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 of
certain parts

 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 well-

being.
 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 MASLOW’S HIERARCHY OF
NEEDS

 Why do we study this?

In order to prioritize

nursing actions
ABRAHAM MASLOW’S HIERARCHY OF
NEEDS

 Physiologic needs

Food
Air
Drink
Shelter
Warmth
Sex
Sleep
Maintenance of
homeostasis
ABRAHAM MASLOW’S HIERARCHY OF
NEEDS

 Safety and security

Protection
Security
Order
Law
Limits
Stability
ABRAHAM MASLOW’S HIERARCHY OF
NEEDS

 Love and Belongingness

Family
Affection
Relationships
Work group
ABRAHAM MASLOW’S HIERARCHY OF
NEEDS

 Self-esteem
Feeling good about
one’s self
Two factors affecting
Self-esteem
Yourself
• Sense of
adequacy
• Accomplishment
Others
• Appreciation
• Recognition
• Admiration
ABRAHAM MASLOW’S HIERARCHY OF
NEEDS

 Self-actualization

Personal growth and

fulfillment
Able to fulfill needs and
ambitions
Maximizing one’s full
potential
ABRAHAM MASLOW’S MODIFIED HIERARCHY
OF EIGHT NEEDS (1990)

 Additional needs:

Need to know and

understand

Aesthetic needs

Transcendence
ABRAHAM MASLOW’S 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 MASLOW’S MODIFIED HIERARCHY
OF EIGHT NEEDS (1990)

 Aesthetic needs:

Beauty
Balance
Form
ABRAHAM MASLOW’S MODIFIED HIERARCHY
OF EIGHT NEEDS (1990)

 Transcendence:

Helping others to self-

actualize
 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 Health
Organization

Health is the complete

physical, mental, social
(totality) well-being and
not merely the absence
of disease or infirmity

A high-level wellness!
DEFINITIONS OF HEALTH

 Claude Barnard

Ability to maintain
internal milieu
DEFINITIONS OF HEALTH

 Walter Cannon

Ability to maintain
homeostasis

A dynamic equilibrium

A state of balance of
the internal
environment while
external environment is
changing
DEFINITIONS OF HEALTH

 Florence Nightingale

Health is using one’s

power to the fullest

Being well

Can be maintained by
manipulating the
environment
DEFINITIONS OF HEALTH

 Virginia Henderson

Viewed in terms of
ability to perform the
fourteen (14)
fundamental needs or
components of nursing
care UNAIDED
DEFINITIONS OF HEALTH

 Martha Rogers

Positive health
symbolizes wellness

Health is a value term

defined by a certain
culture
DEFINITIONS OF HEALTH

 Sister Calista Roy

A state and process of

being and becoming an
INTEGRATED
PERSON
DEFINITIONS OF HEALTH

 Dorothea Orem

Characterized by
soundness and
wholeness of
DEVELOPED HUMAN
STRUCTURES and
FUNCTIONS
DEFINITIONS OF HEALTH

 Imogene King

A dynamic state in the

life cycle (contrasted
with illness)

Illness is interference in
the life cycle
DEFINITIONS OF HEALTH

 Betty Neuman

Wellness is that all

parts and subparts are
in harmony with each
other and the whole
system
DEFINITIONS OF HEALTH

 Dorothy Johnson

Elusive dynamic state

influenced by biologic,
psychologic and social
factors
 MODELS OF HEALTH AND ILLNESS

 Health-Illness Continuum: Dunn’s 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
 DUNN’S 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

 FOUR LEVELS OF HEALTH BY SMITH

 2. Role Performance Model

As long as you are able to perform SOCIETAL functions

and ROLES you are healthy
 FOUR LEVELS OF HEALTH BY SMITH

 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

 FOUR LEVELS OF HEALTH BY SMITH

 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 multi-
factorial disease)

 Triad is composed of the agent, host and environment

 Based on the interplay of three components of the model

DEFINITIONS OF NURSING
DEFINITIONS OF NURSING

 American Nurses
Association

Nursing is the diagnosis

and treatment of human
responses to illness (to
actual and potential
health problems)
 DEFINITIONS OF NURSING

 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
DEFINITIONS OF NURSING

 Florence Nightingale

Nursing is the act of

utilizing the
ENVIRONMENT for the
following purposes:
Recovery
Reparative
process
DEFINITIONS OF NURSING

 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
DEFINITIONS OF NURSING

 Martha Rogers

Nursing is a
HUMANISTIC
SCIENCE dedicated to
compassionate concern
for the promotion of
health, prevention of
illness and rehabilitation
of the sick
DEFINITIONS OF NURSING

 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

DEFINITIONS OF NURSING

 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!
DEFINITIONS OF NURSING

 Imogene King

Nursing is a helping
profession that assists
a person (same with
Henderson) towards a
DIGNIFIED DEATH
DEFINITIONS OF NURSING

 Betty Neuman

Nursing is a profession
that is concerned with
INTRAPERSONAL,
INTERPERSONAL,
and
EXTRAPERSONAL
VARIABLES affecting a
person’s response to
stressors
DEFINITIONS OF NURSING

 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
DEFINITIONS OF NURSING

 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
DEFINITIONS OF NURSING

 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
DEFINITIONS OF NURSING

 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”.

 Nightingale’s theory
remains an integral part
of nursing and healthcare
today.
 1) FLORENCE NIGHTINGALE:
ENVIRONMENTAL NURSING THEORY

 5 Environmental Factors:

Pure or fresh air

Pure water
Efficient drainage
Cleanliness
Light, especially direct
sunlight
 1) FLORENCE NIGHTINGALE:
ENVIRONMENTAL NURSING THEORY

 Nightingale’s general
concepts are:

Ventilation
Cleanliness
Quiet
Warmth
Diet
 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
 3) VIRGINIA HENDERSON:
FOURTEEN FUNDAMENTAL NEEDS
 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
3) VIRGINIA HENDERSON:
FOURTEEN FUNDAMENTAL NEEDS

 8) Keeping the body

clean and well groomed
to protect the integument.

 9) Avoiding dangers in
the environment and
avoiding injuring others.

 10) Communicating with

others in expressing
emotions, needs, fears,
or opinions

 11) Worshipping
according to one’s faith
 3) VIRGINIA HENDERSON:
FOURTEEN FUNDAMENTAL NEEDS
 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:
PROBLEM SOLVING APPROACH TO
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:
PROBLEM SOLVING APPROACH TO
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:
PROBLEM SOLVING APPROACH TO
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:
PROBLEM SOLVING APPROACH TO
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:
PROBLEM SOLVING APPROACH TO
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:
PROBLEM SOLVING APPROACH TO
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 client’s
response as
functional or
dysfunctional
 5) MARJORIE GORDON:
HUMAN FUNCTIONAL HEALTH PATTERNS

 Eleven Functional Health

Patterns

Health perception
Nutritional / Metabolic
Elimination
Activity and Exercise
Pattern
Cognitive Perceptual
Pattern
 5) MARJORIE GORDON:
HUMAN FUNCTIONAL HEALTH PATTERNS

 Eleven Functional Health

Patterns
Sleep and Rest
Self perception / Self
concept
Role Relationship
Pattern
Sexuality /
Reproductive
Coping-Stress-
Tolerance
Value Belief Patterns
 6) IMOGENE KING:
GOAL ATTAINMENT THEORY

 Patient has three (3)

interacting systems:

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
patient’s privacy

 4. Conservation of Social
Integrity
Example: maintenance
of patient’s
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

Nurse-Patient Interaction

1. Orientation
Nurse and patient
test the role each
one assumes
Prepares patient
for termination
Patient identifies
areas of difficulty
11) HILDEGAARD PEPLAU:
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
11) HILDEGAARD PEPLAU:
INTERPERSONAL MODEL

4. Resolution Phase or

Termination Phase
Occurs when
patient’s 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 person’s 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 patient’s 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
24) PHIL BARKER & POPPY BUCHANAN-
BARKER:
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
Patient’s 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
baby’s 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
 SECONDARY PREVENTION

 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

 SECONDARY PREVENTION

 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
TEACHING AND LEARNING STRATEGIES

 Basic Guidelines

Develop a well-defined objective

Assess client’s readiness to learn

Start with what the client is concerned about

TEACHING AND LEARNING 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 of problem-solving techniques and

principles

 Problem-oriented, flexible, open to new information

 Allows creativity of nurse and patient

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 CLIENT-CENTERED or
PATIENT-CENTERED and NOT NURSE-
CENTERED
BENEFITS DERIVED FROM
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

BENEFITS DERIVED FROM
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
BENEFITS DERIVED FROM
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 client’s 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
FOUR TYPES OF 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
FOUR TYPES OF ASSESSMENT

 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)
FOUR TYPES OF ASSESSMENT

 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
FOUR TYPES OF ASSESSMENT

 3. Emergency Assessment

Framework or Principle in Emergency Assessment

A – Airway
B – Breathing
C – Circulation

Utilize either Maslow’s Hierarchy of Needs or ABC

principle
FOUR TYPES OF ASSESSMENT

 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 patient’s 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

Patient’s 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 Rapport-

building 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
TYPES OF INTERVIEW QUESTIONS

 1. Open-Ended Questions

Questions not answerable by “yes” or “no”

Questions that elicit information or explanation

TYPES OF INTERVIEW QUESTIONS

 2. Closed-Ended Questions

Questions answerable by “yes” or “no”

Leading Questions

Phrasing of question suggests what answer the

interviewer is expecting
TYPES OF INTERVIEW QUESTIONS

 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, clustering, analyzing and

interpreting data
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 related to

excessive and tenacious secretions
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 client’s health status has
changed
To decide which problems to focus on during the
shift
To set priorities for client care during the shift
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

IMPLEMENTING PHASE OF
THE NURSING PROCESS

 Purpose of Implementation

To carry out planned activities

To help the client

IMPLEMENTING PHASE OF
THE NURSING PROCESS

 Concept!!!

The implementation phase ends upon recording of the

care given and the response of the patient to that
procedure
IMPLEMENTING PHASE OF
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
IMPLEMENTATION PHASE

 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
IMPLEMENTATION PHASE

 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 client’s progress

To determine the effectiveness of the care plan

To determine as to what extent the nursing goals have

been met
EVALUATION PHASE 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 client’s 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
GUIDELINES ON DOCUMENTATION

 Signature
Sign full name and append R.N.

 Accuracy
Ensure that data is correct
Avoid biases
Avoid ambiguous terms

 Appropriateness
Write only appropriate information
GUIDELINES ON DOCUMENTATION

 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

 Doctor’s Treatment and Order Sheet

 Therapeutic Sheet
PROBLEM-ORIENTED
CLINICAL RECORD

 Same as Problem Oriented Medical Record

 Entry of data is based on CLIENT’S PROBLEM
Example:
Problem No. 1: constipation
• Increase fluid intake: doctor
• Diatabs: pharmacist
• NPO:
 Includes observations about the patient
Example:
Radiologist’s notes are with doctor’s 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
FOUR BASIC COMPONENTS OF
PROBLEM-ORIENTED CLINICAL RECORD

 2. Problem List

Contains only ACTIVE problems (and relevant

information about the problem)

No potential problems (these are contained only in the

progress notes)
FOUR BASIC COMPONENTS OF
PROBLEM-ORIENTED CLINICAL RECORD

 3. Initial list of orders or Care Plans

FOUR BASIC COMPONENTS OF
PROBLEM-ORIENTED CLINICAL RECORD

 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 patient’s special concern to a higher

authority or a specialized department or personnel
COMMON METHODS OF COMMUNICATION AMONG
NURSES

 2. Confer

Verifying information
COMMON METHODS OF COMMUNICATION AMONG
NURSES

 3. Reporting

Giving information to a concerned person

KARDEX

 Is the Kardex a part of the patient’s 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
THERAPEUTIC COMMUNICATION
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
THERAPEUTIC COMMUNICATION
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 person’s 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
TYPES OF SLEEP: REM SLEEP

 Penile erection (males) and vaginal moistening (females)

 Easy to awaken
 Usually a time for more intensive, vivid dreams
TYPES OF SLEEP: REM SLEEP

 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
TYPES OF SLEEP: NON-REM SLEEP STAGE 2

 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
TYPES OF SLEEP: NON-REM SLEEP STAGE 3

 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
TYPES OF SLEEP: NON-REM SLEEP STAGE 4

 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
WELLNESS TEACHINGS TO
ENHANCE OR PROMOTE SLEEP

 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
WELLNESS TEACHINGS TO
ENHANCE OR PROMOTE SLEEP

 Avoid shabu

 Use the bed mainly for sleep

 If unable to sleep, get up and pursue satisfying

activity
WELLNESS TEACHINGS TO
ENHANCE OR PROMOTE SLEEP

 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
WELLNESS TEACHINGS TO
ENHANCE OR PROMOTE SLEEP

 Do something HOT!

Twice-a-week masturbation is ideal

Facilitates release of tension of the day

WELLNESS TEACHINGS TO
ENHANCE OR PROMOTE SLEEP

 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 is contraindicated in the following

patients:

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 sneezing also stimulate surfactant

production
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 the

oxygen administered

 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 patient’s 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 to this
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)
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 procedure to check

effectiveness of the procedure.
CONCEPTS!

 Vibration and percussion are done to

mechanically dislodge secretions

 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 POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
OROPHARYN WHILE PASS OF
-GEAL SUCTIONING SUCTION
SUCTIONING
If the patient is Fowler’s (high or 10 – 15 cm Not more than 20 – 30 Not more than
conscious moderate); 10 – 15 seconds 5 minutes
Head turned to seconds
one side (towards
the nurse)

If the patient is Place on one side 10 – 15 cm Not more than 20 – 30 Not more than
unconscious (facing the nurse); 10 – 15 seconds 5 minutes
Tilt neck to move seconds
head slightly
forward towards
the basin to avoid
aspiration during
suctioning
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
NASOPHA- WHILE PASS OF
RYNGEAL SUCTIONING SUCTION
SUCTIONING
If the patient is Neck should be From tip of Not more than 20 – 30 Not more than
conscious hyperextended; the nose to 10 – 15 seconds 5 minutes
Fowler’s position tip of the seconds
earlobe

If the patient is Flat on bed with From tip of Not more than 20 – 30 Not more than
unconscious head turned to the the nose to 10 – 15 seconds 5 minutes
nurse tip of the seconds
Lateral position earlobe
may be assumed
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
OROTRA- WHILE PASS OF
CHEAL SUCTIONING SUCTION
SUCTIONING
If the patient is Low to semi- Measure Not more than 20 – 30 Not more than
conscious fowler’s position from 10 seconds seconds 5 minutes
mouth to
mid-
sternum

If the patient is Flat on bed; Measure Not more than 20 – 30 Not more than
unconscious Suction trachea from 10 seconds seconds 5 minutes
through the mouth mouth to
mid-
sternum
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
NASOTRA- WHILE PASS OF
CHEAL SUCTIONING SUCTION
SUCTIONING
If the patient is Low to semi- From tip of Not more than 20 – 30 Not more than
conscious fowler’s position the nose to 10 seconds seconds 5 minutes
earlobe to
dominating
side of
neck to the
thyroid
cartilage
If the patient is Flat on bed; From tip of Not more than 20 – 30 Not more than
unconscious Suction trachea the nose to 10 – 15 seconds 5 minutes
through the nose earlobe to seconds
dominating
side of
neck to the
thyroid
cartilage
TYPES OF SUCTIONING
TYPE OF POSITION OF DEPTH DURATION INTERVAL TOTAL TIME
SUCTIONING: THE PATIENT WITH EACH
WHILE PASS OF
SUCTIONING SUCTION
ENDOTRA- Semi-Fowler’s if 12.5 cms. 5 – 10 2 – 3 minutes Not more than
CHEAL TUBE not or 6 seconds 5 minutes
SUCTIONING contraindicated inches;
Insert as
far as it
goes until
you meet
resistance
or until
patient
coughs
TRACHEOS- Semi-Fowler’s if Insert as 5 – 10 2 – 3 minutes Not more than
TOMY TUBE not far as it seconds 5 minutes
SUCTIONING contraindicated gets until
you meet
resistance
or until the
patient
coughs
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

GENERAL CONDITIONS FOR SUCTIONING

 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
GENERAL CONDITIONS FOR SUCTIONING

 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

AXILLARY TEMPERATURE

 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
AXILLARY TEMPERATURE

 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:

Sim’s left position
Sim’s right position
For Newborn, lift up ankles to keep buttocks up
In Toddlers, set on prone position on adult’s 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 37°C to 40°C

 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 -3°C, making a person enter the

FIRST STAGE OF FEVER
FIRST STAGE OF FEVER

 Typical signs and symptoms indicate the body’s

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
FIRST STAGE OF FEVER

 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
FIRST STAGE OF FEVER

 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
FIRST STAGE OF FEVER

 Question:
When will you start application of TSB?

 Answer:
If there is a 1°C to 2°C 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
SECOND STAGE OF FEVER

 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
SECOND STAGE OF FEVER

 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 32°C

This temperature is maintained throughout the
procedure

 How to apply:
Done by patting

 Rationale:
To avoid friction, which increases temperature
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 32°C

 Procedure will go on with gradual decrease in water

temperature until it is maintained at 18°C

 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
STAGES OF DECUBITUS ULCER FORMATION

 Stage 2
 Partial Thickness Skin Loss
 Involves epidermis and dermis
 Manifestation
 Blister formation
 Shallow craters
 Shallow abrasion and ulceration
STAGES OF DECUBITUS ULCER FORMATION

 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
STAGES OF DECUBITUS ULCER FORMATION

 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

 Norton’s Pressure Area Risk Assessment Form

 Shannon’s 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 vasodilation causes re-
circulation of fluid

Concept!
This is contraindicated if there is inflammation
ASSESSMENT OF EDEMA

 Induration

1+ - 1 cm induration
2+ - 2 cm induration
3+ - 3 cm induration
4+ - 4 cm induration
5+ - 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
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN

 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
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS
TO PAIN

 1) Cutaneous Stimulation

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
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS
TO PAIN

 1) Cutaneous Stimulation

1E) Cold Application

Maximum vasoconstriction is reached when skin
reaches 15°C
If there is further drop in temperature, there is
vasodilation (skin becomes reddish)
This is the inherent defense mechanism from being
frozen
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN

 1) Cutaneous
Stimulation

1F) Accupressure
Pressure on certain
points of the body
Stimulates release
of endorphins,
which have natural
analgesic effects
This started in
Ancient China
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN

 1) Cutaneous
Stimulation

1F) Accupuncture
Insertion of long
slender needles on
certain chemical
pathways
Origin is also
Ancient china
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS
TO PAIN

 1) Cutaneous Stimulation

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
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS
TO PAIN

 2) Immobilization
Application of splints
NON-PHARMACOLOGIC PHYSICAL
INTERVENTIONS TO PAIN

 3) Transcutaneous
Electrical Nerve
Stimulation
Composed of
electrodes
Operated by battery
Electrodes are applied
on painful site or over
the spinal cord
NON-PHARMACOLOGIC PHYSICAL INTERVENTIONS
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
COGNITIVE AND BEHAVIORAL
NON-PHARMACOLOGIC INTERVENTIONS TO 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
COGNITIVE AND BEHAVIORAL
NON-PHARMACOLOGIC INTERVENTIONS TO PAIN

 2) Massage and Rhythmic Breathing

COGNITIVE AND BEHAVIORAL
NON-PHARMACOLOGIC INTERVENTIONS TO PAIN

 3) Rhythmic Singing and Tapping

Key Concept!
Faster beat music is more preferable
COGNITIVE AND BEHAVIORAL
NON-PHARMACOLOGIC INTERVENTIONS TO PAIN

 4) Guided Imagery
Imagine that you are
walking along a
peaceful shore
Eyes are closed and
suggestions are given
COGNITIVE AND BEHAVIORAL
NON-PHARMACOLOGIC INTERVENTIONS TO PAIN

 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
TYPES OF INCONTINENCE

 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
TYPES OF INCONTINENCE

 3) Stress Incontinence

Loss of urine is less

than 50 ml occurring
with increased intra-
abdominal pressure
Occurs when laughing
Occurs when sneezing
Occurs when smiling
TYPES OF INCONTINENCE

 4) Total Incontinence

Continuous flow of urine

No bladder distention
No bladder spasm
No awareness of bladder filling
TYPES OF INCONTINENCE

 5) Urge Incontinence

Urine flows as soon as

a strong sense of
feeling to void occurs
Strong bladder spasm
MANAGEMENT OF INCONTINENCE

 1) Kegel’s 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
MANAGEMENT OF INCONTINENCE

 1) Kegel’s Exercises

Alternative way:
When urinating, try to stop in the middle of flow or try
to stop diarrhea from flowing

Advantage of Kegel’s Exercises

Increases muscle tone of the pelvis
Increases muscle control
MANAGEMENT OF INCONTINENCE

 2) Clean Intermittent
Self Catheterization

Applicable for Reflex

Incontinence

How done:
Use a mirror for:
• Obese male
patients
• Female patients
MANAGEMENT OF INCONTINENCE

 2) Clean Intermittent Self

Catheterization
 Question:
 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.
MANAGEMENT OF INCONTINENCE

 3) Crede’s 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)
MANAGEMENT OF INCONTINENCE

 4) Prompted Voiding or Scheduled Toileting

For Reflex Incontinence

MANAGEMENT OF INCONTINENCE

 5) Application of Adult Catheter and External

Condom Catheter

For elderly with Total Incontinence

MANAGEMENT OF 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-Fowler’s 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
TYPES OF URINARY CATHETERS

 2) Robinson Catheter

Straight catheter
TYPES OF URINARY CATHETERS

 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
self-sealing 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

CONCEPTS IN MALE CATHETERIZATION

 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
CONCEPTS IN MALE CATHETERIZATION

 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.
SPECIAL GASTRO-INTESTINAL LABORATORY
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
SPECIAL GASTRO-INTESTINAL LABORATORY
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!!!
DIFFERENT TYPES OF ENEMA

 1) Cleansing Enema
Nursing Alert!
Also
contraindicated in
possible
appendicitis or
appendicitis
patients
Rationale:
Can lead to rupture
of the appendix
DIFFERENT TYPES OF ENEMA

 2) Carminative Enema

Used to expel out flatus

Burned sugar
Now commercially available
DIFFERENT TYPES OF ENEMA

 3) Oil Retention Enema

To lubricate the colon and to soften the feces

Retention time is one (1) to three (3) hours
DIFFERENT TYPES OF ENEMA

 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, Sim’s 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