ncm101 120210093635 Phpapp02

FUNDAMENTALS OF NURSING
CONCEPT OF MAN
MAN
Forms the foundation of Nursing
FOUR COMPONENTS OR ATTRIBUTES OF

MAN
Capacity to think on an Abstract Level
Establish a family
Establish a territory
Ability to use verbal symbols as language
CONCEPT
Animals form a family by instinct
Via hormonal scents
NURSING CONCEPTS OF MAN

Biopsychosocial Being
Open System
Unified Whole
Vital Reparative Process
Man is a whole. Man is complete
BIOPSYCHOSOCIAL BEING
By Sister Calista Roy
Man interacts with the
environment
OPEN SYSTEM
By Martha Rogers
Man interacts with the
environment
Exchanges matter with
energy
Exchanges energy with
environment
UNIFIED WHOLE
By Martha Rogers
Man is composed
certain parts
of
Total of those parts is

more than the sum of all
parts
This is because man has
attributes
VITAL REPARATIVE PROCESS

By Florence Nightingale
Man
is
passive
in
influencing the nurse or
the environment
MAN IS A WHOLE. MAN IS COMPLETE

By Virginia Henderson
Man has fourteen (14)
fundamental needs
HUMAN NEEDS
Needs are physiologic and psychologic.
Both these needs must be met in order to maintain wellbeing.
KEY CONCEPT
Basic Human Needs are equivalent to COMMON
NEEDS
CHARACTERISTICS OF HUMAN NEEDS

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

NEEDS
Why do we study this?
In order to prioritize
nursing actions
ABRAHAM MASLOWS HIERARCHY OF NEEDS

Physiologic needs
Food
Air
Drink
Shelter
Warmth
Sex
Sleep
Maintenance of
homeostasis

Safety and security
Protection
Security
Order
Law
Limits
Stability

Love and Belongingness
Family
Affection
Relationships
Work group

Self-esteem
Feeling good about ones
self
Two factors affecting Selfesteem
Yourself
Sense of adequacy
Accomplishment
Others
Appreciation
Recognition
Admiration

Self-actualization
Personal growth and
fulfillment
Able to fulfill needs and
ambitions
Maximizing ones full
potential
ABRAHAM MASLOWS MODIFIED HIERARCHY

OF EIGHT NEEDS (1990)
Additional needs:
Need to know
understand
Aesthetic needs
Transcendence
and
ABRAHAM MASLOWS MODIFIED HIERARCHY

OF EIGHT NEEDS (1990)
Need
to
know
and
understand or Cognitive
needs is supported by
Richard Kalish who says
that:
Man needs stimulation
Needs to explore
Sex
Activity
Novelty
Stimulator
Desire to come up
with something of
your own
ABRAHAM MASLOWS MODIFIED

HIERARCHY OF EIGHT NEEDS (1990)
Aesthetic needs:
Beauty
Balance
Form
ABRAHAM MASLOWS MODIFIED

HIERARCHY OF EIGHT NEEDS (1990)
Transcendence:
Helping others to selfactualize
CHARACTERISTICS OF
SELF-ACTUALIZED PERSONS
Judges people correctly
Superior perception
Decisive
Capable of making decisions
Clear notion as to what is right and wrong
CHARACTERISTICS OF
SELF-ACTUALIZED PERSONS
Open to new ideas
Not adopts new ideas
Not one track mind
Highly creative and flexible
Does not need fame
Problem-centered rather than self-centered
CONCEPT
Self-Actualization is very difficult to attain
It is impossible to attain
New needs come after getting one need
ILLNESS, WELLNESS AND

HEALTH
ILLNESS
Highly subjective feeling
of being sick or ill
TWO TYPES OF ILLNESS

Acute Illness
Chronic Illness
ACUTE ILLNESS
Sudden in onset (most of the time, but not always)
Less than six (6) months
CHRONIC ILLNESS
Gradual in onset (most of the time, but not always)
Types of Chronic Illness
Exacerbation
Period characterized by active signs and symptoms
of the illness
Remission
Periods where no signs and symptoms are present
DISEASE
Objective pathologic process
CONCEPTS ON DISEASE
Illness without disease is possible
Disease without illness is possible
Illness may or may not be related to a disease
One can have a disease without necessarily feeling ill
DEVIANCE
Any behavior that goes against social norms
Shortens life span
Results to disrupted family and community
CONCEPT
Deviant behavior can be considered a disease
RATIONALE
Because it also shortens the life span like a disease
EXAMPLE OF DEVIANCE
Alcoholism
A disease rather than a social problem
WELLNESS
Feeling of being well
DEFINITIONS OF HEALTH
World
Organization
Health
Health is the complete

physical, mental, social
(totality) well-being and
not merely the absence
of disease or infirmity
A high-level wellness!
Claude Barnard
Ability
to
maintain
internal milieu
Walter Cannon
Ability
to
homeostasis
maintain
A dynamic equilibrium
A state of balance of
the
internal
environment
while
external environment is
changing
Florence Nightingale
Health is using ones
power to the fullest
Being well
Can be maintained by
manipulating
the
environment
Virginia Henderson
Viewed in terms of
ability to perform the
fourteen
(14)
fundamental needs or
components of nursing
care UNAIDED
Martha Rogers
Positive
health
symbolizes wellness
Health is a value term
defined by a certain
culture
Sister Calista Roy
A state and process of
being and becoming an
INTEGRATED
PERSON
Dorothea Orem
Characterized
by
soundness
and
wholeness
of
DEVELOPED HUMAN
STRUCTURES
and
FUNCTIONS
Imogene King
A dynamic state in the
life cycle (contrasted
with illness)
Illness is interference in
the life cycle
Betty Neuman
Wellness is that all
parts and subparts are
in harmony with each
other and the whole
system
Dorothy Johnson
Elusive dynamic state
influenced by biologic,
psychologic and social
factors
MODELS OF HEALTH AND ILLNESS

Health-Illness Continuum: Dunns High-level Wellness
and Grid Model
Health Belief Model by Rosentock
Four Levels of Health by Smith
Agent, Host and Environment Model by Leavell and
Clark
DUNNS HIGH-LEVEL WELLNESS AND

GRID MODEL
X-axis is HEALTH
Y-axis is environment
Quadrant 1
High-level wellness in favorable environment
Quadrant 2
Protected poor health in favorable environment
Quadrant 3
Poor health in unfavorable environment
Quadrant 4
Emergent
high-level
wellness
in
unfavorable
environment
HEALTH BELIEF MODEL BY ROSENTOCK

Based on a motivational theory
It assumed that good health is an objective common to
all people
Consider perceptions (influences individuals motivation
toward results)
Perceived susceptibility
Perceived seriousness
Perceived threat
Likelihood of Action influenced by:
Perceived benefit out of the action
Perceived barriers
FOUR LEVELS OF HEALTH BY SMITH

1. Clinical Model
Man is viewed as a Physiologic Being
If there are no signs and symptoms of a disease, then
you are healthy
Against WHO definition of health
This is the NARROWEST concept of health

2. Role Performance Model
As long as you are able to perform SOCIETAL functions
and ROLES you are healthy

3. Adaptive Model
Health is viewed in terms of capacity to ADAPT.
Therefore, goal of treatment is to restore capacity to
adapt.
Failure to adapt is disease

4. Eudaemonistic Model
This is the BROADEST concept of health
Because health is viewed in terms of Actualization
AGENT, HOST, ENVIRONMENT MODEL BY

LEAVELL AND CLARK
Also known as the Ecologic Model
Expands to the MULTI-CAUSATION of a DISEASE
Definitions of a disease as to its cause is expanded to a
multi-causation of a disease (i.e. cancer is a multifactorial disease)
Triad is composed of the agent, host and environment
Based on the interplay of three components of the model
DEFINITIONS OF NURSING
American
Association
Nurses
Nursing is the diagnosis

and treatment of human
responses to illness (to
actual and potential
health problems)
Canadian Nurses Association

The same definition as that of the American Nurses Association
plus
includes the supervision of functions and services in
collaboration with others to promote health
Florence Nightingale
Nursing is the act of
utilizing the
ENVIRONMENT for the
following purposes:
Recovery
Reparative
process
Virginia Henderson
The unique function of
the nurse is to assist
individuals, sick or well,
with
the
activities
towards health that he
would do unaided, if
with
strength
and
knowledge. If that is
not possible, towards a
PEACEFUL DEATH
Martha Rogers
Nursing
is
a
HUMANISTIC
SCIENCE dedicated to
compassionate concern
for the promotion of
health, prevention of
illness
and
rehabilitation of the sick
Sister Calista Roy
Nursing
is
a
THEORETICAL
SYSTEM
OF
KNOWLEDGE
that
prescribes analysis and
action related to the
care of the sick or ill
It is a set of knowledge
Dorothea Orem
Nursing is a helping
service to any individual
who is sick
It comprises of wholly
dependent or partly
dependent care when
the person is unable to
do so.
Defines nursing in terms
of a NEED!
Imogene King
Nursing is a helping
profession that assists
a person (same with
Henderson) towards a
DIGNIFIED DEATH
Betty Neuman
Nursing is a profession
that is concerned with
INTRAPERSONAL,
INTERPERSONAL,
and
EXTRAPERSONAL
VARIABLES affecting a
persons response to
stressors
Dorothy Johnson
Nursing
is
an
EXTERNAL
REGULATORY FORCE
that
regulates
the
ACTION or BEHAVIOR
of a person when such
behavior constitutes a
threat, in order to
preserve
his
organization
Dorothy Johnson
Example:
In a COPD patient
who remains a
smoker, the nurse
who encourages
the patient not to
smoke, serves as
an
external
regulatory force
Faye Abdella
Nursing is a service to
individuals, families
and
therefore,
to
society
Conceptualized nursing
as
an
ART
and
SCIENCE of MOLDING
THE
INTELLECT,
ATTITUDE and SKILLS
of the nurse
Nursing in terms of
providing education
Hildegard Peplau
Nursing
is
the
INTERPERSONAL
process
of
THERAPEUTIC
INTERACTION
between the nurse and
the patient.
NURSING THEORIES
1) FLORENCE NIGHTINGALE:
ENVIRONMENTAL NURSING THEORY
Often considered the first
nurse theorist
Defined nursing as the act
of utilizing the environment
of the patient to assist him
in his recovery.
Nightingales
theory
remains an integral part of
nursing and healthcare
today.
5 Environmental Factors:
Pure or fresh air
Pure water
Efficient drainage
Cleanliness
Light, especially direct
sunlight
Nightingales
concepts are:
Ventilation
Cleanliness
Quiet
Warmth
Diet
general
CONCEPT
First Nursing School Florence Nightingale
2) DOROTHY JOHNSON:
BEHAVIORAL SYSTEMS MODEL
Seven Subsystems
Attachment
and
Affiliative
Dependency
Ingestive
Eliminative
Sexual Achievement
Aggressive
3) VIRGINIA HENDERSON:
FOURTEEN FUNDAMENTAL NEEDS
Fourteen
(14)
Fundamental
Needs
focusing
on
PHYSIOLOGIC SOCIAL
RECREATION
1) Breathing normally
2) Eating and drinking
adequately
3) Eliminating body waste
4) Moving and maintaining
a desirable position
5) Sleeping and resting
6)
Selecting
suitable
clothes
7)
Maintaining
body
temperature within normal
range by adjusting clothing
and
modifying
the
environment
8) Keeping the body clean
and well groomed to protect
the integument.
9) Avoiding dangers in the
environment and avoiding
injuring others.
10) Communicating with
others
in
expressing
emotions, needs, fears, or
opinions
11) Worshipping according
to ones faith
12) Working in a such
way that one feels a
sense of accomplishment
13)
Playing
or
participating in various
forms of recreation
14) Learning, discovering,
or satisfying the curiosity
that leads to normal
development and health,
and using available health
facilities
4) FAYE ABDELLA:
PROBLEM SOLVING APPROACH TO
21 NURSING PROBLEMS
Focus is on PROPER
IDENTIFICATION of the
problem
Particularly about the
proper nursing diagnosis
4) FAYE ABDELLA:
21 NURSING PROBLEMS
1.To maintain good hygiene.
2.To
promote
optimal
activity: exercise, rest,
and sleep.
3.To promote safety.
4.To maintain good body
mechanics.
5.To
facilitate
the
maintenance of supply of
oxygen.
4) FAYE ABDELLA:
21 NURSING PROBLEMS
6.To facilitate maintenance
of nutrition.
7.To facilitate maintenance
of elimination.
8.To
facilitate
the
maintenance of fluid and
electrolytes balance.
9.To
recognize
the
physiologic response of
the body to disease
conditions.
4) FAYE ABDELLA:
21 NURSING PROBLEMS
10.To
facilitate
the
maintenance of regulatory
mechanisms and functions.
11.To
facilitate
the
maintenance of sensory
function.
12.To identify and accept
positive
and
negative
expressions, feelings and
reactions.
13.To identify and accept the
interrelatedness
of
emotions and illness.
4) FAYE ABDELLA:
21 NURSING PROBLEMS
14.To
facilitate
the
maintenance of effective
verbal and non-verbal
communication.
15.To
promote
the
development
of
productive interpersonal
relationship.
16.To facilitate progress
toward achievement of
personal spiritual goals.
17.To create and maintain a
therapeutic environment.
4) FAYE ABDELLA:
21 NURSING PROBLEMS
14.To
facilitate
the
maintenance of effective
verbal and non-verbal
communication.
15.To
promote
the
development
of
productive interpersonal
relationship.
16.To facilitate progress
toward achievement of
personal spiritual goals.
17.To create and maintain a
therapeutic environment.
4) FAYE ABDELLA:
21 NURSING PROBLEMS
18.To facilitate awareness of
self as an individual with
varying needs.
19.To accept the optimum
possible goals.
20.To
use
community
resources as an aid in
resolving
problems
arising from illness.
21.To understand the role of
social
problems
as
influencing factors.
5) MARJORIE GORDON:
HUMAN FUNCTIONAL HEALTH PATTERNS
Focus is on Eleven (11)
Health Patterns
Advantage to the nurse:
It enables the
nurse to determine
the
clients
response
as
functional
or
dysfunctional
5) MARJORIE GORDON:
Eleven Functional Health
Patterns
Health perception
Nutritional / Metabolic
Elimination
Activity and Exercise
Pattern
Cognitive
Perceptual
Pattern
5) MARJORIE GORDON:
Eleven Functional Health
Patterns
Sleep and Rest
Self perception / Self
concept
Role
Relationship
Pattern
Sexuality
/
Reproductive
Coping-StressTolerance
Value Belief Patterns
6) IMOGENE KING:
GOAL ATTAINMENT THEORY
Patient has three
interacting systems:
(3)
Individuals / Personal
systems
Group
systems
/
Interpersonal systems
fraternity
Social systems
7) MADELEINE LEHNINGER:
TRANSCULTURAL NURSING THEORY
Nursing
is
a
HUMANISTIC
and
SCIENTIFIC mode of
helping
through
CULTURE-SPECIFIC
PROCESS
8) MYRA LEVINE:
FOUR CONSERVATION
PRINCIPLES OF NURSING
1.
Conservation
of
Energy
Example: complete bed
rest without bathroom
privileges
2.
Conservation
of
Structural Integrity
Example: turn patient
from side to side every
two hours to avoid bed
sores
8) MYRA LEVINE:
FOUR CONSERVATION
PRINCIPLES OF NURSING
3.
Conservation
of
Personal Integrity
Example:
maintain
patients privacy
4. Conservation of Social
Integrity
Example: maintenance
of
patients
relationships
9) BETTY NEUMAN:
HEALTH CARE SYSTEMS MODEL
The concern of nursing is
to PREVENT STRESS
INVASION
10) DOROTHEA OREM:

SELF CARE AND
SELF CARE DEFICIT THEORY
Three
(3)
Nursing
Systems based on Art of
Care of Patient Needs
10) DOROTHEA OREM:

SELF CARE AND
SELF CARE DEFICIT THEORY
1. Partial Compensatory
Patient performs some
of nursing care needs
2. Wholly Compensatory
or Total Compensatory
For paralyzed patients,
for ICU patients
3. Supportive-Educative
For up and about
patient
11) HILDEGAARD PEPLAU:

INTERPERSONAL MODEL
Four (4) Phases of NursePatient Interaction
1. Orientation
Nurse and patient

test the role each
one assumes
Prepares patient
for termination
Patient identifies
areas of difficulty

INTERPERSONAL MODEL
2. Identification Phase
Patient identifies
with the personnel
who can satisfy his
needs
3. Exploitation Phase
Nurse maximizes
all the resources to
benefit the patient

INTERPERSONAL MODEL
4. Resolution Phase or
Termination Phase
Occurs
when
patients
needs
have been met
CONCEPTS!
Various settings for application of:
Pre-Interaction Phase
In psychiatric setting, this consists of gathering data
Pre-Entry Phase
In community health nursing, this consists of a
courtesy call
12) MARTHA ROGERS:

SCIENCE OF UNITARY HUMAN BEINGS
Man is composed of
energy fields, which are
in constant interaction
with the environment
CONCEPT!
The most reliable method of identification is the Energy
Field.
This is better than the fingerprints as a persons energy
field is absolutely unique!
13) SISTER CALISTA ROY:

ADAPTATION MODEL
Man is a
BIOPSYCHOSOCIAL
BEING
Four (4) modes of
Adaptation
Physiologic Mode
Compatible with
Hans Selye
Self Consent
Role Function
Interdependence
14) LYDIA HALL:

CARE, CORE, CURE
Care
Comfort measures given by the nurse to a
patient
Nurturance aspect of Nursing
Core
Therapeutic use of self
Cure
Activities in relation to doctors orders
Dependent orders
15) JEAN WATSON:

HUMAN CARING MODEL
Nursing
involves
the
application of ART and
HUMAN
SCIENCE
through
TRANSPERSONAL
TRANSACTIONS in order
to help the person
achieve mind, body and
soul harmony
16) ROSEMARIE RIZZO PARSE:

THEORY OF HUMAN BECOMING
Emphasis is a FREE
CHOICE (with personal
meaning)
Actions of patients may
either be:
Revealing
or
concealing
Enabling or limiting
Therefore, there is a
consequence
This
pertains
to
behavior and action
17) JOSEPHINE PATTERSON &

LORETA ZDERAD:
HUMANISTIC NURSING PRACTICE THEORY
Nursing is an EXISTENTIAL EXPERIENCE between the
nurse and the patient (nagkataon-nagkatagpo!)
Nursing is a LIVE DIALOGUE between the patient who
wants to be nursed and the nurse who has the skill to
nurse
18) HELEN TOMLIN, EVELYN TOMLYN

&
MARY ANN SWAIN:
MODELING AND REMODELING
THEORY
Focus is on the PERSON
Emphasis is on the UNCONDITIONAL ACCEPTANCE of
the PATIENT
19) ANN BOYKIN & SAVINA

SCHOENHOFER:
GRAND THEORY OF NURSING AS A
CARING THEORY
Nursing is NOT BASED

on a DEFICIT but rather it
is
an
EGALITARIAN
MODE of helping
This theory is against the
theory of OREM
19) ANN BOYKIN & SAVINA

SCHOENHOFER:
GRAND THEORY OF NURSING AS A
CARING THEORY
Nursing is an obligation
towards
humanity,
whether there is a need
or NOT!
20) MARGARET NEWMAN:

HEALTH AS EXPANDING
CONSCIOUSNESS
Humans are Unitary Human Beings
The nurse is a NOT A GOAL-SETTER or an OUTCOME
PREDICTOR, rather is a PARTNER OF THE PATIENT
21) JOYCE TRAVELBEE:

INTERPERSONAL PROCESS THEORY
Nurse needs to go beyond nursing roles to establish
therapeutic relationship
TRANSPERSONAL COMMUNICATION as the means to
establish therapeutic relationship
This implies that the nurse should not be rigid in the
nursing role
22) IDA JEAN ORLANDO:

DYNAMIC NURSE-PATIENT RELATIONSHIP
MODEL
There is movement, the relationship is not static

If the patients condition improved, then the intervention
is effective and the patient moves on to new problems
23) NOLA PENDER:

HEALTH PROMOTION MODEL
Motivation to participate in
health
care
activities
influenced by COGNITIVE and
PERCEPTUAL FACTORS:
Importance of health to the
person
Perceived control of health
Self-efficiency
Perceived health status
Definition of health
Perceived
barriers
to
action
24) PHIL BARKER & POPPY BUCHANANBARKER:

TIDAL MODEL
Helping patients recall
their own personal stories
of DISTRESS is the
FIRST STEP in helping
them regain control of
their lives again!
25) CORBIN AND STRAUSS:

TRAJECTORY MODEL
The patient moves in a TRAJECTION of Eight (8)

Phases
Nurse needs to follow the patient along the eight phases
of trajection
EIGHT PHASES OF TRAJECTION

BY CORBIN AND STRAUSS
1. Pre-Trajectory Phase
Patient shows no signs and symptoms of illness
No sickness
2. Trajectory Onset Phase
Patient now has signs and symptoms of illness
3. Crisis Phase
Patient is unstable
Patient is in a life-threatening situation
Patient is critical
4. Acute Phase
Patient is in a state of active illness
EIGHT PHASES OF TRAJECTION

BY CORBIN AND STRAUSS
5. Stable Phase
Patients illness is controlled
Patient may still be in the hospital
6. Unstable Phase
Patient is on a critical period
Signs and symptoms are present
Patient is NOT in the hospital
Patient is NOT under control
Patient is OUT of the hospital
7. Downward Phase
Patient is in a deteriorating phase
8. Death
26) BONNIE WEAVER DULDT BATTEY:

HUMANISTIC NURSING COMMUNICATION
THEORY
Emphasis is on the
interpersonal relationship
between the nurse, the
patient, the peers and
colleagues
27) MCGILL:
MODEL OF NURSING
Emphasis is to encourage
and engage the patient
and the family to actively
participate in learning
about health
28) KATHRYN BARNARD:

PARENT-CHILD INTERACTION MODEL
In order to produce a
healthy
person,
the
babys need should be
ADDRESSED AT ONCE!
Application: Bonding
29) ALFRED ADLER:

THEORY OF PERSONALITY
The personality of an individual is affected by the BIRTH

ORDER
30) GLADYS HUSTED & JAMES HUSTED:

SYMPHONOLOGICAL-BIOETHICAL THEORY
Symphono- means harmony and agreement
Governed by ethical standards, which influence nursing
actions.
LEVELS OF PREVENTION
LEVELS OF PREVENTION
Primary Prevention
Secondary Prevention
Tertiary Prevention
PRIMARY PREVENTION
Emphasis on:
Generalized health promotion and specific protection
Recipients are GENERALLY HEALTHY PEOPLE
When given:
Before onset of illness or before onset of disease
PRIMARY PREVENTION
Examples:
Generalized health education
Prevention of accidents
Standards of nutrition
Immunizations
Specific preventions
Risk Assessment for specific disease
Family Planning Services and Marriage Counseling
Environmental Sanitation
Recreation and Housing
SECONDARY PREVENTION
Emphasis placed on:
Early detection / diagnosis
Prompt treatment
Health maintenance of persons already having health
problems
Prevention of complications
When given:
During illness
Examples:
Screening survey
Encouraging regular check-ups
Complying with regular check-ups
Teaching Breast-self-examination
Teaching Testicular-self-examination
CONCEPT!
Most effective method of teaching is DEMONSTRATION
Additional Examples of Secondary Prevention
Assessment of growth and development
General nursing assessment and care at the hospital,
community and the home
TERTIARY PREVENTION
Emphasis placed on:
Support of the client to achieve the following:
Successful re-adaptation
Optimal reconstitution
Regain high-level wellness
Therefore, the purpose is more of REHABILITATION
When given:
Begins after the illness or when a defect or disability is
fixed or irreversible
TERTIARY PREVENTION
Examples:
Referring a client to support groups
Teaching a diabetic client how to inject insulin
ROLES OF A NURSE
ROLES OF A NURSE
1. Caregiver / Care Provider
To convey understanding and support
Activities:
Support and comfort measures (mothering aspect of
nursing / nurturance aspect of nursing)
ROLES OF A NURSE
2. Counselor
Involves helping patient identify and avoid stressful and
psychological problems
Focuses on:
Helping client establish capacity for successful
interpersonal relations
Helping the patient develop new coping skills
CONCEPT!
Do not give advice!
This is meant to facilitate decision-making on the part of
the client
This is observed so that the client would not develop
DEPENDENCY
ROLES OF A NURSE
3. Client Advocate
Protects rights of patients
Activity:
Speaking on behalf of the patient
ROLES OF A NURSE
4. Change Agent
Brings change or adjustments
Nurse only influences a patient
Nurse does not change the patient
ROLES OF A NURSE
5. Teacher
Teaching
Imparting of knowledge
ROLES OF A NURSE
6. Leader
Application of interpersonal influence to bring out
desired behavior (leadership)
ROLES OF A NURSE
7. Manager
Decision-making
Planning
Giving directions
Monitoring operations
Facilitating staff development
Therefore, this is done on the supervisory level of
organization
ROLES OF A NURSE
8. Researcher
After graduation, nurse cannot yet be a researcher
He can only be a researcher after he receives his
Master of Arts in Nursing (M.A.N) degree
TEACHING AND LEARNING

STRATEGIES

STRATEGIES
Basic Guidelines
Develop a well-defined objective
Assess clients readiness to learn
Start with what the client is concerned about

STRATEGIES
Basic Guidelines
Assess and start with what the client already knows;
proceed from the known to the unknown
Start with the simple proceeding to the complex
Schedule a review of the content
CONCEPT!
Areas of Learning Domain
Knowledge cognitive
Skills motor
Attitude emotional
TEACHING STRATEGIES
1. Explanation and Description
Address cognitive aspect of learning
TEACHING STRATEGIES
2. One-to-one Discussion
Addresses affective and cognitive learning
TEACHING STRATEGIES
3. Answering Questions
Cognitive
TEACHING STRATEGIES
4. Demonstration
Motor
TEACHING STRATEGIES
5. Discovery
Cognitive and Affective
CONCEPT!
Learning is more effective if the learner discovers the
content for himself. (That is, through experience!)
TEACHING STRATEGIES
6. Group Discussion
Affective and Cognitive
Sharing feelings during group dynamics
TEACHING STRATEGIES
7. Practice
Motor
TEACHING STRATEGIES
8.Printed and Audiovisual Material
TEACHING STRATEGIES
9. Role-playing
For pediatric and psychiatric nursing settings
TEACHING STRATEGIES
10. Modeling
What you say is what you do
TEACHING STRATEGIES
11. Computer Assisted Learning Programs
Online review
NURSING PROCESS
THE NURSING PROCESS
Definition:
The Nursing Process is a systematic, organized, rational

method of planning and providing individualized, humanistic
nursing care
PURPOSES OF THE NURSING PROCESS

To identify health status
Actual health problems
Potential health problems
To establish plans
To deliver specific nursing care
CHARACTERISTICS OF
THE NURSING PROCESS
Goal-oriented and client-centered
Cyclical (no absolute beginning and end), dynamic

(moving) rather than static
Plan of care organized according to client problems

rather than nursing goals
CHARACTERISTICS OF
THE NURSING PROCESS
Basis of prioritizing nursing activities would be the

problems and not the goals
Follows a logical sequence
Universally applicable (to any type of patient)
Interpersonal and collaborative

Work with patients and relatives
Work with colleagues and other members of the
health team
CHARACTERISTICS OF
THE NURSING PROCESS
Adaptation
principles
of
problem-solving
techniques
Problem-oriented, flexible, open to new information
Allows creativity of nurse and patient
and
BENEFITS DERIVED FROM

THE NURSING PROCESS
Concepts:
Both the nurse and the patient benefit from the nursing
process
Patient obtains greater benefit
Remember:
Nursing process is
PATIENT-CENTERED
CENTERED
CLIENT-CENTERED or
and
NOT
NURSE-

THE NURSING PROCESS
Improves quality of care
Ensures continuity and appropriate level of care
Facilitates client participation through planning with
patient
Enables nurse to maximize resources

THE NURSING PROCESS
Feedback allows nurse to evaluate care
Serves as a framework for accountability through
documentation
Promotes a positive working atmosphere through
collaboration
Helps the nurse define roles to those outside the
profession

THE NURSING PROCESS
For job satisfaction
Facilitates professional growth
Avoidance of legal action
Meeting standards of accredited hospitals
PARTS OR COMPONENTS OF
THE NURSING PROCESS
Assessment Phase
Diagnosing Phase
Planning Phase
Intervention Phase
Evaluation Phase
ASSESSMENT PHASE
OF THE
NURSING PROCESS
ASSESSMENT PHASE OF
THE NURSING PROCESS
Nursing Activities in the Assessment Phase
Data Collection
Data Organization
Data Validation
Data Recording
IMPORTANT CONCEPT!
No conclusion is developed in the assessment phase
ASSESSMENT PHASE OF
THE NURSING PROCESS
Purposes of the Assessment Phase
To create a data base of the clients response to health
and illness
To determine the nursing care needs of the patient
FOUR TYPES OF ASSESSMENT

Initial Assessment
Focus Assessment or On-going Assessment
Emergency Assessment
Time-Lapsed Assessment

1. Initial Assessment
When performed:
At specified time after admission
Where done:
Done at the ward
Where Admitted:
At the ward
Purpose of Initial Assessment:
To create a data base for problem identification
For reference and future comparison

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

3. Emergency Assessment
When done:
During acute physiologic and psychologic crisis
Where done:
Emergency Room
Comfort Room
Anywhere!!!
On site!!!
Purpose of Emergency Assessment
To identify life-threatening condition

3. Emergency Assessment
Framework or Principle in Emergency Assessment
A Airway
B Breathing
C Circulation
Utilize either Maslows Hierarchy of Needs or ABC
principle

4. Time-Lapsed Assessment
When done:
Several months after initial assessment
Purpose of Time-Lapsed Assessment
To compare current status of patient with base line
data (initial assessment)
ASSESSMENT PROCESS
Concept:
Data is equivalent to information
ASSESSMENT PROCESS
What is the initial output of the Assessment Phase?
Data or Recorded Data
Never validated data!!!
TYPES OF DATA
1. Subjective or Covert Data
Felt by the patient
During the recording of data, this should be stated using
the patients own words
These are the symptoms felt by the patient
TYPES OF DATA
2. Objective or Overt Data
Capable of being observed by use of senses sight,
touch, smell, taste, hearing
These are the signs which are observable
SOURCES OF DATA
1. Primary Source
Patient himself except when:
He is unconscious
Patient is a baby
Patient is insane
SOURCES OF DATA
2. Secondary Source
Patients record
Health care members
Related literature or journals
Significant others (they become primary source when
patient is unconscious)
Family or relatives
The person who brought the patient to the hospital
SOURCES OF DATA
3. Environment of the Patient
Example:
Patient with diabetes mellitus exhibits acetone
breath
Assess for diabetic ketoacidosis
METHODS OF DATA COLLECTION

Observing
Interviewing
Examining
METHODS OF DATA COLLECTION: OBSERVING

It should be deliberate
Exert effort!!!
METHODS OF DATA COLLECTION: OBSERVING

Two (2) aspects of observation process:
Noticing the stimuli
Do an interpretation of the stimuli
METHODS OF DATA COLLECTION: INTERVIEWING
Two types of Interview

Directive Type of Interview
Non-directive Type of Interview or Rapportbuilding Interview
DIRECTIVE TYPE OF INTERVIEW

Structured
Uses closed-ended questions calling for specific data
When used:
When you need to elicit specific data
When there is little time available
CONCEPT!
Characteristics of Closed-ended questions:
Yes or No questions
Asks when or asks for the time when event happened
Asks how many
Point with finger when asking to provide clarity
Therefore, they call for highly specific answers
NON-DIRECTIVE TYPE OR
RAPPORT-BUILDING INTERVIEW
Uses more open-ended questions
Advantage is that it allows the patient to volunteer
information
TYPES OF INTERVIEW QUESTIONS

Open-Ended Questions
Closed-Ended Questions
Neutral Questions

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

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

3. Neutral Questions
Phrasing allows patient to answer with least pressure
Usually NOT addressed to patient personally (i.e. what
is your opinion about)
Raised as a general topic
PLANNING THE INTERVIEW SETTING

Concepts:
Before the interview, determine what information you
already know or what information is available
An interview is a planned conversation with a purpose
An interview is a two-way process
PLANNING THE INTERVIEW SETTING

Concepts:
When is it done?
When patient is available
When patient is comfortable
Recommended distance from the patient is three (3) to
four (4) feet.
STAGES OF THE INTERVIEW

1. Opening Stage
Key Concept!!!
This is the most important part of the interview
Rationale
What was said and done during the opening stage
sets the tone all throughout the interview
THE INTERVIEW
2. Body of the Interview
Occurs when patient responds to questioning
THE INTERVIEW
3. Closing Stage
How to close the interview:
Summarizing Technique
VALIDATION OF DATA
Act of double-checking the data
Purposes of Data Validation
To ensure the:
Correctness
Completeness
Accuracy of the data
GUIDELINES IN VALIDATION OF DATA

Compare subjective and objective data
Be familiar with word usage (particularly if the patient is a child)
Reassess / double-check data which are extremely abnormal
Be sure that your data contains CUES and not INFERENCES
Be sure that your data is FREE OF BIASES
Avoid jumping to conclusions
DATA RECORDING
Concepts:
Data Recording COMPLETES the Assessment Phase
Initial Output of the Assessment Phase is DATA
Final Output of the Assessment Phase is RECORDED
DATA
DIAGNOSING PHASE
OF THE
NURSING PROCESS
DIAGNOSING PHASE OF
THE NURSING PROCESS
Activities during the Diagnosing Phase:
This involves sorting,
interpreting data
clustering,
analyzing
and
DIAGNOSING PHASE OF
THE NURSING PROCESS
Concept:
The final output in the Diagnosing Phase is a NURSING
DIAGNOSIS!!!
DIFFERENT TYPES OF
NURSING DIAGNOSES
1. Actual Nursing Diagnosis
Problem present at the time the statement was

made
Describes a clinical judgment that the nurse has
validated because of the presence of major defining
characteristics.
Example: Ineffective Airway Clearance
excessive and tenacious secretions
related
to
DIFFERENT TYPES OF
NURSING DIAGNOSES
2. High-Risk Nursing Diagnosis
A diagnosis that a patient is more vulnerable or

susceptible compared with others in the same
situation
Example: Risk for Impaired Skin Integrity related to
immobility secondary to fractured hip.
DIFFERENT TYPES OF
NURSING DIAGNOSES
3. Possible Nursing Diagnosis
There is an evidence of a health problem but the

causes are NOT fully understood
An option to indicate that some data are present to
confirm a diagnosis but are insufficient as of this time
Example: Possible Self Care Deficit related to impaired
ability to use left hand secondary to presence of
intravenous therapy.
DIFFERENT TYPES OF
NURSING DIAGNOSES
4. Wellness Nursing Diagnosis
A positive statement
Indicates a healthy response
Examples:
Potential for increased compliance related to
increased level of knowledge
Potential for enhanced body image related to regular
exercise
Potential for effective coping related to adequate
support systems
DOMAINS OF NURSING DIAGNOSES

Key Concept!
It only includes health problems that a nurse is capable
and licensed to treat
PARTS OF A NURSING DIAGNOSIS

1. Problem Statement
Example:
Fluid Volume Deficit
2. Presumed Etiology
Example:
related to frequent loss of bowel movement
3. Defining Characteristics
Example:
as manifested by decreased skin turgor
ADVANTAGES OF USING A STANDARDIZED

DIAGNOSTIC TERMINOLOGY
Provides professional accountability and autonomy by
defining and describing the independent areas of
practice
Provides effective vehicle of communication
Provides an organizing principle for meaningful research
Facilitates continuity and individualized care
PLANNING PHASE
OF THE
NURSING PROCESS
PLANNING PHASE OF
THE NURSING PROCESS
Concept:
Planning means:
Determining ahead of time
Forecasting a course of action
PLANNING PHASE OF
THE NURSING PROCESS
Key Concept!!!
For your plans to be effective, involve the patient and
the family
PLANNING PHASE OF
THE NURSING PROCESS
IMPORTANT CONCEPT!!!
Final output of the Planning Phase is a NURSING
CARE PLAN or a WRITTEN CARE PLAN
TYPES OF PLANNING
1. Initial Planning
Done by the nurse
When done:
At specified time upon or after admission of the
patient
TYPES OF PLANNING
2. On-going Planning
Who are involved:
Done by all nurses who worked with the patient
The patient himself
The family
But primarily, the NURSE
TYPES OF PLANNING
2. On-going Planning
Purposes of On-going Planning
To determine if the clients health status has
changed
To decide which problems to focus on during the
shift
To set priorities for client care during the shift
To coordinate the patient care and activities so
that more than one problem can be addressed at
the same time
TYPES OF PLANNING
3. Discharge Planning
Purpose of Discharge Planning
To ensure continuity of care
CHARACTERISTICS OF
THE PLANNING PROCESS
S Specific
M Measurable
A Attainable
R Realistic
T Time bound
ACTIVITIES DURING
THE PLANNING PROCESS
Set priorities
Set goals
Identify alternatives of nursing care
Select nursing measures
Write nursing orders (supervisors do this)
Write the nursing care plan
PURPOSES OF GOAL-SETTING
To set direction
To provide a time span
To have a criteria for evaluation
To enable the nurse and the patient to determine
whether the problem has been resolved or not
To help motivate the client and the patient by providing a
sense of accomplishment
KEY CONCEPT IN GOAL SETTING!

For your goal to be useful during evaluation, it should be
stated in BEHAVIORAL TERMS
IMPLEMENTATION PHASE
OF THE
NURSING PROCESS
IMPLEMENTING PHASE OF
THE NURSING PROCESS
Implementation
Putting the care plan into action
THE NURSING PROCESS
Purpose of Implementation
To carry out planned activities
To help the client
THE NURSING PROCESS
Concept!!!
The implementation phase ends upon recording of the
care given and the response of the patient to that
procedure
THE NURSING PROCESS
Requirements for Implementation
Adequate knowledge
Technical Skills
Communication skills
Therapeutic use of self
Right attitude as a requirement
NURSING ACTIVITIES DURING THE

Reassess the patient
Rationale
To determine if the procedure is still needed
Determine the need for nursing assistance
Implement the nursing strategies
NURSING ACTIVITIES DURING THE

Communicate the procedure performed by documenting
the procedure
Understand orders
Clarify / verify doctors orders
Encourage patient to participate actively
GUIDELINES FOR IMPLEMENTATION OF NURSING

STRATEGIES
It should be based on scientific knowledge, research,
professional standards of practice (care)
Rationale:
This is done to ensure safe nursing care
It should be adapted to the individual patient
GUIDELINES FOR IMPLEMENTATION OF NURSING

STRATEGIES
It should always be safe. Do not compromise
It should be holistic
It should be accompanied by support, comfort and
teaching
EVALUATION PHASE
OF THE
NURSING PROCESS
EVALUATION PHASE OF
THE NURSING PROCESS
Purpose of the Evaluation Phase
To determine clients progress
To determine the effectiveness of the care plan
To determine as to what extent the nursing goals have
been met
EVALUATION PHASE OF
THE NURSING PROCESS
Importance of doing an Evaluation
It determines if the care plan will be:
Continued
Modified
Discontinued
EVALUATION PHASE OF
THE NURSING PROCESS
Activities during the Evaluation Phase
Identify the OUTCOME CRITERIA to be used as
measurement
Gather information (data) relevant to the outcome
criteria
Compare outcome (data) with the criteria
Assess the reasons for the outcome
Revise the nursing care plan as needed
TYPES OF EVALUATION
1. On-going Evaluation
When done:
During or immediately after the intervention
Importance:
Allows the nurse to decide and make on-the-spot
modification/s in an intervention
TYPES OF EVALUATION
2. Intermittent Evaluation
When done:
At a specified time
Purpose:
It shows the extent of progress of the patient
Importance:
Enables the nurse to correct deficiencies and modify
the nursing care plan
TYPES OF EVALUATION
3. Terminal Evaluation
When done:
At or immediately before discharge
Importance:
States the status of a health problem at the time of
discharge
It determines whether the goals are:
Met
Partially met
Unmet
DOCUMENTATION
DOCUMENTATION
It is a written, formal document
A record of clients progress
PURPOSES OF DOCUMENTATION
Planning Care
Communication
For legal documentation purposes
For research
For education
Reimbursements
For statistics, reporting, epidemiology
Accreditation, licensing
GUIDELINES ON DOCUMENTATION
Timing
Document patient care as soon as possible
Observe confidentiality
Observe permanence
Use non-erasable ink
Do not use sign pen
Signature
Sign full name and append R.N.
Accuracy
Ensure that data is correct
Avoid biases
Avoid ambiguous terms
Appropriateness
Write only appropriate information
Completeness
Use standard terminology
Brevity
Make it concise yet meaningful
Legal Awareness
Cross out erroneous entry
Write Error
Countersign
TYPES OF RECORDS
Source-Oriented Clinical Record
Problem-Oriented Clinical Record
SOURCE-ORIENTED CLINICAL RECORD

Accumulation of chronological, variative notations that
are difficult to follow because they are not assembled
into an orderly or scientific manner
Classification of information is based on SOURCE
Each person or department maintains a different section
on chart
COMPONENTS OF A
SOURCE-ORIENTED CLINICAL RECORD
Admission Sheet
Face Sheet
Medical History and Physical Examination Sheet
Diagnostic Findings Sheet
TPR Graphic Sheet
Doctors Treatment and Order Sheet
Therapeutic Sheet
PROBLEM-ORIENTED
CLINICAL RECORD
Same as Problem Oriented Medical Record
Entry of data is based on CLIENTS PROBLEM
Example:
Problem No. 1: constipation
Increase fluid intake: doctor
Diatabs: pharmacist
NPO:
Includes observations about the patient
Example:
Radiologists notes are with doctors notes under one
problem
FOUR BASIC COMPONENTS OF

PROBLEM-ORIENTED CLINICAL RECORD
1. Baseline Data
All information gathered from a patient when he first
entered the agency

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

progress notes)

3. Initial list of orders or Care Plans

4. Progress Notes
Includes:
Nurses narrative notes (SOAPIE)
Flow sheets
Discharge Notes and Referral Summaries
Formats:
SOAPIE for revisions
COMMON METHODS OF COMMUNICATION AMONG

NURSES
1. Referring
To endorse patients special concern to a higher
authority or a specialized department or personnel

NURSES
2. Confer
Verifying information

NURSES
3. Reporting
Giving information to a concerned person
KARDEX
Is the Kardex a part of the patients record?
No, it is not!!!
It is just a bulletin board
PURPOSES OF THE KARDEX

To make valuable information readily available
Allergies are written in red ink
It is a reminder
It is not a record
IMPORTANT CONCEPT
A Nursing Care Plan is not a record!!!
COMMUNICATION
COMMUNICATION
Exchange of ideas, information, feelings, data between
two communicators
CONCEPT!
Communication is the basic component of Human
Relationships
ELEMENTS OF COMMUNICATION
1. Message
Data
2. Sender
Encoder
3. Receiver
Decoder
4. Feedback
5. Context
Setting
Overall environment where the communication takes
place
MODES OF COMMUNICATION
1. Verbal
Oral
Spoken
Written communication
Text communication
Cable communication
Telex communication
Facsimile communication
MODES OF COMMUNICATION
2. Non-verbal communication
Facial expression
Grimacing
Posture
Gait
Adornment
Make-up
Gestures
FACTORS AFFECTING COMMUNICATION

Ability of the communicator
Perceptions
Proxemics
Distances between communicators
Intimate Distance
Actual physical contact to 1.5 feet
Personal Distance
1.5 feet to 4 feet
3 feet to 4 feet for interview
Social Distance
4 feet to 12 feet
Public Distance
12 feet and beyond
FACTORS AFFECTING COMMUNICATION

Territoriality
One person believes that the space and all the things in
that space belongs to him
Do not enter abruptly; this may result in breach of
privacy
Roles and relationships
THERAPEUTIC COMMUNICATION
IN NURSING
Using Silence
Supplement with non-verbal communication
Provide General Leads
Examples:
go on
tell me more
Open-ended questions
IN NURSING
Use Touch
But assess the culture of the patient
If the patient is a child, touch the patient on the top of
the head
If the patient is an elderly, touch the patient on the hand
If the patient is of the same age level, touch the patient
on the shoulder
Offering yourself
For autistic child
Stay nearby or stay beside the patient
IN NURSING
Presenting Reality
Example:
You are in the hospital
Reflecting
Example:
What do you think will make you happy
Never agree nor disagree
Reflect it back or throw it back
NON-THERAPEUTIC COMMUNICATION
Stumbling blocks to effective communication
Stereotyping
Generalizing
Agreeing and Disagreeing
No confrontation
No argument
Being defensive
Moralizing or Passing Judgment
Giving Common Advise
Examples:
If I were you
You should have done it
PROMOTING REST AND SLEEP
CIRCADIAN RHYTHM
A biological rhythm
A biological clock
Regulated from outside the persons body
TYPES OF SLEEP
1. Rapid Eye Movement Sleep (REM Sleep)
Increased brain metabolism and activity
Also called PARADOXICAL SLEEP
Characterized by:
Vivid dreams
Easily recalled upon awakening
TYPES OF SLEEP: REM SLEEP
Colorful, dramatic, emotional, implausible dream

Characterized by rapid eye movements
Almost complete loss of muscle control
Penile erection (males) and vaginal moistening (females)

Easy to awaken
Usually a time for more intensive, vivid dreams
REM sleep varies
Adolescents spend 30% of total sleep time in REM sleep

Adults spend 15% of total sleep in REM sleep
CONCEPTS!
REM sleep is NOT AS RESTFUL as NON-REM sleep
However, REM sleep is NEEDED
Dreaming is a psychological outlet of pent up emotions
NURSING ALERT!
Deprivation of REM sleep results to:
Irritability
Restlessness
Poor concentration
TYPES OF SLEEP
2. Non-Rapid Eye Movement Sleep (Non-REM Sleep)
Deep restful sleep
Benefit is that it restores the body physically and
psychologically (especially for post-operative patients)
TYPES OF SLEEP: NON-REM SLEEP STAGE 1
Stage of very light sleep

The eyes roll from side to side
Heart and respiratory rates drop slightly
The sleeper can be readily awakened
Stage only lasts for a few minutes
Stage of light sleep in which the body processes continue to slow down
The eyes are generally still
The heart and respiratory rates decrease slightly
The body temperature falls
Lasts only about 10 to 15 minutes but constitutes 40 45% of total sleep
The heart and respiratory rates, as well as other body processes, slow further because of the domination of the parasympathetic
nervous system
The sleeper becomes more difficult to arouse
The person is not disturbed by sensory stimuli
The skeletal muscles are very relaxed
The reflexes are diminished and snoring may occur
Delta sleep or deep sleep

Heart and respiratory rates drop 20 30% below that exhibited during waking hours
Sleeper is very relaxed, rarely moves and is difficult to arouse
This stage is thought to restore the body physically
The eyes usually roll and some dreaming occurs
CONCEPT!
Deprivation of Non-REM sleep causes:
Physical exhaustion
Decreased resistance against infection
WELLNESS TEACHINGS TO
ENHANCE OR PROMOTE SLEEP
Establish a regular routine
Have adequate exercise at daytime
Avoid stimulating activity by bedtime
Avoid all types of stimulants
Caffeine-containing foods
Coffee
Cocoa
Chocolate
Tea
Cola
Nicotine
Alcohol
Prolongs the REM stage of sleep
It excites the patient like an anesthetic
Not a stimulant
Avoid shabu
Use the bed mainly for sleep
If unable to sleep, get up and pursue satisfying
activity
Drink something warm or hot (except stimulants)
Milk contains L-tryptophan
L-tryptophan is an amino acid with a natural sedative
effect that induces one to sleep
Do something HOT!
Twice-a-week masturbation is ideal
Facilitates release of tension of the day
Side-to-side turning every two hours with back
tapping
Support bedtime rituals
Remove all music in order to sleep
PROMOTING OXYGENATION
DEEP BREATHING
Two (2) types of Deep Breathing:

Apical Deep Breathing
Basal Deep Breathing
APICAL DEEP BREATHING

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

Taught to patients who will undergo:
Upper abdominal surgery
Cholecystectomy
Incision site on diaphragm
Patient does not want to breathe
Predisposed to hypostatic pneumonia
BASAL DEEP BREATHING

Same procedure
Area of concentration is the lower ribcage
When to teach patient:
Before surgery
Before pain is present
Rationale:
If pain is already present, it would be difficult for patient
to follow
BASAL DEEP BREATHING

When done:
Done q2 hours together with turning
COUGHING EXERCISES
Purpose
To expand the lungs
To facilitate expectoration of secretions
How often done:
At least every two (2) hours
COUGHING EXERCISES
Procedure
Teach the patient to inhale and exhale
Tell the patient to inhale and exhale a second time
Tell the patient to inhale and cough out
NURSING ALERT!
Coughing
patients:
is
contraindicated
in
the
following
With increased intracranial pressure (ICP)

With increased intraoptical pressure (IOP)
With cardiac arrhythmias (but are allowed to do
deep breathing)
CONCEPTS!
Deep Breathing and Coughing
Purpose is to stimulate surfactant production
Yawning and
production
sneezing
also
stimulate
surfactant
OXYGEN INHALATION AND ADMINISTRATION

Practical Application Concept!
When administering oxygen, be sure to open the valve
of the oxygen tank first.
Be certain that the valve on the regulator is closed so
that the flow meter would not break!
CONCEPTS!
Humidifier
moistens
oxygen administered
the
Purpose
To avoid drying and

irritation of the mucosal
lining
Also traps particulates
from the tank
Iron oxide may be
present in the tank (iron
plus oxygen produces
iron oxide or rust)
CONCEPTS!
Fire Precaution
Place NO SMOKING sign at the door or at the head
part of the patient
Tank and oxygen do not explode
They merely support combustion
OTHER CONCEPTS!
Do not use volatile substances
Acetone and alcohol can react with oxygen and lead to
toxicity of patient
Do not use oil based or grease on any part of the oxygen
set
Do not allow the patient to use an electric razor as
sparks may trigger combustion
NURSING ALERT!
Retrolental Fibroplasia occurs if there is excess oxygen
administration in infants.
Excess oxygen leads to destruction of the retina and
blindness
MODES OF ADMINISTRATION
1. Low Flow Administration
Utilizes nasal cannula or

nasal prongs or nasal
catheters
Given to COPD patients
2. High Flow Administration
Uses a venturi mask
NEBULIZATION
With sodium chloride and salbutamol
A physiologic solution
Water liquefies secretions
Sodium chloride stimulates coughing
Salbutamol is a bronchodilator
Purpose:
For expectoration of secretions
NURSING PRE-THERAPY ASSESSMENT PRIOR TO

NEBULIZATION
Have baseline data of patients breath sounds
Assess again after nebulization to assess effectiveness
of the procedure
SPIROMETRY
Purpose is to expand the lungs
Done when inhaling
Instruction to the patient:
Inhale from the spirometer and

NOT blow to the spirometer
Procedure:
Inhale exhale
Inhale exhale fully
Place mouthpiece between
teeth
Hold breath for four (4)
seconds
Then inhale, fully rising the ball
Upon inhalation, the ball rises
CHEST PHYSIOTHERAPY
This is a dependent procedure
There are no absolute contraindications
procedure
Contraindicated for the following patients with:
Pacemakers
Lung abscess
Hemoptysis
Dangerous Arrhythmias
Active PTB (which goes to the other lobe)
Lung CA (malignancy goes to other lung)
to
this
THREE COMPONENTS OF
CHEST PHYSIOTHERAPY
Percussion
Vibration
Postural Drainage
THREE COMPONENTS OF
CHEST PHYSIOTHERAPY
1. Percussion
Use cupped hands

Hands alternate in rising and coming into contact
with chest or back of patient
THREE COMPONENTS OF
CHEST PHYSIOTHERAPY
2. Vibration
Palms of your hand are placed on chest or back of

patient giving quivering motions
Palms remain in contact with the chest or back
THREE COMPONENTS OF
CHEST PHYSIOTHERAPY
3) Postural Drainage
Drain secretions by gravity
Change positions
POSTURAL DRAINAGE POSITIONS
IMPORTANT CONCEPT!
Rule out contraindications before performing chest
physiotherapy
PRE-THERAPY ASSESSMENT FOR VIBRATION AND

PERCUSSION
Assess breath sounds to know which lung fields have
secretions
Then
assess
again
after
effectiveness of the procedure.
procedure
to
check
CONCEPTS!
Vibration and percussion are

mechanically dislodge secretions
done
to
Nebulization is done to liquefy secretions

Suctioning is done to clear secretions
Postural Drainage is done to drain secretions
using gravity
POSTURAL DRAINAGE
When done:
Before meals
Two (2) hours after meals
Before doing the procedure, the following baseline
data are needed:
Breath sounds
Vital signs
Continuous ECG monitoring
POSTURAL DRAINAGE
During the procedure:
Ensure the comfort of the patient
Provide a kidney basin and tissue paper
NURSING ALERT!
Watch out for signs of symptoms which may require
stopping of the procedure:
Sudden dyspnea
Cyanosis
Extreme diaphoresis
Sudden alteration of blood pressure, respiratory
rate, pulse rate
Appearance of arrhythmias
Hemoptysis
General intolerance of the procedure
IMPORTANT CONCEPT!
If any of those written on the previous slide occurs,
STOP THE PROCEDURE and inform the physician
CONCEPT!
After the procedure assess the following:
Breath sounds
Vital signs
Quantity and quality of sputum
Overall response of the patient to the procedure
Give oral hygiene
Rationale:
To eliminate phlegm from the mouth
IMPORTANT CONCEPT!
Patients with cystic fibrosis benefit much from postural
drainage
SUCTIONING
SUCTIONING
Purpose is to seek out secretions
CONCEPTS ON SUCTIONING
Question:
If you have only one (1) suction catheter, which will you
suction first, the nose or the mouth?
Answer:
If the patient is an infant or a newborn:
Start on the mouth then proceed to the nose
Rationale:
If you start on the nose, you will trigger the sneezing
reflex and this would result into aspiration
CONCEPTS ON SUCTIONING
Question:
If you have only one (1) suction catheter, which will you
suction first, the nose or the mouth?
Answer:
If the patient is an adult, suction the mouth first, then
proceed to the nose
Rationale:
This is done for aesthetic reasons
TYPES OF SUCTIONING
TYPE OF
SUCTIONING:
OROPHARYN
-GEAL
SUCTIONING
POSITION OF
THE PATIENT
WHILE
SUCTIONING
DEPTH
DURATION
INTERVAL
WITH EACH
PASS OF
SUCTION
TOTAL TIME
If the patient is
conscious
Fowlers (high or
moderate);
Head turned to
one side (towards
the nurse)
10 15 cm
Not more than

10 15
seconds
20 30
seconds
Not more than

5 minutes
If the patient is
unconscious
Place on one side

(facing the nurse);
Tilt neck to move
head slightly
forward towards
the basin to avoid
aspiration during
suctioning
10 15 cm
Not more than

10 15
seconds
20 30
seconds
Not more than

5 minutes
TYPES OF SUCTIONING
TYPE OF
SUCTIONING:
NASOPHARYNGEAL
SUCTIONING
POSITION OF
THE PATIENT
WHILE
SUCTIONING
DEPTH
DURATION
INTERVAL
WITH EACH
PASS OF
SUCTION
TOTAL TIME
If the patient is
conscious
Neck should be
hyperextended;
Fowlers position
From tip of
the nose to
tip of the
earlobe
Not more than

10 15
seconds
20 30
seconds
Not more than

5 minutes
If the patient is
unconscious
Flat on bed with

head turned to the
nurse
Lateral position
may be assumed
From tip of
the nose to
tip of the
earlobe
Not more than

10 15
seconds
20 30
seconds
Not more than

5 minutes
TYPES OF SUCTIONING
TYPE OF
SUCTIONING:
OROTRACHEAL
SUCTIONING
POSITION OF
THE PATIENT
WHILE
SUCTIONING
DEPTH
DURATION
INTERVAL
WITH EACH
PASS OF
SUCTION
TOTAL TIME
If the patient is
conscious
Low to semifowlers position
Measure
from
mouth to
midsternum
Not more than

10 seconds
20 30
seconds
Not more than

5 minutes
If the patient is
unconscious
Flat on bed;
Suction trachea
through the mouth
Measure
from
mouth to
midsternum
Not more than

10 seconds
20 30
seconds
Not more than

5 minutes
TYPES OF SUCTIONING
TYPE OF
SUCTIONING:
NASOTRACHEAL
SUCTIONING
POSITION OF
THE PATIENT
WHILE
SUCTIONING
DEPTH
DURATION
INTERVAL
WITH EACH
PASS OF
SUCTION
TOTAL TIME
If the patient is
conscious
Low
to
semifowlers position
From tip of
the nose to
earlobe to
dominating
side
of
neck to the
thyroid
cartilage
Not more than

10 seconds
20 30
seconds
Not more than

5 minutes
If the patient is
unconscious
Flat on bed;
Suction
trachea
through the nose
From tip of
the nose to
earlobe to
dominating
side
of
neck to the
thyroid
cartilage
Not more than

10 15
seconds
20 30
seconds
Not more than

5 minutes
TYPES OF SUCTIONING
TYPE OF
SUCTIONING:
POSITION OF
THE PATIENT
WHILE
SUCTIONING
DEPTH
DURATION
INTERVAL
WITH EACH
PASS OF
SUCTION
TOTAL TIME
ENDOTRACHEAL TUBE
SUCTIONING
Semi-Fowlers
not
contraindicated
if
12.5 cms.
or
6
inches;
Insert as
far as it
goes until
you meet
resistance
or
until
patient
coughs
5 10
seconds
2 3 minutes
Not more than

5 minutes
TRACHEOSTOMY TUBE
SUCTIONING
Semi-Fowlers
not
contraindicated
if
Insert as
far as it
gets until
you meet
resistance
or until the
patient
coughs
5 10
seconds
2 3 minutes
Not more than

5 minutes
IMPORTANT CONCEPTS ON SUCTIONING!!!

For Endotracheal suctioning:
NO TUBE IS USED HERE
This is suctioning of the trachea through the mouth or
through the nose
Two (2) types of Endotracheal Suctioning:
Orotracheal Suctioning
Oral approach
Nasotracheal Suctioning
Nasal approach
GENERAL CONDITIONS FOR SUCTIONING

For Endotracheal and Tracheostomy (Naso and Oral and
Tube)
Before suctioning, HYPEROXYGENATE the patient
During intervals, HYPEROXYGENATE the patient

For ET, Tracheostomy, ET tube:
Nursing Alert!
During insertion, if you encounter resistance,
withdraw the catheter about one centimeter (1 cm)
before applying suction
Rationale:
To avoid trauma on the mucous membrane

For ET, Tracheostomy, ET Tube:
Do suctioning intermittently
Suctioning should not be continuous
Rotate the catheter (between the thumb and the index
finger) as you withdraw
Apply suction only when you are ready to withdraw (i.e.
keep finger away from suction port if you are still not
ready)
HOW TO HYPEROXYGENATE THE PATIENT

Give two (2) to three (3) blows by ambubag
Increase flow rate and concentration of oxygen
Nursing Alert!
If the patient has thick, tenacious secretions, DO NOT
USE AN AMBUBAG
Use
an
OXYGEN
INSUFFLATION
SUCTION
CATHETER instead!!!
This is a two-lumen catheter (one lumen brings oxygen
to the patient, the other lumen brings out secretions
from the patient)
HOW TO HYPEROXYGENATE THE PATIENT

In the event of encrustations, PERFORM TRACHEAL
LAVAGE
Instill 2.5 ml to 5.0 ml Normal Saline Solution for adults
to liquefy the mucous plug
Instill 2.0 ml Normal Saline Solution for children to
liquefy the mucous plug
Instill 0.5 ml to 1.0 ml Normal Saline Solution for infants
to liquefy the mucous plug
VITAL SIGNS
TEMPERATURE
TEMPERATURE
Oral Temperature
Axillary Temperature
Rectal Temperature
ORAL TEMPERATURE
Most convenient
Most accessible
Nursing Alert!
Applicability is for children aged six (6) years and above
Not applicable for children below six (6) years old
ORAL TEMPERATURE
Contraindicated in the patients with:
Oral surgery
Mouth breathers
History of convulsive seizures
Unconscious
Incoherent
Irrational
Mentally disrupted
Insane
ORAL TEMPERATURE
Procedure
Nothing Per Orem for about thirty (30) minutes before
taking temperature
No food intake
No drinks
No smoking
No chewing gum
No whistling
No gargling
Rationale
Any of the above would alter the results
ORAL TEMPERATURE
Placement:
Under the tongue, beside the frenulum (right or left)
Total Time:
Two (2) to three (3) minutes
AXILLARY TEMPERATURE
Least reliable
Safest method
Nursing Alert!
During application, be sure that axilla is dry
Dry using a patting motion
Nursing Alert!
Do not RUB!
Rationale
This increases heat due to friction
Rubbing increases blood supply to the area
Therefore, there will be increase in temperature
reading
Rubbing provides a false-positive elevation of
temperature reading
Duration:
In adults nine (9) minutes
In children five (5) minutes
RECTAL TEMPERATURE
Most reliable (except for Tympanic Thermometer)
Most accurate (except for Tympanic Thermometer)
Concept!
If tympanic method is used using a tympanic
thermometer, the rectal method is only second most
reliable and second most accurate
RECTAL TEMPERATURE
Disadvantage:
Placement on a different site yields a different reading
Therefore, ensure that the bulb of the rectal
thermometer rests on the mucous membrane.
Contraindications:
Hemorrhoids
Rectal Surgery
Certain Cardiac ailments due to stimulation of the vagus
nerve; valsalva maneuver leads to arrhythmias
RECTAL TEMPERATURE
Position of the patient when taking the reading:
Sims left position
Sims right position
For Newborn, lift up ankles to keep buttocks up
In Toddlers, set on prone position on adults lap
Duration:
Two (2) minutes
TEMPERATURE SCALES
Conversion of Centigrade to Fahrenheit
Centigrade = (5/9)F 32
Centigrade = (F/1.8) 32
TEMPERATURE SCALES
Conversion of Fahrenheit to Centigrade
Fahrenheit = (9/5)C + 32
Fahrenheit = (1.8)C + 32
CONCEPTS ON HUMAN BODY TEMPERATURE

Highest body temperature is usually reached between
8:00 PM to 12:00 MN
Lowest body temperature occurs in the early morning
hours of the day at around 4:00 AM to 6:00 AM
FEVER
Normally, the hypothalamus is able to adjust body
temperatures between 37C to 40C
But due to the presence of pyrogenic materials like the
following:
Pathogenic microorganisms
Toxins
Foreign substances
Any substance capable of increasing body temperature
Creates a deficiency of -3C, making a person enter the
FIRST STAGE OF FEVER

Typical signs and symptoms indicate the bodys
compliance mechanism to increase and conserve heat:
Chills
Shivering
Gooseflesh
Contraction of arectores pilorum or pilo arecti
muscles
Vasoconstriction
Decreases blood supply to the skin
Pallid Skin
Cyanotic nail beds

Key Concept!!!
Patient complains of feeling cold
Sweating will stop because body will minimizes heat
loss
Also called:
Onset Stage
Chill Stage
Cold Stage
This stage is characterized by low febrile temperatures

Nursing Management:
Aim is to minimize heat loss
Do NOT apply TEPID SPONGE BATH because this
would make patient progress to SHOCK
Provide additional clothing as necessary
Provide additional blankets as necessary
Provide something warm to drink
These measures would result to a gradual increase in
body temperature

Question:
When will you start application of TSB?
Answer:
If there is a 1C to 2C increase in body temperature
SECOND STAGE OF FEVER

Also called:
Coarse Stage of Fever
Peak Stage of Fever
Key Concepts!
Patient does not feel hot or cold
Skin is warm to touch
Skin is flushed
Fever blisters are present
Herpetic lesions
Absence of shivering
Possible dehydration

Important Concept!!!
For every increase of temperature, there is a
corresponding increase in pulse rate
Rationale:
Increase in temperature results in an increase in pulse
rate due to increased metabolic rate
Increased metabolic rate increases oxygen demand
Due to increased oxygen demand of susceptible brain
cells, CONVULSIVE SEIZURES may occur. These may
also be due to irritation of nerve cells FEBRILE
CONVULSIONS

Increased oxygen demand also leads to an increase in
respiratory rate
Patient complains of:
Loss of appetite
Myalgia or muscle pains due to increased catabolism
Nursing Management
Tepid Sponge Bath
Cooling Bed Bath
TEPID SPONGE BATH

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

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

Water temperature will start at 32C
Procedure will go on with gradual decrease in water
temperature until it is maintained at 18C
Therefore, to achieve this drop in temperature, utilize ice
Same procedure of application as in Tepid Sponge Bath
TYPES OF FEVER
1. Intermittent Fever
A fever that is alternated at regular intervals by periods
of normal and subnormal temperature
TYPES OF FEVER
2. Remittent Fever
Fever alternated by wide range of fluctuations in
temperature, all of them are ABOVE NORMAL.
Duration is within a 24-hour period
TYPES OF FEVER
3. Relapsing Fever
Short periods of febrile episodes alternated by one (1)
to two (2) days of normal temperature
TYPES OF FEVER
4. Constant Fever
Minimal fluctuations of temperature, all of which are
ABOVE NORMAL
TYPES OF FEVER
5. Staircase or Spiking Fever
Common in patients with TYPHOID FEVER
PULSE RATE
PULSE ASSESSMENT
Concepts!
If pulse is regular, count or monitor pulse for thirty (30)
seconds and multiply by two (2). This is legal!
If pulse is irregular, count or monitor the pulse for one
(1) FULL minute
ASSESSMENT OF THE PULSE DEFICIT

Pulse Deficit is the difference between the apical pulse
and the radial pulse.
Obtained by having one person count the apical pulse as
heard through a stethoscope over the heart and another
person count the radial pulse at the same time.
ASSESSMENT OF THE PULSE DEFICIT

This is the most accurate method
Involves two nurses using one watch
Starts at the same time
Ends at the same time
Comparison of results ensues
Count is done for one (1) full minute
SCALE IN PULSE ASSESSMENT

0
Absent or cannot be felt
1+
Weak or thready
2+
Normal
3+
Bounding
BLOOD PRESSURE
BLOOD PRESSURE
Systolic
Produced by ventricular contraction
Pressure on blood vessels during depolarization or
ventricular contraction
Diastolic
Pressure that remains in the walls of the blood vessels
during relaxation or repolarization or resting
BLOOD PRESSURE
Broadly two (2) types:
Direct
By insertion of a catheter
Indirect Method
Auscultatory method
Palpatory method
Flush Method
AUSCULTATORY METHOD
Uses Korotkoff sound
A popping sound
NOT the heart beat
It is a phenomenon an unknown phenomenon!
AUSCULTATORY METHOD
Determining Amount of Inflation
Using auscultatory method
Ask patient what is his last BP reading and then add 30
40 mmHg from last systolic reading.
Deflate gradually rate is approximately 2 3 mmHg per
second
Alternative auscultatory method
Auscultate for the last sound as you go up. Then add 30
40 mmHg
Then deflate
AUSCULTATORY METHOD
Tripartite Blood Pressure
Done if patient is an adult.
Example:
140 mmHg systolic first loudest sound
100 mmHg 1st diastolic muffling
70 mmHg 2nd diastolic last sound
Therefore, the tripartite blood pressure is 140 / 100 /
70
If there is no muffling, an example would be:
160 / no muffling / 110
AUSCULTATORY METHOD
Concepts!!!
Take systolic on loudest sound if patient is an adult
If patient is pediatric or up to ten (10) years old, take the
first sound, whether it is faint or loud
If, for example, first sound is at 190 mmHg and there is
silence up to 140 mmHg and then there is a sound at
130 mmHg down to 80 mmHg then
Use the PALPATORY METHOD in combination with
the AUSCULTATORY METHOD because there is an
auscultatory gap
Repeat using:
Auscultatory method
Palpatory method
HOW TO DO THE PALPATORY METHOD

Inflate
Determine up to what point to inflate
Palpate pulse
If pulse is absent, add 30 40 mmHg
Deflate
First palpable pulse is true systolic pressure
For diastolic pressure, proceed using the auscultatory
method
FLUSH METHOD
Represents the mean blood pressure
Represents the average of the systolic and diastolic
pressures
FLUSH METHOD
When done:
When you have a BP apparatus without a stethoscope
Used for pediatric patients
FLUSH METHOD
How done:
Inflate up to the point where extremity becomes pale
Deflate slowly and look for a REBOUND FLUSH when
extremity becomes red again
This is the true reading!!

Note that there is only ONE reading!!!
PULSE PRESSURE
It is the difference between systolic and diastolic
pressures
Normal is 30 40 mmHg
HYPERTENSION
This is an abnormally high blood pressure over140
mmHg systolic and or above 90 mmHg diastolic for at
least two consecutive readings
HYPOTENSION
This is an abnormally low blood pressure, systolic
pressure below 100 mmHg and diastolic pressure below
60 mmHg
RESPIRATORY RATE
THREE PROCESSES IN RESPIRATION

Ventilation
The movement of gases in and out of the lungs
Involves inhalation or inspiration and exhalation or
expiration
Diffusion
The exchange of gases from an area of higher
pressure to an area of lower pressure
It occurs at the alveolo-capillary membrane
Perfusion
The availability and movement of blood for transport
of gases, nutrients, and metabolic waste products
ASSESSING RESPIRATIONS
Rate
Normal is 12 20 cycles per minute in an adult
Depth
Observe the movement of the chest.
May be normal, deep, or shallow
ASSESSING RESPIRATIONS
Rhythm
Observe for regularity of exhalations and inhalations
Quality or Characteristic
Refers to respiratory effort and sound of breathing
MAJOR FACTORS AFFECTING THE

RESPIRATORY RATE
Exercise
Increases respiratory rate
Stress
Increases respiratory rate
Environment
Increased temperature of the environment decreases
RR; Decreased temperature, increases RR
Increased altitude
Increases RR
Medications
(e.g., narcotics decrease RR)
SKIN INTEGRITY
DECUBITUS ULCERS
Decubitus ulcers are caused by:
Unrelieved, sustained pressure
Localized ischemia
Shearing force
Pressure plus friction
DECUBITUS ULCERS
Predisposing Factors:
Unconsciousness
Incontinence
Loss of Sensation
Hypoproteinemia
Decreased lean muscle mass
Increase in fluid shifting leads to edema
Dependent position is the skin attached to or facing
the bed
Emaciation
STAGES OF DECUBITUS ULCER FORMATION
Stage 1
Involves the epidermis

Manifestation
Non-blanchable erythema of INTACT SKIN
This is the first heralding sign of decubitus ulceration
Stage 2
Partial Thickness Skin Loss

Involves epidermis and dermis
Manifestation
Blister formation
Shallow craters
Shallow abrasion and ulceration
Stage 3
Full Thickness Skin Loss Ulceration

There is skin loss already
Involves necrosis of the skin and subcutaneous tissues
EXTENDING TO but NOT THROUGH the underlying fascia
Stage 4
Formations and manifestations of Stage 3 plus

Involvement of bones, supporting structures (tendons),
joint capsules
Massive damage
TOOLS TO ASSESS RISK OF ULCERATION

Nortons Pressure Area Risk Assessment Form
Shannons Scoring System
Branden Scale of Predicting Ulceration
Waterlow Risk Assessment Cards
Most important tool
Most common tool
Most often used tool
EDEMA
EDEMA
Caused by shifting of fluid into the interstitial tissues
MANAGEMENT OF EDEMA
1) Elevation of the edematous part
Nursing Alert!
If edema is due to Congestive Heart Failure (Right
Sided), NEVER ELEVATE THE LOWER EXTREMITIES
Rationale:
This increases the workload of the right side of the
heart
Concept!
If edema is due to prolonged standing, DO THE
ELEVATION
MANAGEMENT OF EDEMA
2) Wear elastic stockings
MANAGEMENT OF EDEMA
3) Use warm compress alternated with cold compress
Rationale:
Vasoconstriction and
circulation of fluid
vasodilation
causes
Concept!
This is contraindicated if there is inflammation
re-
ASSESSMENT OF EDEMA
Induration
1+
2+
3+
4+
5+
1 cm induration
2 cm induration
3 cm induration
4 cm induration
5 cm induration
PAIN MANAGEMENT
PAIN
A noxious stimulation of actual or threatened / potential

tissue damage
CATEGORIES OF PAIN ACCORDING TO ORIGIN

1) Cutaneous
Skin
2) Deep Somatic
Tendons, ligaments
Bones
Blood Vessels
3) Visceral Pain
Organs of the body
CATEGORIES OF PAIN BASED ON CAUSE

1) Acute
Due to trauma or surgery
Persists for less than six (6) months
2) Chronic Malignant Pain
Related to cancer
On and off
Persists for more than six (6) months
3) Chronic Non-malignant Pain
Persists for more than six (6) months
CATEGORIES OF PAIN ACCORDING TO WHERE IT IS

EXPERIENCED
1) Radiating Pain
Felt on the source and is extending to nearby tissues
2) Referred Pain
Felt on other parts detached from the source
Example:
Pain on a lacerated liver may be felt on the right
shoulder and not on the right upper quadrant
CATEGORIES OF PAIN ACCORDING TO WHERE IT IS

EXPERIENCED
3) Intractable Pain
Highly resistant to pain-relief methods
4) Phantom Pain
Pain that is felt on a MISSING BODY PART or a PART
THAT IS PARALYZED by SPINAL CORD INJURY.
PAIN THRESHOLD
Amount of pain stimulation that is required in order to
feel pain
PAIN TOLERANCE
Maximum amount of pain and duration that a person is
willing to endure
PAIN MANAGEMENT STRATEGIES

1) Pharmacologic Methods
Narcotics
NSAIDs
Adjuvants or Co-analgesics
2) Non-Pharmacologic Methods
Physical Interventions
Cognitive / Behavioral Interventions
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN
1) Cutaneous
Stimulation
1A) Massage
Effleurage
Soft massage
Gentle stroking
1)
Cutaneous
Stimulation
1B) Petrissage
Hard massage
Large and quick
pinches
Also
done
by
striking
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS

TO PAIN
1) Cutaneous Stimulation
1C) Application of Counter-Irritant
Bengay
Menthol
Omega Pain Killer
Flax Seeds
Poultices

TO PAIN
1D) Heat and Cold Application
Nursing Alert!
Rebound Phenomenon
When you apply heat (usually done for 20
minutes), vasodilation is produced
If heat is applied for more than 20 minutes,
there is vasoconstriction
This is an inherent defense mechanism from
burning of tissues

TO PAIN
1E) Cold Application
Maximum vasoconstriction is reached when skin
reaches 15C
If there is further drop in temperature, there is
vasodilation (skin becomes reddish)
This is the inherent defense mechanism from being
frozen
1F) Accupressure
Pressure on certain
points of the body
Stimulates release of
endorphins,
which
have
natural
analgesic effects
This
started
in
Ancient China
1)
Cutaneous
Stimulation
1F) Accupuncture
Insertion of long
slender needles on
certain
chemical
pathways
Origin
is
also
Ancient china

TO PAIN
1G) Contralateral Stimulation
Example: Injury on left side and massage is done on
the right side
Useful when patient cannot be accessed:
For patients in a cast
For patients with burns

For patients with phantom pain

TO PAIN
2) Immobilization
Application of splints
3)
Transcutaneous
Electrical
Nerve
Stimulation
Composed
of
electrodes
Operated by battery
Electrodes are applied
on painful site or over
the spinal cord

TO PAIN
4) Administration of a Placebo
Relieves pain because of its intent and not because of
physical or chemical properties
COGNITIVE AND BEHAVIORAL

NON-PHARMACOLOGIC INTERVENTIONS TO PAIN
Purpose:
To alter pain perception
To alter pain behavior
To provide client with a greater sense of control over the
pain

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

2) Massage and Rhythmic Breathing

3) Rhythmic Singing and Tapping
Key Concept!
Faster beat music is more preferable

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

5) Hypnosis
The
success
of
hypnosis depends on
the ability of the
patient to concentrate
and the capacity of the
hypnotist to suggest
Based on suggestion
Progressive relaxation
URINARY ELIMINATION
URINARY ELIMINATION
Oliguria
Renal output of less than 500 ml per day
Anuria
Renal output of less than 100 ml per day
Retention
Positive for distended bladder
May also occur in the absence of bladder distention
ALTERED URINARY ELIMINATION

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

Incontinence
Involuntary passage of urine
TYPES OF INCONTINENCE
1) Functional Incontinence
Involuntary passage
Unpredictable time
2) Reflex Incontinence
Occurs at somewhat predictable times when specific
bladder volume is reached
No awareness of bladder filling
No urge to void
It may be related to neurologic impairment
3) Stress Incontinence
Loss of urine is less
than 50 ml occurring
with increased intraabdominal pressure
Occurs when laughing
Occurs when sneezing
Occurs when smiling
4) Total Incontinence
Continuous flow of urine
No bladder distention
No bladder spasm
No awareness of bladder filling
5) Urge Incontinence
Urine flows as soon as
a strong sense of
feeling to void occurs
Strong bladder spasm
MANAGEMENT OF INCONTINENCE
1) Kegels Exercises
Also called:
Pubococcygeal Muscle Exercises
Pelvic Floor Muscle Exercises
Applicable for:
Functional Incontinence
Stress Incontinence
How done:
Advise patient to stand with legs slightly apart
Concentrate on perineum
Draw perineum upward slowly
1) Kegels Exercises
Alternative way:
When urinating, try to stop in the middle of flow or try
to stop diarrhea from flowing
Advantage of Kegels Exercises
Increases muscle tone of the pelvis
Increases muscle control
2) Clean Intermittent Self
Catheterization
Applicable for Reflex
Incontinence
How done:
Use a mirror for:
Obese
male
patients
Female patients
2) Clean Intermittent
Catheterization
Question:
Self
Is
your
Clean
Intermittent
Self
Catheterization
procedure
a
sterile
procedure?
Answer:
No, it is just a clean
procedure.
Therefore,
you can just wash the
catheter for the next use.
3) Credes Maneuver
Application of a steady but gentle pressure on the
supra-pubic region to force urine out of the bladder
Nursing Alert!
Do not use if there is OBSTRUCTION (i.e. renal
obstruction in the form of renal stones)
This is done only for patients who are no longer
expected to regain control (Reflex incontinence and
retention)
4) Prompted Voiding or Scheduled Toileting
For Reflex Incontinence
5) Application of Adult Catheter and External

Condom Catheter
For elderly with Total Incontinence
6) Catheterization
MIDSTREAM CLEAN CATCH URINE SPECIMEN

How is this done?
If patient is a Male
Clean the penis
Do this from the meatus down to the shaft
Let the patient urinate
Discard the first or the initial urine
Collect midstream urine
Purpose is to attain sterile specimen for urine culture
and sensitivity testing
MIDSTREAM CLEAN CATCH URINE SPECIMEN

If patient is a Female
Let patient wash genitals
Dry the genitals
Get to bed
Place patient in semi-Fowlers position when she is ready
to void
Clean and spread labia with two fingers
Remain holding labia
Then let patient urinate
Let go of first flow
Collect next flow
CATHETERIZATION
TYPES OF URINARY CATHETERS

1) Coude Catheter
Elbowed catheter for
Benign
Prostatic
Hypertrophy patients
2) Robinson Catheter
Straight catheter

Multi-Lumen Retention
Catheter
Foley catheter
One lumen is for inflation
One lumen is for
drainage of urine
One lumen is for
irrigation
A three-way catheter
Aspirate using syringe
and needle
This is made with a selfsealing rubber
CONCEPTS IN MALE CATHETERIZATION

Procedure for Insertion:
See to it that penis is perpendicular to body to straighten
up the urethra to bladder
While inserting the catheter, ask the patient to breathe
through the mouth
Cleanse the penis before insertion
Grasp penis firmly to avoid stimulating erections

Where to tape catheter
Tape it upward on the abdomen
Rationale:
To avoid scrotal excoriation
Tape on the inner thigh (with penis sideways either on
left or right and follow the normal contour of the penis

Length of Catheter
40 centimeters
Depth of Insertion
While inserting, the point at which urine starts to flow,
insert further by five (5) centimeters and then inflate the
balloon KOZIER
Insert up to a the Y-point, retract after inflating (this
method is more prone to infection
CONCEPTS IN FEMALE CATHETERIZATION

Area of Insertion
Insert at female Urethra
Length of Catheter
22 centimeters
Depth of Insertion
Point at which urine starts to flow, insert further by five
(5) centimeter before inflating balloon
GIT FECAL ELIMINATION
WELLNESS TEACHINGS
Fluid intake of at least 2,000 ml per day
Regular exercise
High fiber diet
Avoid ignoring the urge to defecate
Do not abuse laxatives
CONCEPTS FOR FLATULENCE

Avoid carbonated drinks
Do not use straw
Avoid chewing gum
Avoid gas-forming foods:
Camote
Cabbage
Cauliflower
Onions
CONCEPTS FOR CONSTIPATION

Increase fluid intake
Take prune juice
Eat papaya
Increase fiber in the diet
Use METAMUCIL (natural fiber) instead of laxatives
SPECIAL GASTRO-INTESTINAL LABORATORY

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

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

PROCEDURES
2) GI SERIES
2B) Lower GI Series Barium Enema
Done at the radiology department
Nursing Concern:
Elimination of Barium
How:
Cleansing enema may be needed after barium
enema
DIFFERENT TYPES OF ENEMA

1) Cleansing Enema
Soap suds enema
Alkaline solution
Nursing Alert!
Contraindicated in patients with liver cirrhosis and
with increased ammonia in the blood
Rationale:
Alkaline solution facilitates transfer of ammonia from
the GI tract to the bloodstream
Therefore, use lemon juice or dilute vinegar
instead!!!

1) Cleansing Enema
Nursing Alert!
Also
contraindicated in
possible
appendicitis
or
appendicitis
patients
Rationale:
Can lead to rupture
of the appendix

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

3) Oil Retention Enema
To lubricate the colon and to soften the feces
Retention time is one (1) to three (3) hours

4) Retention Flow Enema
Also called Harish Flush Enema
Solution is continually administered until what comes
out of the body is clear.
POSITIONS IN ENEMA
High Cleansing Enema
Clean as much of the colon as possible
On introduction, Sims Left position facilitates flow of
enema to sigmoid colon
Then, assume Dorsal Recumbent position to facilitate
flow of enema to transverse colon
Then, Right Side-Lying position to facilitate flow of
enema to the descending colon
POSITIONS IN ENEMA
Low Cleansing Enema
For cleaning of rectum and colon only

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FUNDAMENTALS OF NURSING

FOUR COMPONENTS OR ATTRIBUTES OF

NURSING CONCEPTS OF MAN

Total of those parts is

VITAL REPARATIVE PROCESS

MAN IS A WHOLE. MAN IS COMPLETE

CHARACTERISTICS OF HUMAN NEEDS

ABRAHAM MASLOWS HIERARCHY OF

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS HIERARCHY OF NEEDS

ABRAHAM MASLOWS MODIFIED HIERARCHY

ABRAHAM MASLOWS MODIFIED HIERARCHY

ABRAHAM MASLOWS MODIFIED

ABRAHAM MASLOWS MODIFIED

ILLNESS, WELLNESS AND

TWO TYPES OF ILLNESS

Health is the complete

MODELS OF HEALTH AND ILLNESS

DUNNS HIGH-LEVEL WELLNESS AND

HEALTH BELIEF MODEL BY ROSENTOCK

FOUR LEVELS OF HEALTH BY SMITH

FOUR LEVELS OF HEALTH BY SMITH

FOUR LEVELS OF HEALTH BY SMITH

FOUR LEVELS OF HEALTH BY SMITH

AGENT, HOST, ENVIRONMENT MODEL BY

Nursing is the diagnosis

Canadian Nurses Association

10) DOROTHEA OREM:

10) DOROTHEA OREM:

11) HILDEGAARD PEPLAU:

Nurse and patient

11) HILDEGAARD PEPLAU:

11) HILDEGAARD PEPLAU:

12) MARTHA ROGERS:

13) SISTER CALISTA ROY:

14) LYDIA HALL:

15) JEAN WATSON:

16) ROSEMARIE RIZZO PARSE:

17) JOSEPHINE PATTERSON &

18) HELEN TOMLIN, EVELYN TOMLYN

19) ANN BOYKIN & SAVINA

Nursing is NOT BASED

19) ANN BOYKIN & SAVINA

20) MARGARET NEWMAN:

21) JOYCE TRAVELBEE:

22) IDA JEAN ORLANDO:

There is movement, the relationship is not static

23) NOLA PENDER:

24) PHIL BARKER & POPPY BUCHANANBARKER:

25) CORBIN AND STRAUSS:

The patient moves in a TRAJECTION of Eight (8)

EIGHT PHASES OF TRAJECTION

EIGHT PHASES OF TRAJECTION

26) BONNIE WEAVER DULDT BATTEY:

28) KATHRYN BARNARD:

29) ALFRED ADLER:

The personality of an individual is affected by the BIRTH

30) GLADYS HUSTED & JAMES HUSTED:

TEACHING AND LEARNING

TEACHING AND LEARNING