FUNDAMENTALS OF NURSING

GLADYS BAUTISTA JAIME 2010

HISTORY OF NURSING
Intuitive Period
Apprentice Period
Educated Nursing Period
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Contemporary Period
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INTUITIVE PERIOD
Nursing was untaught and instructive
Beliefs and practices
i.
Nomads
ii.
Women
iii.
Black magic/ evil spirits (voodoo)
iv.
White magic/ shaman/ witch doctors
v.
Trephining
ANCIENT CITIES AND CONTRIBUTIONS
I.
BABYLONIA
Code of Hammurabi (Law affecting medical
practice)
RA 9173 Phil. Nursing Act of 2001
RA 7164 Old Phil. Nursing Act of 1991
II.
EGYPT
Art of Embalming (Enhance the knowledge
about human anatomy)
Recognize 250 diseases
III.
ISRAEL
Moses Father of Sanitation
Give laws on communicable disease
Ritual circumcision
IV.
CHINA
Materia Medica (pharmacology)
Used girl clothes for male babies
V.
INDIA
Intuitive Asepsis
SUSHURUTU record of function and
responsibility of nurses
VI.
ANCIENT GREECE
Hippocrates Father of Scientific Medicine

VII.

ROME
Roman Catholic
Fabiola made her home as the first hospital
under the Christ Era

APPRENTICE PERIOD
11TH century 1836
On the job training period
From the rise of religious orders from secular orders up
to the dark period of nursing up to the establishment
of the 1st training school.
RELIGIOUS ORDERS
Knights of St. John ranks and superiority
Teutonic Knights tent hospitals
Knights of St. Lazarus lepers/leprosy
SECULAR ORDERS
St. Catherine of Siena Lady with a lamp
St. Elizabeth of Hungary Patroness of Nurses
Clara Barton Founder of American Red Cross
St. Claire founded the 2nd order of St. Francis de Asisi
Dark Period of Nursing
Religious upheaval led by Martin Luther
Theodore Fliedner
Establish the 1st training school in Germany
Kaiserwerth Institute for the Training of the
Deaconesses
EDUCATED NURSING PERIOD
Florence Nightingale May 12, 1820 in Florence, Italy
Crimean War
Lady with a lamp
St. Thomas School of Nursing
Mother of modern nursing

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GLADYS BAUTISTA JAIME 2010

Notes: on nursing/ on hospital

Environmental Theory (first theorist)
Lilian Wald
Founder of the Public Health Nursing

Linda Richards
1st graduate as a nurse in US
Initiated the use of white uniforms
Use of Nurses Notes and Doctors Order

Mary Mahoney
1st African American Nurse

18 THEORIES AND THEORIST

1) FLORENCE NIGHTINGALE
ENVIRONMENTAL THEORY
Cleanliness, Light, Air, Water, Diet, Warm, Noise Free,
Drainage
2)

Lavinia Dock
Active in Protest
Women has privilege to VOTE
Margaret Higgins Sanger
Founder of the Planned Parenthood (Family Planning)
CONTEMPORARY PERIOD
World War II up to the present
Scientific and Technological Advancement
Computer, Sophisticated Equipment, Disposable
Supplies
Own Nursing Law (RA 9173)
ROLES AND RESPONSIBILITIES OF NURSES
CAREGIVER providing care
COUNSELOR supporting emotionally
CHANGE AGENT modification of lifestyle
CLIENTS ADVOCATE protects clients right
CASE MANAGER collaborates with other member
MANAGER Planning, Organizing, Delegation,
Controlling
TEACHER health promotion and teaching
LEADER attaining goals and objectives

RESEARCHER development of profession

LYDIA HALL
CORE, CARE and CURE
Core person (therapeutic use of self/communication)
Care body (bed bath, oral care, hygiene)
Cure disease (medication, IV Therapy)

3) VIRGINIA HENDERSON
14 Basic Human Needs
Breath normally, Eat and Drink, Eliminate, Move and
Maintain Posture, Sleep and Rest, Dress and Undress,
Maintain Body Temperature, Keep Clean, Avoid Danger,
Communicate, Worship, Work, Play and Learn
4) HILDEGARD PEPLAU
Psycho dynamic Theory
4 Phases of Nurse Patient Relationship
Orientation problem identification
Identification feeling of belongingness, trust,
Setting GOALS
Exploitation use all resources to resolve
problem, IMPLEMENTATION
Resolution goals met, TERMINATION Phase
5) DOROTHEA OREM
Self-care Deficit
Whole Compensatory 100% nurse
Partially Compensatory 50-50 nurse-patient

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Supportive-Educative discharge planning and

health teaching

6) MARTHA ROGERS
Science of Unitary Human Beings
Man is a unified whole inter-related parts
7) IMOGENE KING
Goal Attainment Model
Transaction (Communication Skills)
8) DOROTHY JOHNSON
Behavioral Model
7 SUBSYSTEMS
AGGRESSIVE self-protective behavior
AFFILIATE security seeking behavior
ACHIEVEMENT master of oneself
DEPENDENCY nurturance seeking
ELIMINATIVE moving out of wastes
INGESTIVE taking-in nutrients
SEX procreation and satisfaction
9) FAYE GLENN ABDELLAH
21 Nursing Problems
Interrogative = ?
10)
MADELIENE LEININGER
Transcultural Theory
Beliefs and Practice = Respect

GLADYS BAUTISTA JAIME 2010

STRUCTURAL INTEGRITY physical boundaries of

human should be intact (skin and mucus
membrane)

12)
BETTY NEUMAN
Health Care System Model
Origins of Stressors
INTRA within the person/inside
INTER between friends and family
EXTRA outside the person
13)
SISTER CALLISTA ROY
Adaptation Model
Process of Adaptation
INPUT stressor
CONTROL manage physically and emotionally
OUTPUT outcome and result
FEEDBACK how it affects the next input
14)
PATRICIA BENNER
Stages of Expertise
NOVICE bounded with rules and standards, no
experience
ADVANCE BEGINNER demonstrate marginally
acceptable procedure, real experiences
COMPETENT 2-3yrs. experience, consciously
plan the care
PROFICIENT 3-5yrs. Experience, perceive
situation as a whole rather than in parts,
HOLISTIC VIEW
EXPERT highly fluid and flexible

11)
MYRA LEVINE
Conservational Model
ENERGY Input (Food, O2, Water) = Output =
15)
ROSEMARIE RIZZO PARSE
Energy
Human Becoming Theory
PERSONAL INTEGRITY self-worth/ self-identity
16)
IDA JEAN ORLANDO
SOCIAL INTEGRITY interpersonal needs
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Dynamic Nurse Patient Relationship

17)
JEAN WATSON
Caring Model
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18)
ERNESTINE WIEDENBACH
Helping Art of Clinical Nursing

Activity
Thyroxin Output
Epinephrine/NorEpinephrine
Fever

Radiation
Convection
Evaporation

SMITHS MODEL OF HEALTH

Healthy
X

Clinical Model
Signs/Symptoms
Adaptation Model Adapt
Role Performance Duties
Eudemonistic
SelfModel
actualization

Illness

X
X
X

RECTAL

STAGES OF EXPERTISE
SYMPTOM EXPERIENCE subjective
ASSUMPTION OF SICK ROLE accept illness and seek
advice
MEDICAL CARE CONTACT seek advice from
professionals, validation and explanation of disease
DEPENDENCY ROLE healthcare, passive communication
REHABILITATION going back to the pre-illness stage,
RECOVERY

ORAL

TYMPANIC

N
VALUES
37-38.1
35.8-37
36.537.5
36.837.9

Pyrexia more than normal temperature

Hyperpyrexia more than 41C

HYPOTHALAMUS
DETERMINED BY METABOLISM
BALANCED BETWEEN HEAT PRODUCTION AND HEAT LOSS
HEAT PRODUCTION
Basic Metabolic Rate

AXILLARY

THERMOMETER
ADVANTAGE
NSG.CONSIDERATIO
N
Most accurate
0.5-1.5 inches
Most reliable
1-2 minutes
Safest
Pat dry before use
Non-invasive
5-9 minutes
Most
30min rest before
convenient
2-3 minutes
Most
accessible
Very fast
Prevent puncture of
TM
Within seconds

Cleaning Before Use: bulb to stem

After Use: stem to bulb

NURSING PROCESS:
ASSESSMENT
Vital Signs: TEMPERATURE

ROUTE

HEAT LOSS
Conduction

TYPES OF FEVER
INTERMITTENT fluctuation of temperature bet. normal
and abnormal
REMITTENT fluctuation of temperature but all above
normal
RELAPSING fever with 1-2 days of normal temperature

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CONSTANT minimal fluctuation, consistently high

PULSE

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Autonomic Nervous System

Pulse Sites:
Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal,
Posterior Tibia, Dorsalis Pedis
PULSE RATE:
1 month
80-180
1 year
80-140
2 years
80-130
6 years
80-120
Adult
60-100
PULSE FORCE
3 Full Bounding
2 Normal
1 Weak Thready Pulse
0 No Pulse
PULSE Pressure (Systole-Diastole=PP) N= 30-40mmHg
PULSE Deficit (Apical-Peripheral Pulse)
RESPIRATION
Medulla
PONS Pneumotaxics Center (rhythmic)
- Apneustic Center (deep prolonged respiration)
- Aortic and Carotid Bodies
Rate:
APNEA cessation of breathing
ORTHOPNEA inability to breathe except in upright
EUPNEA normal breathing
TACHYPNEA increased respiratory rate
BRADYPNEA decreased respiratory rate
Rhythm:

CHEYNES STOKE very deep to very shallow then apnea

KUSSMAULS deep rapid labored breathing
BIOTS very shallow with apnea
Sounds:
STRIDOR harsh, shrill sound on inspiration
- Laryngeal obstruction
STRETOR snoring sound on expiration
- Obstructed or narrowed airway
WHEEZE squeaky musical sound on expiration
- Narrow or constricted bronchus
BUBBLING gurgling sound, air passing through secretions
- Heard both on inspiration and expiration
Volumes:
TIDAL VOLUME inhalation and exhalation
INSPIRATORY RESERVED VOLUME maximum air that can be
inhaled after
normal breathing
EXPIRATORY RESERVED VOLUME - maximum air that can be
exhaled after
normal breathing
RESIDUAL VOLUME remaining in the lungs
TOTAL LUNG CAPACITY (T I E R)
CHEST INDRAWING retraction
Suprasternal above the clavicle
Subcostal below the breast bone
Intercostal between the ribs
BLOOD PRESSURE
Normal Value: Systole = 100-140
Diastole = 60-90
Nursing Consideration:
Rested = 30minutes
Position: at the level of heart and supported
- Above = false low
- Below = false high
Palpatory BP (+30mmHg)

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GLADYS BAUTISTA JAIME 2010

Bell low pitch sound (Korotkoff)

BP Cuff Too narrow = false high
- Too wide = false low
Inflate 2-3mmHg at a time Too slow = false high
- Too fast = false low
Meniscus lower, at the level of eye to prevent ERROR OF
PARALLAX
Popliteal Pulse 10-40mmHg higher than the brachial
artery

PHYSICAL EXAMINATION
Skin, Hair, Nails color and lesion
Pale Pallor
Blue Cyanosis
Yellow Jaundice
Red Erythema
Virtiligo Patches or hypopigmented skin
Lesion:
FLAT non palpable
Macule <1cm
- Patch >1cm
CIRCUMSIDE elevated form by solid mass
(papule, plaque, nodule, tumor)
C/E formed by free fluid
Loose of Skin Surface
- Erosion (epidermis, without scar)
- Ulcer (epidermis, dermis, subcutaneous with scar)
- Fissures (linear crack with sharp edges)
Papule - <1cm (warts, acne)
Plaque coalescence of papule (psoriasis)
Nodule 0.5-2cm (squamous and carcinoma)

Tumor - >2cm
Wheal irregular shape, insect bite
Vesicle - <.5cm (early chicken pox)
Bullae - >.5cm (blister, sign of herpes)
Pustule- pus
HAIR

Thickness/Thinness normal = thick

Infection and Infestation
Amount of Hair
Texture of Hair
Growth of Hair

NAILS
Normal Angle = 160 angle
Flat = 180angle indication of early clubbing
- Long term lack of oxygen
Capillary Refill Test Blanch Test
- Pedia = >2seconds
- IMCI = more than 3seconds
- Funda = 4seconds
EYES
Darken the room (dilate)
Pupils PERRLA
Size 3-7mm
Miosis constricted
Mydriasis dilated
Anisocona unequal
Visual Acuity Snellens Chart
- Normal = 20/20
- 20/200 = legal blindness
Myopia near = concave
Hyperopia far = convex
Presbyopia loss of elasticity of lens caused by aging
Astigmatism uneven curvature of the cornea

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EARS
4 years old up and back
3 years old above up and back
3 years old below down and back
Page WEBERS TEST bone conduction, lateralization of sounds
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- Bad Bone Conduction = conductive hearing loss
- Good = sensory neural hearing loss
RINNES TEST conductive hearing loss

THORAX
Shape oval, elliptical (adult), equal or cylindrical (infant)
Spinal Alignment
Sound percussion
ABDOMEN
Palpation void first
Dorsal Recumbent supine with knees flexed to relaxed
abdominal muscle
Warm hands during palpation rub
Slow approach
Indusperpal prevent the distortion of abdominal sounds

LABORATORY EXAMS
URINE routine urinalysis
- 24hour urine specimen
- Catheterization
STOOL routine fecalysis
- Guiac Stool Exam
SPUTUM AFB
- Blood specimen

Collect 30-50ml
Culture and Sensitivity 5-10ml
24hours urine specimen
- First void discard
- Collect with same container
Catheterization
- Dos: clamp below the cord (30-60mins)
- Sterile syringe inserted diagonally (self-sealing)
- Donts: do not collect from bag
Acetic Acid Test protein
- Do not heat could explode
- (+) cloudiness of solution
BENEDICTS TEST glucose
Result Blue (-)
- Green (+)
- Yellow (++)
- Orange (+++)
- Red (++++)

STOOL
Routine fecalysis
- 1inch or 2.5cm/tsp
- 15-30ml liquid stool (diarrhea)
Guiac Stool Exam
- Occult blood exam
- Dont give dark color foods (red meat, Iron
Supplement)
- Avoid turnips and radishes
False Positive for 3days
False Negative vit.C 250mg/day for 3days

URINE
SPINAL ALIGNMENT
Routine urinalysis
Lordosis lumbar region is affected
- First thing in the morning
Kyphosis thoracic region is affected
- First voided (collect)
- Best position when assessing: standing straight
- First flow is discarded (midstream catch)

Scoliosis
lateral deviation of spine
- Perineal Care first
- Best position: bending forward in 90angle
- Send to laboratory (ideal: add preservatives as
protocol of agency)
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SOUNDS
Bronchial high pitch sound; hear over the trachea
Bronchovesicular moderate pitch sound; hear over main
bronchi
Page Vesicular low pitch sound; heard over the lung fields
| 8 Use diaphragm for high pitch sound
PERCUSSION
Dull liver and heart
Flat bones and muscles
Resonance normal lung sound
Hyper resonance - hyper inflated lung
Tympany stomach
Thorax Normal Resonance
- If dull; solidation of lung tissue
- Patient with Pneumonia, Emphysema and Asthma
ACID FAST BACILLI
Early AM collection
No toothbrush, mouthwash and food
Plain water only
BLOOD SPECIMEN
FASTING BUN = triglyceride
- CREATININE = serum lipid amylase
indicative for kidney function
NON-FASTING CBC, Hemoglobin, Hematocrit, Serum
Electrolytes, Clotting Studies

GLADYS BAUTISTA JAIME 2010

Infant
95-50mmHg
5-2
LENGTH nose to earlobe (13cm or 5inches)
Lubricant
- Nasopharyngeal water soluble lubricant (KY Jelly)
- Oropharyngeal sterile water
TIME 5-10seconds (15sec. maximum) with 20sec.
interval
- 30 seconds for hyper oxygenation
TECHNIQUE Never apply suction during the insertion
- Apply only during withdrawal; intermittent
suctioning (on&off)
SIZES
- Adult = 18-12 French
- Children = 10-8 French
- Infant = 8-5 French
OXYGENATION
Support combustion
- No smoking
- No faulty electrical devices
- No friction
- No wool fabrics
Emergency: nurse can give 2-3liters/min. (independent)
Carbon dioxide major stimuli for respiration
TYPES
CONCENTRATION
LITERS PER
MINUTE
Nasal Cannula
24-45
2-6
Simple Face Mask
40-60
5-8
Partial Rebreather
60-90
6-10
Non Rebreather
95-100
10-15
Venturi Mask
24-40-50
4-10

BASIC NURSING SKILLS

SUCTIONING
CATHETERIZATION
POSITION Conscious: semi-fowlers
Straight catheterization common
- Unconscious: Side-lying or lateral to prevent
Indwelling 5-10ml, inflate balloon, sterile balloon
aspiration
SIZES
PRESSURE
- Male: 18-16 French
AGE
WALT
PORTABLE
- Female: 14-12 French
Adult
120-100mmHg
15-10
LENGTH
Child
110-95mmHg
10-5
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GLADYS BAUTISTA JAIME 2010

- Male: 6-9 inches

- Female: 3-4 inches
POSITION
- Male: supine with legs slightly abducted
- Female: dorsal recumbent with knees flexed
LUBRICANT water soluble lubricant
LOCATION
- Male- tip of glands penis
- Female: urethral meatus between clitoris and
vagina
ANCHOR
- Male: lower abdomen
- Female: inner aspect of thigh

NASOGASTRIC TUBE (NGT)

For feeding - Gavage

For irrigation Lavage

Decompression preparation for surgery

POSITION Feeding: high-fowlers for 30minutes

LENGTH Nose Earlobe Xiphoid (50cm or

20inches)

PLACEMENTS Air: aseptosyringe/stethoscope

LUQwhooshing sound
- Aspirate: color = greenish or yellowish
- pH: Acid = <6
- Lithmus Paper: Blue to Red
- X-Ray: most effective
RESIDUAL VOLUME 50ml withhold the fluid (12inches)
ENEMA
RETENTION
Oil, Carminative
12 inches
1-3 hours
105-110F

COMPARISON
SOLUTION
HEIGHT
TIME
TEMPERATURE

NON-RETENTION
Plain NSS, Soap
Suds
18 inches
5-10 minutes
115-125F

SIZES
- Adult: 32-22 French
- Children: 18-14 French
- Infant: 12 French
LENGTH
- Lubricate: 2 inches or 5cm
- Insert: 3 inches or 7cm
POSITION
- A: left lateral position to follow the contour
- C: dorsal recumbent

MEDICATIONS
Traditional Five Rights:
- Right Drug
- Right Dose
- Right Time
- Right Patient
- Right Route
60mg = 1gram
1tsp = 5ml/cc
1gram = 15 grains
1tbs = 3tsp = 15-30ml
1ml = 15gtts
1 cup = 240ml
DRUGS
- 3x check the label:
- Before removing from shelves
- After removing from container
- Before returning to the drawer or shelves
DOSE Desired Dose/Stock on Hand X Dilution
PATIENT check for ID band (safest)
TIME
- AC = before meals
- PC = after meals
- PRN = as needed
- STAT = immediately
- BID = twice a day
ROUTE
- Oral and Sublingual easy absorbed thru
bloodstream
- Less expensive, most convenient, safest

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GLADYS BAUTISTA JAIME 2010

Disadvantage remain under the tongue, if

Sites: inner lower arm (skin test)
Upper chest and back
swallowed notify the physician. Dissolved by
Beneath the scapula
gastric juice
Indications: Check for allergy
o Cause staining of teeth
Vaccine (Mantoux test)
o Contraindicated with Nausea and Vomiting
Tuberculin Test
- TOPICAL dermatologic
Gauge:
25,
26, 27
- Only applied at the thin layer
Length:
3/8,
5/8,
- Patch (Nitroglycerin Patch) clean, hairless,
Degree: 10-15
proximal surface
o SUBCUTANEOUS
- OPTALMIC Sitting Position or Lying
Sites: outer upper arm
- OINTMENT clean, inner to outer canntus
Abdominal (insulin)
- Instill at the lower canntus 2drops, wait for 5mins
Anterior Thigh
to absorb
Ventro Gluteal
- Prevent the systemic effect press nasolacrimal
Dorso Gluteal
and close eyes
Indications:
Insulin, Vaccine, Heparin
- OTIC side-lying; use cotton tip applicator for
Gauge:
25,
26,
27
cleaning
Length: 3/8, 5/8,
- Instill: allow to flow to side; to change the temp. of
Degree: 0-90 (obese); 45 (thin and average)
meds to body temp.; absorption for 5minutes
o INTRAMUSCULAR
- INHALATION
Ventro Gluteal best site for adult
- Position: semi-fowlers / high fowlers (for full lung
Position: Prone
expansion)
Location: Greater Trochanter
- Instill: nebulizer 1-2inches away from the mouth
Dorso Gluteal contraindicated for 3years
Metered dose inhaler hold breath for
below
10seconds; wait for another minute before giving
Position: Prone
another dose
Location: Lateral superior, upper outer
Bronchodilator with multiple medications
quadrant
Steroid Inhalation oral hygiene; cause oral fungal
Vastus Lateralis best site for infant
infection
Position: Sitting or Lying
- VAGINAL vaginal suppository, vaginal duche
Location: middle third anterior lateral aspect
- Position: dorsal recumbent, remain free for 5of thigh
10minutes
Rectus Femoris same with vastus lateralis (NT
- During irrigation BL with hips higher than the
LATERAL)
shoulders
Deltoid 0.5-1.5ml
- RECTAL left lateral position/ Sims Position, right
Position:
Sitting
leg flexed
Location: Acromian Process 2-3 finger
- Insert until something has grabbed it away
breaths below
20mins absorption
Gauge: 20, 21, 22, 23
- PARENTERAL
Length: 1, 1 , 2
o INTRADERMAL
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Degree: 90

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Z-TRACK Technique
Used for parenteral IRON preparations
Retract the skin, inject slowly, hold retraction of the
skin until needle is withdrawn, do not massage
Principles: Use separate needles for aspiration and
injection of medication, Introduce air into the vial
before aspirating, Introduce needle in quick twist

INTRAVENOUS THERAPHY
TYPES OF SOLUTION
- ISOTONIC plain NSS(green) , LR(dark blue) ,
D5W(red)
- HYPOTONIC lower concentration; D.45/D.33 (light
blue)
- HYPERTONIC higher concentration; D5LR(pink),
D5NSS(yellow)
GAUGE
- 16 biggest (gray)
- 18 blood transfusion (green)
- 20 (pink)
- 22 (blue)
- 24 pedia (yellow)
Points to remember in IVT
- Place in the non-dominant hand, distal side
(metacarpal)
- Select: large vein, easily palpable and naturally
splinted by bone
- Avoid highly visible, areas of flexion, damage by
previous use and surgically compromised
Nursing Consideration
- Air Embolism (5ml of air) prime to remove air
- Change IV site and tubing every 72hours, bottle
every 24hours regardless how many cc is remaining
- Regulate every 15-30 minutes

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