alert for signs of ineffective coping such as inability to carry out activities of daily living,
signs of depression, or lack of expression of grief.
30

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Far Eastern University-Institute of Nursing

In-House Nursing Review Hand-out

THEORETICAL FRAMEWORK of NURSING PRACTICE

COPING STRATGIES (COPING MECHANISMS)

TYPES of NURSING DIAGNOSES

METHODS USED for ASSESSMENT

DOCUMENTING and REPORTING

THE COMMUNICATION PROCESS

PRINCIPLES of ASEPSIS and INFECTION CONTROL

Far Eastern University-Institute of Nursing

DRUG NOMENCLATURE and FORMS

BASIC HUMAN NEEDS

MEETING OXYGENATION NEEDS

MEETING URINARY ELIMINATION NEEDS

MEETING BOWEL ELIMINATION NEEDS

NASOGASTRIC and INTESTINAL TUBES

LOSS AND GRIEF

Far Eastern University-Institute of Nursing

1. THEORETICAL FRAMEWORK of NURSING PRACTICE

Focused on changing and manipulating the environment in order to

Introduced the Interpersonal Model.

She defined nursing as a therapeutic, interpersonal process which

Defined nursing as having a problem-solving approach, with key

IDA JEAN ORLANDO

Developed the three elements client behavior, nurse reaction and

Described the Four Conservation Principles.

Developed the Behavioral System Model.

Conceptualized the Science of Unitary Human Beings. She asserted

Emphasizes the clients self care needs; nursing care becomes

Nursing process is defined as dynamic interpersonal process between

Stress reduction is a goal of system model of nursing practice. Nursing

Presented the Adaptation Model. She viewed each person as a unified

Far Eastern University-Institute of Nursing

Introduced the notion that nursing centers around three components:

Conceptualized the Human Caring Model. She emphasized that nursing

Introduced the Theory of Human Becoming. She emphasized free

Developed the Transcultural Nursing Model. She advocated that

ROLES AND FUNCTION OF A NURSE

B. Concepts of Health and Illness

Far Eastern University-Institute of Nursing

Health As defined by the World Health Organization (WHO): state of complete

Health-Illness Continuum (Neuman) Degree of client wellness that exist at

Agent any internal or external factor that disease or illness.

Host the person or persons who may be susceptible to a

Environment consists of all factors outside of the host

The individual is perception of susceptibility to an illness

The individuals perception of the seriousness of the illness

The perceived threat of a disease

The perceived benefits of taking the necessary preventive

Evolutionary Based Model Illness and death serves as a evolutionary

Life style determinants

Evolutionary viability within the social context

vi. Health Promotion Model A complimentary counterpart models of health

It identifies factors (demographic and socially) enhance or

It organizes cues into pattern to explain likelihood of a clients

It explains the reasons that individuals engage in health activities

Far Eastern University-Institute of Nursing

Stage of Recovery (Rehabilitation or Convalescence) The patient

Stress response is natural, productive and adaptive

III. Stressors Factor or agent producing stress, maybe: physiological, psychological,

External Stressors originate outside a person. E.g. change in

b. Factors influencing response to stressors

Far Eastern University-Institute of Nursing