1 Fundamentals in Nursing

8/3/2019 1 Fundamentals in Nursing

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FUNDAMENTALS INNURSING

BY: NURSE_JHEN


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1. What vitamin is necessary for a patient suffering from pellagra?a. vitamin B1 c. vitamin B3b. vitamin B2 d. vitamin B6

2. According to the intentional torts, which of the following describesthe intentional touching of a person or something that person isholding or wearing, which is wrong in some way.a. assault c. domestic violenceb. battery d. false imprisonment

3. What stage of illness will the person belong if the client is

expectedly to gradually become independent and resume formerroles and duties?a. symptom experience c. assumption of sick roleb. dependent role d. recovery period

4. This is considered to be the 4th stage of grief and loss accordingto Kubler-Ross.

a. denial c. bargainingb. anger d. depression

5. According to Jean Piaget, in his theory of cognitive development,OBJECT PERMANENCE belongs to what level?a. Preoperational c. concreteb. Sensorimotor d. formal


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METAPARADIGMS INNURSING


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THEORIES OFNURSING


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FLORENCE NIGHTINGALE12 May182013 August1910

"The Lady with theLamp

Bplace: Florence, Italy Raised: England Educated:

Kaiserswerth,Germany founded byTheodore Fleidner

At 17 entered thecovenant

Crimean war
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St. Thomas Hospital School of Nursing,London June 15, 1860

Works: notes on nursing(1860) andnotes on hospital

1st theory of nursing

Environmental Model

Changing or manipulating theenvironment

The body can repair itself in anurturing environment
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FAYE GLENN

ABDELLAH born March 13,1919

nursing research
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nursing as an artand a science

Identified 21 nursing problems

nursing is a society

Works: Better Nursing CareThrough Nursing Research andPatient-Centered Approaches to

Nursing


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Abdellah's Typology of 21 Nursing Problems: To promote good hygiene and physical comfort To promote optimal activity, exercise, rest, and sleep To promote safety through prevention of accidents, injury, or other trauma and

through the prevention of the spread of infection

To maintain good body mechanics and prevent and correct deformities To facilitate the maintenance of a supply of oxygen to all body cells To facilitate the maintenance of nutrition of all body cells To facilitate the maintenance of elimination To facilitate the maintenance of fluid and electrolyte balance To recognize the physiologic responses of the body to disease conditions To facilitate the maintenance of regulatory mechanisms and functions

To facilitate the maintenance of sensory function To identify and accept positive and negative expressions, feelings, and reactions To identify and accept the interrelatedness of emotions and organic illness To facilitate the maintenance of effective verbal and nonverbal communication To promote the development of productive interpersonal relationships To facilitate progress toward achievement of personal spiritual goals To create and maintain a therapeutic environment To facilitate awareness of self as an individual with varying physical, emotional,

and developmental needs To accept the optimum possible goals in light of physical and emotional limitations To use community resources as an aid in resolving problems arising from illness To understand the role of social problems as influencing factors in the cause of

illness


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VIRGINIA AVENEL HENDERSON

(Nov. 30, 1897Mar. 19, 1996) first lady of

nursing

born in Kansas City,Missouri

graduated fromthe Army School

of Nursing,Washington
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14 basic needs assist clients to a peaceful death nursing as "assisting individuals to gain

independence in relation to the performance ofactivities contributing to health or its recovery"

Works: The Principles and Practice of Nursing

described the nurse's role as substitutive(doingfor the person), supplementary(helping theperson), or complementary(working with theperson), with the goal of helping the personbecome as independentas possible.


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DOROTHY E. JOHNSONBSN, MPH

1919 - 1999

"first four yeargeneric basic nursingprogram in the UnitedStates


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Behavioral system model

7 subsystems: ingestive, eliminative,affiliative, aggressive, dependence,achievement and sexual

patients health is dependent onnurses behavior

Works: One Conceptual Model of

Nursing
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IMOGENE KING Ed.D.

RN(1971, 1981) Goal attainment theory "General Systems

Framework" theory nursing as a

profession nurses help individuals

die with dignity interaction between

nurses and patients.


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King's Conceptual System:

Three Interacting Systems

Personal Systems InterpersonalSystems

Social Systems

perception interaction organization

self communication authority

growth &development

transaction status

body image role decision making

space stress

time
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MADELINE LEININGER PhD,LHD, DS, RN, CTN, FRCNA,

FAAN, LL

Transcultural nursing

model Nursing is a humanistic

and scientificmode ofhelping a client through

specific cultural caringprocess


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Works: Journal of Transcultural Nursing

The main goal of transcultural nursing is to provideculturally specific care

Transcultural Nursing focused upon differences and similarities among cultures

respect to human care, health, and illness based upon the people's cultural values, beliefs, andpractices, and

to use this knowledge to provide cultural specific orculturally congruent nursing care to people


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MYRA ESTRIN LEVINE

(1973) Supportive & Therapeutic Conservation model

4 Principles E

P

S

SWorks: Humanities in Nursing

B M N R N


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Betty M. Neuman, R.N.,B.S.N., M.S., Ph.D., PLC.,

FAAN

Born 1924 near Lowell,Ohio.

pioneer in the field ofnursing involvement incommunity mental health


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Health care systems model nurses help patients adjust to environmental

stressors Works: 'Model for teaching total person

approach to patient problems' in Nursing

Research Neuman Systems Model wholistic overview of the physiological,

psychological, sociocultural, and developmental

aspects of human beings

DOROTHEA ELIZABETH


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DOROTHEA ELIZABETHOREM

(1914June 22, 2007)

SELF CARE andSELF CAREDEFICIT THEORY
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Self care and Self care deficit theory

'the practice of activities that individuals initiate andperform on their own behalf in maintaining life, health,and well-being.'"

individuals can take responsibility for their health and

the health of others

3 nursing systems W P S


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HILDEGARD PEPLAU. EDd

(Sept 1, 1909 - Mar 17, 1999) _ Interpersonal Relations

in Nursing

emphasized the nurse-client relationshipasthe foundation ofnursing practice

Theory is the creationof a shared experience
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4 Phases of Nurse-Client

Relationship1. Orientation2.Identification

3.Exploitation4.Resolution


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DR. MARTHA ELIZABETHROGERS

1914 - 1994

Edited a journalcalled: NursingScience


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Science of Unitary Human Beings

man is an energy field in the environment Man has the capacity for abstraction and

imagery, language and though, sensationand emotion

Works: An Introduction to the TheoreticalBasis of Nursing(Rogers, 1970).


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SISTER CALLISTA ROY

RN, PhD, FAAN Bachelor of Arts with amajor in nursing at MountSt. Mary's College, in LosAngeles.

Nursings goal is topromote adaptation in fourmodes:physiologic, self-concept, role function, andindependence.


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Adaptation model man as a biopsychosocial system - The

person is an open, adaptive system whouses coping skills to deal with stressors sees the environment as "all conditions,

circumstances and influences thatsurround and affect the development andbehaviour of the person"

six-step nursing process which includes:assessment of behaviour, assessment ofstimuli, nursing diagnosis, goal setting,

intervention and evaluation.


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LYDIA ELOISE HALL

1906 - 1969 Nursing process Concept of CARE, CORE,

CURE Hall believed patients

should receive care ONLYfrom professional nurses Hall was not pleased with

the concept of teamnursing--she said that "anycareer that is definedaround the work that hasto be done, and how it isdivided to get it done, is a"trade" (rather than aprofession).


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According to the Care, Core, andCure" model, nurses work in threearenas: care (hands on bodily care),core (using the self in relationship tothe patient), and cure (applying

medical knowledge). three separate domains: the body

(care), the illness, (cure), and the

person (core).


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JEAN WATSON,

Phd, RN, AHN_BC, FAAN Born:West Virginia Educated:BSN,

University of

Colorado, 1964MS, University ofColorado, 1966PhD,University ofColorado, 1973

She is founder of theoriginal Center forHuman Caring inColorado


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Human caring model

Transpersonal caring

Included health promotion andtreatment of illness in nursing

Her latest book is Caring Science asSacred Science(2005)


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TEN CARATIVE FACTORS1. "The formation of a humanistic-altruistic system of values"(Watson, 1979). Thisfactor develops at an early age and involves a broad awareness of self.2. "The instillation of faith-hope"(Watson, 1979). An understanding of andsensitiviy to an individual's beliefs provides a sense of well-being for the client.

3. "The cultivation of sensitivity to one's self and to others"(Watson, 1979). Thisallows the nurse and the client to become increasingly sensitive, and thereforemore genuine.4. "The development of a helping-trust relationship"(Watson, 1979). Effectivecommunication techniques such as congruence aids in the creation of thisrelationship.5. "The promotion and acceptance of the expression of positive and negativefeelings"(Watson, 1979). This factor recognizes that the6. "The systematic use of the scientific problem-solving method for decisionmaking"(Watson, 1979). The problem-solving method is foundational to thepractice of nursing.7. "The promotion of interpersonal teaching-learning"(Watson, 1979). Theprovision of information empowers a client to make informed decisions abouthealth and healing.8. "The provision for supportive, protective, and (or) corrective mental, physical,sociocultural, and spiritual environment"(Watson, 1979). This factor encompassesinternal and external variables that the nurse is responsible for guiding.

9. "Assistance with the gratification of human needs"(Watson, 1979). Humanneeds include all acts of life, ranging from food to the need for achievement.10. "The allowance for existential-phenomenological forces" (Watson, 1979). Thenurse needs to view each person's reality through the individual's eyes.It was on Christine Donald's site


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ROSEMARIE RIZZO

PARSE, RN; PhD; FAAN Theory of humanbeing

Free choice of

personal meaning inrelating valuepriorities

Used terms such asrevealing-concealing,

enabling-limiting,connecting-separating


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BASIC HUMAN NEEDS

( Abraham Maslow)


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Maslows Characteristics of a

Self-Actualized Person1. realistic2. judges people correctly3. superior perception, is

more decisive

4. clear notion of what isright or wrong

5. usually accurate inpreceding future events

6. understands art, music,

politics, philosophy7. possesses humility,listens attentively

8. dedicated to work, task,duty, perception

CONCEPTS OF


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CONCEPTS OFHEALTH,WELLNESS AND

ILLNESS Health is a state of complete physical, mental andsocial well-being, and not just merely the absenceof disease of infirmity (WHO)

Wellness is well-being. It involves in engaging inattitudes and behaviors that enhance quality oflife and maximize personal potential

Illness is a state in which the person perceivesphysical, emotional, intellectual, social,developmental or spiritual functioning to bedecreased.


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MODELS OF HEALTH

AND ILLNESS


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HEALTH-ILLNESS

CONTINUUM (DUNN) describes the interaction of environmentwith well-being and illness

high-level wellness: towards optimum levelof functioning

if not going for OLOF, then the person istowards the illness continuum


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HEALTH BELIEF MODEL(Rosenstock and Becker)

individual perceptions andmodifying factors mayinfluence health beliefsand preventive health

behaviorindividual perceptions mayinclude: perceived threat,perceived susceptibility,perceived seriousness

modifying factors include:demographic variables(age, sex, race),sociophysilogic variables(peer group, clubs),structural variables (knowledge, contact)


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Concept Definition Application

PerceivedSusceptibility

One's opinion of chances ofgetting a condition

Define population(s) at risk, risklevels; personalize risk based

on a person's features orbehavior; heighten perceived

susceptibility if too low.

Perceived SeverityOne's opinion of how serious a

condition and itsconsequences are

Specify consequences of the riskand the condition

Perceived Benefits

One's belief in the efficacy ofthe advised action to

reduce risk or seriousnessof impact

Define action to take; how,where, when; clarify the

positive effects to beexpected.

Perceived BarriersOne's opinion of the tangible

and psychological costs ofthe advised action

Identify and reduce barriersthrough reassurance,incentives, assistance.

Cues to ActionStrategies to activate

"readiness"

Provide how-to information,promote awareness,

reminders.

Self-EfficacyConfidence in one's ability to

take actionProvide training, guidance in

performing action.


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FIVE STAGES OF ILLNESS

Symptomexperiences

When the person believes something iswrong; manifestations of signs and symptoms(they feel unwell or get a rash)

Assumption of

the sick role

When self-management fails, seeks

confirmation from family and friends oftenexcused from normal role expectations

Medical carecontact

When symptoms persist, seeks the advice ofa health professional (check- up)

Dependentclient role Becomes dependent on the professional forhelp with illness (admission to the hospital)

Recovery orrehabilitation

Client is expected to gradually becomeindependent and resume former roles andduties


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STRESS


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MODERN STRESSTHEORY

(HANS SELYE)

stress is a non-specific response ofthe body to any demand made upon it

A stressor is any stimulus that

produces stress and the disturbs thebodys equilibrium

FACTS OF STRESS


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FACTS OF STRESS:1. stress is not a nervous

energy2. man tends to adapt tostress

3. stress is not alwayssomething to be avoided

4. stress does not alwayslead to distress5. a single stress does not

cause a disease6. stress may lead to

another stress7. prolonged stress may

lead to exhaustion8. stress is always a part of

everyday life


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GENERAL ADAPTATION

SYNDROME (GAS) whenever a man responds to stress,

the whole body is involved

Regardless of the cause of stress,the same chain of physiologic eventsoccurs

The GAS is a result of the release ofadrenal hormones, with subsequentchanges in organ systems


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STAGES OF GAS: (ARE)

Stage of Alarm Stage ofResistance Stage ofExhaustion

person becomesaware of the

presence of threator danger

levels of resistanceare decreased

adaptive

mechanism aremobilized (fight orflight reaction)

characterized byadaptation

levels of resistanceare increased

person moves backto homeostasis

result fromprolonged exposure

to stress andadaptive

mechanisms can nolonger persist

unless other

adaptivemechanisms will bemobilized, death

may ensue


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LOCAL ADAPTATION

SYNDROME (LAS) man may respond to stress through a

particular body part or body organ

response is localized It is the reaction of one organ or one

part of the body

Example: inflammation

HEALTH PROMOTION


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HEALTH PROMOTION


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HEALTH PROMOTION

these are activities directed towards

increasing the level of well-being andself-actualization


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THREE LEVELS OF

PREVENTIONPrimaryPrevention

to encourage optimal health and to increase the persons resistance toillness

activities includes health promotion, health teachings

examples: quit smoking, exercise, immunizations, balanced diet, healthylifestyle, avoid alcohol intake, increase water intake, maintain idealbody

SecondaryPrevention

also known as health maintenance

activities include early diagnosis, detection and screening; prompttreatment

examples: PE, pap smear, clinical Breast Exam, sputum exam, stoolexam and rectal exam

TertiaryPrevention

to support the clients achievement of successful adaptation to known risks,optimal reconstitution and/or establishment of high-level wellness

examples: self-monitoring of blood glucose, physical therapy of a CVApatient, cardiac rehab after MI, self-management class for DM,speech therapy after laryngiectomy


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NURSING PROCESS


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NURSING PROCESS

Lydia Hall

G

O S

H


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CHARACTERISTICS OF

THE NURSING PROCESS1. problem oriented, it is comparable with scientificproblem-solving approach

2. goal oriented3. orderly, planned, step by step

4. open to accepting new information during its application,it is flexible to meet the unique needs of the client, groupor community

5. interpersonal it requires that the nurse communicatesdirectly and consistently with the client

6. permits creativity among nurses and clients in devising

ways to solve the health problems7. cyclical steps may overlap because they are interrelated8. universal


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ASSESSMENT collecting, validating, organizing and recordingdata about the clients health status

purpose: ______________

TYPES OF DATA: s -o -METHODS: 1. interview -

2. observation -

SOURCES: Primary Secondary

NURSING DIAGNOSIS


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NURSING DIAGNOSIS 4 parts _______: to identify the clients health care

needs and to prepare diagnostic statements PROBLEM: ETIOLOGY: SIGNS AND SYMPTOMS: SECONDARY FACTORS:

EXAMPLE:Altered Comfort: Pain related to presence of

incision site at the right lower quadrantsecondary to post appendectomy

TYPES OF NURSING


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TYPES OF NURSINGDIAGNOSIS

Actual Example: fluid volume deficit Risk

Example: risk for injury Potential

Example: potential for growth Wellness

Example: family pattern increased Syndrome

Example: altered community pattern


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PLANNING

Determining the strategies or course ofactions to be taken before implementationof nursing care

Purpose: to identify the clients goalsand appropriate nursing interventions

Should only have ONE GOAL but may have

MANY OBJECTIVES

Sh ld b SMART


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Should be SMART SPECIFIC: the goal should be directed to the

patient alone

MEASURABLE: use of action words likedemonstrate, verbalize, manifest, etc. ATTAINABLE: should be well stated in a way that

the goal is achievable REALISTIC: suited for the condition of the

specific patient and is applicable

TIME FRAMED: the time is set for the goal to beachievedEXAMPLE: (altered comfort: pain)At the end of my 8-hour shift, my patient will

verbalize increased level of comfort as evidenced by: Reduced pain scale of 3/10 from 6/10 with 0 as no

pain and 10 as most painful Participate in activities of daily living

Absence of guarding behavior, facial grimacing, andmoaning


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IMPLEMENTATION

Putting the nursing care plan intoaction

Purpose: to carry out plannednursing interventions to help theclient attain goals

h ld b i d i i


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Should be organized in itspresentation

INDEPENDENT: all nursing actions that needsNO doctors orders (vital signs, turning andpositioning, chest physiotherapy)

DEPENDENT: all nursing procedures thatNEEDS doctors orders (medications, special

procedures) INTERDEPENDENT: otherwise known asCOLLABORATIVE, in which other health teammembers are being tapped for the care(speech therapy, respiratory therapy, physical

therapy) REFERRAL: endorsed to the superior (NOD,head nurse, physician)


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EVALUATION

Assessing the clients response to nursinginterventions and then comparing theresponse to predetermined standards or

outcome criteria Purpose: to determine the extent of

which goals of nursing care have been

achieved

COMPONENTS OF A


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COMPONENTS OF ANURSING GOAL:

A. CONCLUSION STATEMENTS 1. GOAL MET 2. GOAL PARTIALLY MET 3. GOAL UNMET

B. JUSTIFICATIONS - written as as evidencedby EXAMPLE: Goal Met. Patient able to verbalize increased

level of comfort as evidenced by:

reduced pain scale cooperate in the ADL no more facial grimacing


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COMMUNICATION

TYPES OF COMMUNICATION:


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TYPES OF COMMUNICATION:

1. NONVERBAL actions or behaviors that communicate a

message without speaking facial expressions, body language, posture, hand gestures,use of space and territory

2. VERBAL transmission of a message using the spokenlanguage

3. THERAPEUTIC communication that pertains to treatmentand healing

important elements contributing to the establishment of thetherapeutic relationship are EMPATHY, ATTENDING,

OBSERVING, and LISTENING4. NON-THERAPEUTIC communication that is a barrier to

free

5. ACTIVE LISTENING attentiveness to the client in aphysical and psychological manner

ESSENTIAL COMPONENTS OF A


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ESSENTIAL COMPONENTS OF ATHERAPEUTIC COMMUNICATION

(ReGRET) RAPPORT IPR characterized by a spirit ofcooperation, confidence and harmony

TRUST a risk-taking process whereby a persons

situation and feeling of well-being depends on theactions of another RESPECT a relationship in which one considers

the other in high esteem or regard

EMPATHY

ability to try and understand what otherperson is feeling; Not actually feeling what the otherperson is feeling

GENUINENESS being as one appears, sincere andhonest

THERAPEUTIC COMMUNICATION


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TECHNIQUESListening Facing and leaning towards the client, using eye contact, relaxed

body posture

Broad opening Open-ended comments

Clarification Nurse communicates an understanding of the thought or feelingtone of the clients message back to him/her to offer another

perspective in the situation

Reflection Reflects back the feeling or thought

Confrontation Describes contraindications in the clients behavior or feeling

Giving information Provides facts and information

Seeking validation Asks to give feedback about the accuracy of the nurses

perceptions

Self-disclosure Occasionally and cautiously reveals something from her ownexperience

Silence To communicate presence and acceptance of the client

Summarizing Progress, evaluates, goals

NONTHERAPEUTIC


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NONTHERAPEUTICCOMMUNICATION

Changing thesubject

Nurse communicates an unwillingness to continue with theclients topic

Interrupting Nurse shows disrespect by breaking into an interferingwith his/her communication

Approving Nurse uses approval and disapproval to control the clientand his/her behavior

Moralizing Nurse passes judgment on the client

Social response Nurse uses superficial, social conversation that is not

client-centered

Belittling Nurse discounts the clients feelings and experiences asnot being valuable or worthwhile

Giving advice Nurse gives advice to the client

LEGAL ISSUES


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LEGAL ISSUES


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PRIVACY being apart from others for observation

INFORMED CONSENT the health care provider has theresponsibility to communicate pertinent information in a manner that

the client is able to understand role of the nurse: advocate

COMMITMENT the legal process by which the clients who havepsychiatric problems are brought to and confined in a secure areabecause their behaviors are so extreme and severe that they pose a

harm to themselves or to others CLIENT RIGHTS

clients retain all of the basic rights that every citizen has

clients also expect that the treatment will be individualized andcollaborative with no verbal or physical abuse

client rights include privacy, confidentiality, and expectation thattreatment will be appropriate to needs with client participation

HUMANE RESEARCH entails voluntary participation, informedconsent, and freedom to withdraw from the study at any time for anyreason, without penalty

LIABILITIES


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LIABILITIES MALPRACTICE incorrect treatment by a professional

that causes injury or harm NEGLIGENCE the commitment of an act that a

reasonable and prudent person would not have done INVASION OF PRIVACYviolation of another persons

rights to be left alone and free from unwarranted contact,

intrusion and publicity DEFAMATION OF CHARACTER any untrue

communication, written (libel) or spoken (slander) thatinjures the good name or reputation of another, or in anyway brings that person into disrepute

FALSE IMPRISONMENT the intentional, unjustified,nonconsensual detention or confinement of a client forany length of time.

RESPONDEAT SUPERIOR the employer is ultimatelyresponsible for the acts of its employees, and is thus liable

for damage to the third parties


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VITAL SIGNS


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TEMPERATURE

balance between the heat producedby the body and the heat lost from

the body body heat is primarily produced by

metabolism

the heat-regulating center is thehypothalamus


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2 TYPES:1. CORE deep tissues of the body2. SURFACE skin, SQ, fats

normal core body temperature isbetween 36.5 C 37.5 C

BASAL METABOLIC RATE the youngerthe person, the higher the BMR; theolder the person, the lower the BMR

PROCE NVOLVED


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PROCESS INVOLVED

IN THE HEAT LOSS1. RADIATION the transfer of heat from the

surface of one object to another without contactbetween the two objects

2. CONDUCTION transfer of heat from onesurface to another but with contact between thetwo objects

3. CONVECTION the dissipation of heat by aircurrents

4. EVAPORATION the continuous vaporization ofmoisture from the skin, oral mucous, heatrespiratory tract (insensible heat loss)

ALTERATIONS IN


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ALTERATIONS INBODY TEMPERATURE

FEBRILE from 37.5 C to 38 CHYPERTHERMIA from 38 C to

39.5 C Febrile and hyperthermia can be

relieved by TSB + antipyreticsPYREXIA from 39.5 C and aboveHYPERPYREXIA pyrexia +

convulsion Pyrexia and hyperpyrexia needs

IV antipyretics +anticonvulsants

Very high body temperature(41-42 C) cause irreversiblebrain cell damage


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TYPES OF FEVERa. INTERMITTENT temperature fluctuates

between periods of fever and periods ofnormal/subnormal temperature

b. REMITTENT temperature fluctuates within a

wide range over the 24-hour period but remainsabove normal range

c. RELAPSING the temperature iselevated for few days, alternated with

1 or 2 days of normal temperatured. CONSTANT body temperature

is consistently high

NURSING INTERVENTION


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NURSING INTERVENTIONOF CLIENTS WITH FEVER

1. monitor VS 2. assess skin color and temp skin flushing 3. monitor WBC NEUTROPHILS will increase f

due to bacterial infection

4. remove excess blankets 5. Provide adequate food and fluid replacement 6. measure I&O 7. promote rest

8. provide TSB prn 9. administer antipyretics


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PULSE A wave of blood created by

contraction of the left ventricle ofthe heart

The PR is regulated by the autonomicnervous system


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FACTS: 1. females have higher

PR after puberty 2. increase in

metabolic rate

increases PR 3. increase in bloodloss increases PR4. thready pulse weak and feeble pulse

5. bounding verystrong pulse


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PULSE SITES: temporal carotid apical

brachial radial femoral posterior tibial

pedal (dorsalis pedis) popliteal

ASSESSMENT OF THE


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ASSESSMENT OF THEPULSE:

A. RATE the normal pulse rates per minute are asfollows: Newborn: 80-180 bpm 1 year: 80-140 bpm 2 years: 80-130 bpm

6 years: 70-120 bpm 10 years: 50-90 bpm Adult: 60-100 bpmB. RHYTHM the pattern and intervals of beats.

Dysrhytmia is an irregular patternC. VOLUME (AMPLITUDE) the strength of the

pulse Words to use: strong or full, weak, feeble,

thready


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RESPIRATION PHYSIOLOGICAL PROCESSES

1. VENTILATION the movement of air in and outof the lungs

2. EXTERNAL RESPIRATION the exchange ofgases from the alveoli to the capillaries and viceversa

3. PERFUSION the transport of oxygen throughoxyhemoglobin throughout the body

4. INTERNAL RESPIRATION exhange of gasesfrom the capillaries to the tissue and vice versa

TYPES OF


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TYPES OFBREATHING:

COSTAL (THORACIC)involves movementof the chest

DIAPHRAGMATIC(ABDOMINAL)involves movementof the abdomen

RESPIRATORY


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RESPIRATORYCENTERS

A. MEDULLA OBLONGATA the primarycenter; in C3 or C4, where the diaphragmis innervated by the PHRENIC NERVE

B. PONS1. PNEUMOTAXIC CENTER: responsible forrhythmic quality of breathing (involuntarybreathing)

2. APNEUSTIC CENTER: responsible for deep,prolonged inspiration

ASSESSING


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ASSESSINGRESPIRATION

1. RATE: 16-20 cpm (adult)

2. DEPTH: observe the movement of thechest. Maybe normal, deep or shallow

3. RHYTHM: observe for regularity ofinhalations and exhalations

4. QUALITY OR CHARACTER: respiratory

effort and sound of breathing

RHYTHM OF RESPIRATION


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RHYTHM OF RESPIRATION(ALTERED BREATHING)

1. CHEYNE-STOKESwaxing and waning

Char: deep, shallow withtemporary apnea

Conditions: increase ICP,drug toxicity

2. BIOTS also known asCLUSTER RESPIRATION

Character: shallow breathsinterrupted by apnea

Condition: CNS disorders


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3. KUSSMAULShyperventilation

Character: tacypnea +metabolic acidosis;deep and rapidbreathing

Condition: DM 4. APNEUSTIC

prolonged gaspinginspiration followed by

a very shortexpiration


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BLOOD PRESSURE

Measure of the pressureexerted by the blood as itpulsates through the arteries

BP = cardiac output x strokevolume

TERMS:


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TERMS:1. SYSTOLIC PRESSURE pressure of the blood

as a result of contraction of the ventricles (110-140 mmHg)

2. DIASTOLIC PRESSURE pressure when theventricles are at rest (60-90 mmHg)

3. PULSE PRESSURE difference between thesystolic and diastolic pressures (normal is 30-40 mmHg)

4. HYPERTENSION abnormally high bloodpressure over 140 mmHg systolic and/or 90mmHg diastolic for at least two consecutivereadings

5. HYPOTENSION abnormally low bloodpressure, systolic pressure below 100 mmHg

FACTS:


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FACTS: increase peripheral

resistance increase BP decrease cardiac output

decreases BP decrease

compliance/elasticityincreases BP

increase hematocritincreases BP

BP is at lowest in themorning and highest inthe late afternoon

KOROTKOFF SOUNDnormal heart sounds


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LABORATORY EXAMSand DIAGNOSTIC

EXAMS

COMPUTED


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COMPUTEDTOMOGRAPHY (CT SCAN)

3-dimensional image INFORMED CONSENT No fasting required

(except for abdomen) Assess for allergic to

seafoods contrastmedium of iodine-basedwill be used

Should remain still Avoid driving immediately

after the exam

ULTRASOUND ( UTZ )


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ULTRASOUND ( UTZ )/ ULTRASONOGRAPHY

Use of ultrasonic waves(sound waves too high infrequency for a human earto detect)

No special preparationneeded or fasting If UTZ of ABD: let the

client void before theprocedure

If UTZ of KUB: let theclient drink water and notvoid till the procedure isdone

MAGNETIC RESONANCE


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MAGNETIC RESONANCEIMAGING (MRI)

Non-invasive test which usespowerful magnetic fields and radiofrequency pulses

No radiation involved Not for pregnant women, those with

metals in the body (artificialpacemakers, hip replacements,inserted metals after fracture)

Bone appears black in the MRIpaper

Remind that it is a noisy procedure

Assess for claustrophobia Keep still the whole procedure INFORMED CONSENT

CHEST X-RAY


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HES X Y Show the bony thorax and

structures Normal: right is slightly

higher than the left Costophrenic angle junction

between the rib cage and

diaphragm No special preparation No inform consent needed Non-invasive procedure

Keep still the wholeprocedure

POSITRON EMISSION


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POSITRON EMISSIONTOMOGRAPHY (PET)

Produces images ofmetabolic and physiologicfunction

Given strong doses ofradioactive tracers (radio-nuclides)

INFORMED CONSENT

Keep still the wholeprocedure

GASTROINTESTINAL


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GASTROINTESTINALSERIES (GI SERIES)

A. BARIUM ENEMA Examination of the patency

of the lower GI

NPO post NOC Give laxatives before theprocedure

Cleansing enema before Increase fluid intake after

the procedure


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BARIUM SWALLOW Examination of the

patency of the upperGI

Also known asESOPHAGOGRAM

Use of radiopaque whenviewed in thefluoroscope then

filmed Increase fluid intakeafter the procedure

INTRAVENOUS


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INTRAVENOUSPYELOGRAPHY

Radiopaque contrastmedium IV

Laxative given night

before NPO till procedure

is over

INFORMEDCONSENT

URINE ANALYSIS


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A. CLEAN CATCH, MIDSTREAM URINE for U/A and culture and sensitivity

The best time to collect urine specimenis EARLY MORNING, first void specimen

Provide sterile container Do perineal care before collection of

urine Discard the first flow of urine

Collect the midstream: 30-50 ml Send the specimen immediately to the

laboratory

24-HOUR URINE


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24 HOUR URINESPECIMEN

Discard first voided specimen

Collect all specimen thereafter until

same time the following day Soak specimen in a container with ice

Add preservative as ordered

C. SECOND-VOIDED


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C. SECOND VOIDEDURINE SPECIMEN

Discard the first voided specimen

Give water to drink

After few minutes, ask to void again,and collect the urine specimen

This is need for test for glucose in

urine

D. CATHETERIZED


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D. CATHETERIZEDURINE SPECIMEN

Clamp the catheter for 30minutes to 1hour

Cleanse the drainage port of the 2-wayfoley catheter with alcohol swab

Use sterile needle and syringe to aspirateurine specimen from the drainage port

DONTS: collect the urine specimenfrom the bag; detach the catheter from

the connecting tube

STOOL SPECIIMEN


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A. ROUTINE FECALYSIS Assess the gross appearance of stool and

presence of ova or parasites Secure sterile specimen container Instruct patient to defecate in the bedpan. If

desired, allow the patient to void first. Discardthe urine and wash the bedpan

Use tongue depressor to collect the stoolspecimen Collect one teaspoonful or 1 inch of well-formed

stool Label the specimen immediately to the laboratory.

Fresh, warm specimen helps detect ova andparasites

B STOOL CULTURE AND


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B. STOOL CULTURE ANDSENSITIVITY TEST

Assess the specific etiologic agent causinggastroenteritis and bacterial sensitivity tovarious antibiotics

Use sterile test tube and sterile cotton-tipped applicator Label the specimen properly Send specimen immediately to the

laboratory

C. GUAIAC STOOLEXAMINATION (OCCULT


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EXAMINATION (OCCULTBLOOD DETERMINATION)

Microscopic study of stool for presence ofbleeding in the gastrointestinal tract

Provide hemoglobin-free diet for 3 days

(no meat for 3 days) Avoid red or dark-colored foods Temporary discontinue iron therapy Positive guaiac stool exam, indicates peptic

ulcer disease and gastric cancer


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PAIN

an unpleasant sensoryand emotional experience

i t d ith t l


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associated with actual orpotential tissue damage

or described in terms ofdamage

purpose: serves as a

warning signal ofimpending tissuemotivating the patient toseek professional help

ALGOLOGY study ofpain

PHYSIOLOGIC DIMENSIONSOF PAIN


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OF PAIN1. TRANSDUCTION conversion of mechanical, thermal, or chemical

stimulus into a neural action potential2. TRANSMISSION movement of pain impulses from the site oftransduction to the brain

Nociceptors pain receptors the fibers (alpha, beta delta) C fibers smallest & unmyelinated; slowest rate; dull sensation

Dermatomes areas on the skin that are innervated primarily by singlespinal cord segment Dorsal horn processing in the spinal cord, release of

neurotransmitters to produce activation or inhibition. Endogenousopioids (enkephalins & B-endorphins) are synthesized by the body toproduce effects same with Morphine.

Spinothalamic tract perception of pain is believed to occur at the

cerebral cortex and the efferent neurons will act on it3. PERCEPTION occurs when pain is recognized, defined andresponded to by the individual

4. MODULATION involves the activation of descendingpathways that exert inhibitory of facilitatory effects on the

transmission of pain


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PAIN THEORIES1. SPECIFICITY THEORY there are certain

specific nerve receptors that respond to noxiousstimuli

2. PATTERN THEORY any stimulus could beperceived as painful if the stimulation wereintense enough

3. GATE CONTROL THEORY if the gate is closed,the signal is stopped before it reaches the brain

Substantia gelatinosa found at the dorsal horn;responsible for exciting and inhibiting signals atthe brain

CYCLE OF PAIN


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Stimulus (nociceptors)

transmission (nervefibers) pain pathway(spinal Cord) painperception (thalamus) pain interpretation

(cerebral cortex) painresponse PAIN THRESHOLD

awareness and integrationof a stimulus

PAIN TOLERANCEpoint at which the personno longer voluntarilyaccepts the pain

CLASSIFICATION OF PAIN1 DURATION A t h t t


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1. DURATION Acute short termChronic long term

2. QUALITY Sharp sticking in natureDull annoying but not as intense as sharp

Diffuse covers a wide area

Shifting moves from one area to another

3. INTENSITY / SEVERITY Mild 1-3Moderate 4-7

Severe 8-10

4. PERIODICITY Continuous constantIntermittent repeating

Transient / brief passes quickly

5. CAUSATION Organic physiologic originPsychogenic emotional in nature

Psychophysiologic migraine

Pretended pain assumed pain

ASSESSMENT OF


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PAIN P provoking factors or precipitating

factors

Q quality R region

S Severity

T timing


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PAIN MANAGEMENT

NON-INVASIVE


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NON INVASIVE1. relaxation technique

2. refraining converting the negative to positiveones3. distraction focusing ones attention on

something other than pain4. guided imagery using imagination to provide a

substitute for pain5. humor laughter is the bestmedicine

6. biofeedback catharsis7. cutaneous stimulation stimulating the

skin to control pain8. hot and cold application


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INVASIVEWHO 3-step analgesic pain

step 1 NSAID (ibuprofen,mefenamic, paracetamol)

step 2 OPIOIDAGONIST (codeine,meperidine, pentazocine)

step 3 AGONISTS-ANTAGOSNISTS(morphine, stadol, narcan)


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NUTRITION

FOOD PYRAMID


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FOOD PYRAMID

NUTRIENTS


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CARBOHYDRATES Primary function: provide the body with energyComposed of carbon, hydrogen, oxygen (CHO)Glucose provides the most efficient form of

energy

Provides 4 kcal/gram of energyConsists of:

Simple sugars sucrose, glucose, dextrose,fructose

Complex sugars starches and fibers

PROTEINS


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Provide 4.5 kcal/gram of energy

Functions include: structure of bones,muscles, enzymes, hormones, blood, andthe immune system

Formed by linking amino acids in variousforms

Composed of carbon, hydrogen, oxygen,

nitrogen (CHON)

FATS


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Lipids are the densest form of energy available

Produce 9 kcal/gram of energyComposed of carbon, hydrogen, oxygen and

oxygen (CHOO) Lipids are insoluble in water

Triglycerides are the primary form of fat infood

Fats are divided in three categories:triglycerides, phospholipids, and sterols

Function: hormone production and providepadding to protect vital organs

MINERALS


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MINERALS

Minerals serve structural purposeand are found in all body fluids andtissues

16 essential minerals are divided into2 categories: major and minor

Minerals are plentiful in all foods,although some may be lost in foodprocessing

WATER


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Water provides a means of transportation

for nutrientsWater acts as a solvent and a lubricant

It is a by-product of metabolism

The human body is approximately 60% waterNeed to consume the equivalent of 2 liters

of fluid/day

Foods with high content of water includemelons, cantaloupe, and berries

FAT-SOLUBLE VITAMINSVITAMINS SOURCE DEFICIENCY MANIFESTATIONS


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A

(retinol)

Yellow fruits andvegetables, liver,

beef, chicken

Night blindness,

xeropththalmia

Dryness of the

cornea, blurredvision

D

(calciferol)

Milk products,tuna, sardines,margarine, egg,liver, cheese,

salmon, mackerel

Ricketts children

Osteomalacia -

adults

Soft bones andskeletal deformities

Brittle bones, bent-

bones, muscularweakness

E

(tocopherol)

Wheat, almonds,sunflower seeds,

peanut butter,cornoil, hazelnuts

Rare in humans;least toxic form

of vitamin

K(phytomenadione)

Acts as a cofactorfor prothrombin

and clotting factors

hemorrhage Bleeding episodes

WATER-SOLUBLE VITAMINSVITAMINS SOURCES DEFICIENCIES MANIFESTATIONS


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VITAMINS SOURCES DEFICIENCIES MANIFESTATIONS

B1

(thiamine)

Green leafyvegetables

Plant oils

Beri-beri

Wernicke-korsakoffsyndrome

Dry skin, irritability, with eventual death

Amnesia secondary to chronic alcoholism

B2

(riboflavin)

Green leafyvegetables

cheilosis Cracking at he sides of the lips

B3

(niacin)

Potato, banana,chicken, egg

Pellagra

(3 Ds)

Dermatatis, diarrhea, dementia

B6

(pyridoxine)

Cereal, potato,banana, chicken,

oatmeal

Microcytic anemia Weakness, fatigue, dyspnea, low immunesystem

B9

(folic acid)

Milk and milkproducts; rice

Megaloblasticanemia; neural tube

defects

Mentally retarded; neural tube defects,premature babies

B12

(cyanocobalamin)

Mollusks, clams,

liver, beef,cereals

Pernicious anemia Neurologic deficits; constipation, fatigue,

weakness

C

(ascorbic acid)

Citrus fruits andvegetables

Scurvy; difficultwound healing

Loose teeth, sore gums, connective tissueproblems

H

(biotin)

Cereal, potato,banana, chicken,

oatmeal

Acidosis anddehydration

Low bp, lethargy

Due to a diet of raw egg whites ( that have

avidin)


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NURSING PROCEDURES

NGT FEEDINGb l


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Nursing responsibilities:

1. Assess for patency a) inject small amount of air;b)aspirating 20-30ml of gastric secretions; c)measure the pH of the aspirated fluid

2. High-Fowlers position before and after feeding

3. Hang no more htan 4 hours of formula formulacontainer should be replaced every 24 hours

4. Check for fod allergies

5. Rinse the tube with water after feeding about 30ml

6. Measure intake and output7. After feeding, clamp the tube to prevent gas pain

BOWEL ELIMINATION


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NURSING RESPONSIBILITIES

1. Promote regular defecation by providing as much privacyas possible

2. Encourage the client to defecate when the urge isrecognized, and to establish a routine and time ofdefecating

3. Assure an adequate intake of fluids and fiber4. Constipated: increase OFI and include hot liquids and

fruit juices

5. Diarrhea: increase OFI and small amount of bland foods.Assess for potassium loss, avoid hot or cold beverages

6. Flatulence: limit carbonated drinks and chewing gum.Avoid use of drinking straws, avoid gas-forming foods

ENEMAS


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TYPES:

1. Cleansing given to remove feces; treat constipation;prevent contamination of sterile field during surgery;promote visualization of intestine

2. Hypertonic solutions fleet enema (medicated enema)

3. Hypotonic solution tap water4. Isotonic solution PNSS

5. Carminative enema release gas, to expel flatus; about60-80ml of fluid us used

6. Oil retention to soften feces and lubricate therectum and anal canal (mineral oil, olive oil, conttonseedoil)

7. Return-flow enema sometimes used to expel flatus

Nursing responsibilities for enemas1 Provide privacy


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1. Provide privacy2. Lubricate insertion tube

3. Place in left lateral Sims position4. Raise the solution container as advocated5. As a general rule, the solution should be about 12

inches above the rectum

6. Measure the volume instilled and document results7. Never release the enema tube when it is in the

rectum8. Client is instructed to hold the fluid for at least

10-15 minutes9. Document and do after care

CATHETHERIZATIONT


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Types:

1. Indwelling / Retention / Foley for continuousdrainage of urine, for gradual decompression of anover-distended bladder, and for intermittentbladder drainage and irrigation

2. Straight used to drain the bladder for short

periods. They are inserted and removedimmediately after the urine is drained

3. Suprapubic catheter catheter inserted through asmall incision just above the pubic area.

4. Condom catheter used for incontinent malesbecause of the risk for infection is minimal

Nursing responsibilities

1 E l i th d


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1. Explain the procedure

2. Provide privacy

3. Use sterile gloves

4. Place in dorsal recumbent or supine position

5. Cleanse the pubic area

6. Lubricate the tip7. Instruct to breathe through the mouth

8. Document accordingly


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THANK YOU

1 Fundamentals in Nursing

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