Fundamentals of Nursing PDF

lOMoARcPSD|35501984 Fundamentals-of-Nursing Theoretical Frameworks of Nursing (University of Cebu) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded...

lOMoARcPSD|35501984 Fundamentals-of-Nursing Theoretical Frameworks of Nursing (University of Cebu) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing  Self-esteem THEORETICAL FOUNDATIONS OF NURSING  Love and belongingness Theory – set of concepts to explain a phenomenon Paradigm – pattern  Safety and Security o Being free from harm or danger 4 Metaparadigms of Nursing o 2 forms: Physical safety (free from physical harm)  Person - Most important because knowing the client will and Psychological safety (explaining the make your nursing care individualized, holistic, ethical, and procedure to the patient) humane.  Physiologic (priority)  Health o If all the needs are within the physiologic level  Environment High Priority needs – (life threatening needs) Airway,  Nursing Breathing, Circulation Medium priority needs – (Health threatening needs) Concepts of Man Elimination, Nutrition, Comfort,  Man is a bio-psychosocial and spiritual being who is in Low Priority needs – (Person’s developmental needs) constant contact with the environment.  Man is an open system in constant interaction with a NURSING THEORISTS changing environment. Florence Nightingale  Man is a unified whole composed of parts, which are  Environment Theory interdependent and interrelated with each other.  May 12, 1830 – August 13, 1910  Man is composed of parts, which are greater than and  Environmental sanitation different from the sum of all his parts. o Simply saying, you cannot remove 1 system from Hildegard Peplau man.  Psychodynamic Theory of Nursing  Man is composed of subsystems and suprasystems.  Interpersonal Process o Subsystem (within) Example: biological,  Phases of Nurse-patient relationship: psychological, emotional. 1. Orientation (client seeks) o Suprasystem (outside) Example: Family, 2. Identification (independence, dependence) community, population 3. Exploitation (accept service of nurse) 4. Resolution CONCEPTS OF NURSING Florence Nightingale Virginia Henderson  Act of utilizing the environment of the patient to assist him  14 Fundamental needs of the person in his recovery. Faye Abdellah Sister Callista Roy  Typology of 21 Nursing problems  Theoretical system of knowledge that prescribes a process  Patient-centered approach of analysis and action related to the care of the ill person. o The client’s needs are the basis of the nursing problems Martha Rogers Lydia Hall  Nursing is a humanistic science dedicated to the  3 C’s: compassionate concern with maintaining and promoting 1. Core (therapeutic use of self) – Patient health and preventing illness and caring for and 2. Care (nursing function) – Nurse rehabilitating the sick and disabled. 3. Cure (medical) – Doctor o Levels of prevention  Primary – Health promotion and disease Jean Watson prevention  Human Caring Theory  Secondary – Treatment, curative  Caring is an innate characteristic of every nurse.  Tertiary – Rehabilitation  10 Carative factors Ida Jean Orlando-Pelletier Dorothea Orem (Self-care and Self-care deficit theory)  Dynamic Nurse-Patient Relationship Model  Helping or assisting service to persons who are wholly or  Nursing Process Theory partly dependent, when they, their parents and guardians, o Nursing as a process involved in interacting with or other adults responsible for their care are no longer able an ill individual to meet an immediate need. to give or supervise their care.  Four Practices Basic to Nursing o I.e. – completely assisted, partially assisted, and o Observation, reporting, recording, and actions self-assisted. Madeleine Leininger ANA (American Nurses Association)  Transcultural Theory of Nursing  Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, Myra Levine alleviation of suffering through the diagnosis and  4 Principles of Conservation advocacy in the care of individuals, families, communities, 1. Conservation of energy and populations (2003). 2. Conservation of structural integrity of the body 3. Conservation of personal integrity Abraham Maslow’s Hierarchy of needs 4. Conservation of social integrity  Self-actualization University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing Sister Callista Roy  Adaptation Model FILIPINO NURSING THEORISTS  Individuals cope through biophysical social adaptation  4 mode of adaptation Carmencita Abaquin o Role function, interdependence, physiological,  Chairman of Board of Nursing self-concept  PREPARE ME intervention  P – presence which in Dorothea Orem  RE – reminisce therapy  Self-care and Self-care Deficit Theory  P - prayer  Universal self-care requirement (nutrition, oxygenation),  Re - relaxation developmental self-care requirement (developmental  ME – medication tasks), health care deviation self-care requirement  3 Nursing systems: wholly compensatory ,partially Sr. Caroline Agravante compensatory, supportive-educative compensatory  The CASAGRA Transformative Leadership model  5 C’s for Transformational leadership: creative, caring, Dorothy Johnson critical, contemplative, collegial  Behavioral Systems Theory  Man is composed of subsystems and these systems exist in Carmelita Divinagracia dynamic stability.  COMPOSURE Behavior for wellness  COMpetence Martha Rogers  Presence of Prayer, Open mindedness, Stimulation,  Science of Unitary Human Being Understanding, Respect, Relaxation, Empathy  Unitary man is an energy field in constant interaction with the environment. Mila Delia Llanes  Conceptual model on Core Competency Development Imogene King  Goal Attainment Theory Ma. Irma Bustamante  Interacting systems framework - The effects of the Nursing Self-Esteem Enhancement  Nurses purposefully interact with the patient and mutually (NurSe) Program to the Self-Esteem of Filipino Abused set the goal, explore, and agree to means to achieve the Women goals. Sr. Letty Kuan Betty Neuman - Retirement and Role Discontinuity  Total Person Model  3 types of stressors: intra-personal, extra personal, St. Elizabeth of Hungary - Patroness of nurses interpersonal St. Catherine of Siena – The 1st lady with the lamp  Primary, secondary, tertiary levels of prevention Clara Barton – Founder of American Red Cross  The goal of nursing is to assist individual families and groups Fabiola – Wealthy Matron who donated her wealth to build a in attaining and maintaining a maximal level of total hospital the Christian world wellness by purposeful interventions. T. Fliedner – Founder of the first organized school of nursing Rose Nicolet – Helped establish the first school of nursing in the Parse Philippines  Theory of Human Becoming Lilian Wald – Founder of Public Health Nursing  emphasizes how individual chose and bear responsibility for patterns of personal health HISTORICAL DEVELOPMENT OF NURSING Patricia Benner  Novice – Expert Theory Intuitive Stage 1: Novice - Practiced during the prehistoric, nursing was untaught, Stage 2: Advance beginner rendered by the mothers (by intuition, it is the woman who Stage 3: Competent (2-3 years) is more caring). Stage 4: Proficient (3-5 years) - Out of love, sickness caused by black spirits, based on Stage 5: Expert instinct  Skills acquisition - Shamans, spells, rituals Joyce Travelbee *Trephining – boring a hole into a skull without anesthesia to release  Human to Human Relationship evil spirits *Egyptians – art of embalming, anatomy and physiology Ernestein Weidenbach *Moses – Father of Sanitation, asepsis, art of circumcision  Clinical Nursing: A Helping Art *China – material medica – book of pharmacology *Babylonians – Bill of Rights, Code of Hammurabi (made by King Nola Pender Hammurabi which include freedom to refuse treatment), medical  Health Promotion Model fee *India – Shushurutu – list of function of the nurse – combination of masseur, caregiver University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing *Romans – Fabiola – a rich matron who contributed her home to - First true nursing law serve as first hospital - Board of Examiner for Nurses (BEN) - 1 Doctor and 2 Nurses - 1920 – First board examination Apprentice - Anna Dulgent – first board exam topnotcher - Known as the “on the job training” period, under the  GN Program (Graduate Nurse) – 1 year supervision of a more experienced person, but yet there is  After World War II, BSN degree for four years was given by no formal education. UST (1946). Managerial, teaching and supervision position. - Experienced (through trial and error) nurse teaches new Equal to Master’s degree. volunteer nurses who usually came from religious orders  RA 877 – BEN is composed of BSN - Nursing the sick and wounded from the wars  1966 – Master’s degree needed - Charles Dickens – novel “Martin Chuzzlewit” about Sairy  RA 6136 – can administer intravenous meds as long as Gump and Betsy Prag (exemplification of nurses in the Dark physician, violaion of professional autonomy; did not Period of Nursing) materialize but instead nurse prepared medication and - Pastor Theodore Fliedner (Protestant) – first training school doctor administered until 1992 but it had conflict with the for Nursing, “Deaconess School of Nursing”, 6 months drug administration principle of “administer what you program at Kaiserswerth,Germany prepare” -  1960s – 5-year curriculum Educated  1976 – 4-year curriculum; GN program was phased out, Florence Nightingale School of Nursing practicing GNs must go back to 4th year to earn a BSN - First theory author, first nurse-researcher degree but they won’t take board exam anymore since - Lady with a Lamp/ Mother of Modern Nursing they are already licensed - 3 months of study from Kaiserswerth  1980 – overlapping of 4 and 5 year curriculum graduates - Developed her own training “Nightingales System of  RA 7164 (1992) – IV training for nurses by ANSAP, signed by Nursing Education” which is implemented in St. Thomas Cory Aquino, valid only after 2 months Hospital in London  RA 9173 (2002) – New Nurse Practice Act - Correlate theory and practice, updates, continuing education, research, self-supporting nursing school HEALTH, DISEASE, AND ILLNESS (separate from hospital) - Changed image of nursing, revolutionized practice Health – Defined as the merely the absence or presence of disease - Professionalized as a nursing or infirmity. WHO defined health is a state of complete physical, - Notes of Nursing: What it is, What it is not, Notes on mental, and social well-being and not just merely the absence of Hospitals disease or infirmity. Nursing as a profession is not as old as mankind but nursing as an act itself is. Disease – Malfunctioning of the body system. Contemporary Illness – It is a state wherein the person’s physical, emotional, and - Modern nursing practice social well-being is thought to be diminishing. Felt by the patient. It is highly subjective. Anastacia Giron-Tupas  2 types - Grand lady of Philipine Nursing o Acute – Sudden onset, short duration, may or - Founded PNA may not require immediate intervention. Hilaria Aguinaldo – Development of Red Cross o Chronic – Gradual/slow onset, long duration, Loreto Tupas – Florence Nightingale of Iloilo lessen complications or debilitating effects of the Melchora Aquino – Tandang Sora condition for the client to be able to function given the limitations of the condition. HISTORY OF NURSING IN THE PHILIPPINES Models of Health  First hospital – Hospital de Real de Manila (1577)  1578 – San Lazaro Hospital, Intramuros – leprosy and mental Judith Smith illness Clinical Model  Hospital de San Gabriel – Chinese General Hospital - Absence of the signs and symptoms of a disease.  Aliping sagigilid and aliping namamahay – first volunteer - Narrowest nurses who served as apprentice in the first hospitals Role Performance Model  1878 – Escuela de Practicantes (UST) - Able to perform job – First school for Nursing (short-lived) Adaptive Model  1906 – Iloilo Mission Hospital School for Nursing - Capable of adjusting – 6 months training, no board exam (NON-EXISTENT) - Although there is infirmity, he is able to find ways to cope.  Mission Hospital (1901) – still existent Eudemonistic Model  1907 – PGH Hospital, St. Lukes Hospital, St. Paul Hospital - Individual is able to achieve the apex of Maslow’s  Normal Hall in PNU is used as training ground – Same Hierarchy of needs (self-actualization). instruction (central school idea) for 6 months then go back - Maximization of potential and mission in life to hospital - Fulfillment of his purpose in life  Act 2493 (1915) – Medical act which included Sec.7 & 8 about nursing practice which mandated registration and Levell and Clark examination Ecologic Model of Health  Act 2808 (1919) - Epidemiological triad –agent, host, environment University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing - Any of these triad must be manipulated or enhanced to Distress – harmful to health maintain health Body adapts to the changes in the environment which leads to Homeostasis (Walter B. Cannon) Cloud Bernard – called homeostasis as “therapeutic milieu” Multiple Causation Theory of Disease - health is affected by different factors in the environment Adaptation - change to maintain integrity of the environment Rosenstoch – Becker’s Health Belief Model - Individual perception affect modifying factors which may Models of Adaptation influence likelihood of action Biological/Physiological – GAS and LAS; compensatory physical changes Travis’ Illness-Wellness Continuum Emotional/Psychological – involves a change in attitudes or - Health is in a spectrum which moves into polarity of behavior directions Socio-cultural – changes in the person’s behavior in accordance - Premature of death  Disability/Disease  Symptoms  with norms, conventions and beliefs of various groups. Signs  Awareness  Education  Growth  High level Technological – involves the use of modern technology wellness Principles of Homeostatic Mechanisms Dunn’s High Level Wellness Grid - Automatic, self-regulatory - Health-illness Continuum - Compensatory - health axis “Favorable/Unfavorable environment” - Negative feedback except for uterine contraction during Quadrants: labor 1. High level wellness in a favorable environment - Has limits 2. Emergent high levels in Level Wellness in an One physiologic error is corrected by several homeostatic unfavorable environment mechanisms 3. Poor Health in an Unfavorable Environment 4. Poor health in a favorable environment STRESS RESPONSE Lazarus’ Stress Response Theory Schumann’s Stages of Illness Behaviors General Adaptation Syndrome (GAS) – a physiological response is a 1. Symptom experience systemic response 2. Assumption of sick role Local Adaptation Syndrome (LAS) - Only a part of the body 3. Medical care contact 4. Dependent client role General Adaptation Syndrome Stages 5. Convalescence/ Rehabilitation  Alarm - Awareness of stressor Opposite of health is illness, not disease - Increase in vital signs - Mobilization of defense STRESS - Decreased body resistance  Organisms reacts as a unified whole - Increased hormone level  Fabric of life  Resistance - Repel of stressor; overcome Models of Stress - Adaptation Response Based Model (Selye) - Normalization of hormone levels and vital signs – Non-specific response of the body to any demand made upon it - Increase in body resistance - Going back to pre-stress state Transaction-based Model  Exhaustion – Individual perceptual response rooted in psychological and - Unable to overcome stressor cognitive process - Decreased energy level - Breakdown in feedback mechanism Stimulus Based Model - Organ/tissue damage; decreased physiological – Disturbing or disruptive characteristics within the environment function - Exaggeration of Adaptation Model – Anxiety provoking stimulus General Adaptation Response – People experience anxiety and increased stress when they are Sympathoadreno-medullary Response (SAMR) unprepared to cope with stressful situations - activation of sympathetic system which stimulated adrenal medulla CRISIS - Release of epinephrine and norepinephrine ---- > inc. - disequilibrium, not merely psychological but physiologic as physiological activities well (shock) - Sympathetic stimulation (inc. HR, RR, BP, visual perception, - spontaneous resolution is 6 weeks metabolism – glycogenolysis in liver, dec. GI, GU) - grieving process: 4 years - Propanolol (Inderal) – bronchoconstriction Stressor - Internal/ intrinsic Adrenocortical Response - External / extrinsic Anterior pituitary gland Adreno corticotropic hormone  adrenal - Developmental/ Maturational cortex - Situational (1) release of aldosterone  kidneys  increase Na reabsorption Eustress – helpful stress (2) release of cortisol  fats & CHON catabolism  glucose University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing Tertiary Intention – “Delated primary intention”, suturing or closing of Neurohypophyseal Response the wound is delayed i.e. due to poor circulation in the area Posterior pituitary gland release (1) Antidiuretic hormone  kidneys  inc. Na, H2O NURSING PROCESS reabsorption  dec. urine output, inc. blood volume, inc. A – Assessment BP D - Diagnosis (2) Inc. oxytocin (aids in ejaculation/sperm motility)  uterine P – Planning contraction I - Implementation E – Evaluation Methods to decrease stress: An overlapping of process can be noted since it is cyclic - Progressive relaxation – muscle tension - Benzon relaxation method – dimming the light, music ASSESSMENT - Yoga, meditation - Ventilation of feelings Types - Initial assessment Local Adaptation Syndrome - Problem focused assessment Inflammatory Response - Emergency assessment All infections cause an inflammatory response - Time-lapsed assessment Not all tissue damage results to inflammation Inflammation can heal spontaneously as long as the body can Data Collection – first step in assessment manage  Primary/ Secondary  Object (over)/ Subjective (covert) I. Vascular Stage (1) Vasoconstriction which limits injury and contain damage Methods of Gathering Data (transient) Interview (2) Release of chemical mediators – kinins  Therapeutic and non-communication a. Bradykinin – most potent vasodilator/ universal  Health history pain stimulus, inc. chemical activity  warmth o Medical history – disease focused (physiological) (calor), redness (rubor) o Nursing history – needs, psychosocial dimension, b. Prostaglandin spiritual aspects (3) Capillary permeability  swelling (tumor), pain (dulor),  Personal space temporary loss of function (function laesa) o Intimate Space – 1 ½ foot o Personal Space – 1 ½ - 4 feet II. Cellular Stage o Social Space – 4 –12 feet (1) Neutrophils – bands and segmenters in differential count; o Public Space – 12–15 feet first one to arrive. If elevated, it suggests acute infection (2) Lymphocytes, Monocytes, or Macrophages – suggests Observation chronic infection.  Use of senses to gather data (3) Eosinophils – allergy  Clinical eye – comes with practice and experience (4) Basophils – healing Examination  Inspection, Palpation, Percussion, Auscultation (general) III. Exudating  Inspection, Auscultation, Percussion, Palpation Types of Exudate (abdominal)  Serous – plasma (watery)  Sanguinous/hemorrages – blood Steps in assessment  Serosaguinous – pink 1. Collection of data  Pus – purulent/ suppurative 2. Validation of data  Catarrhal – mucin 3. Organization of data  Fibrin fibers – fibrinous 4. Categorizing or identifying patterns of data 5. Making influences or impressions of data IV. Reparative Phagocytosis – ingestion of foreign substances After data collection, synthesis, analysis and validation are Macrophages  Monocytes performed Chemotaxis – movement of substances to a chemical signal Healing methods: DIAGNOSIS  Cold compress for first hours then warm compress after Problem + etiology +defining symptoms  Nutrition and fluid intake *Guided by the NANDA Knowledge deficit – kulang sa kaisipan Types of wound healing Knowledge deficiency – kulang sa kaalaman (preferred) Primary Intention – Wound edges are well approximated (closed), Self-care deficit – acceptable minimal tissue damage i.e. surgically created wound; this can be done with stitches, staples, etc. Types of Nursing Diagnosis  Actual Secondary Intention – Wound edges are not well approximated,  Risk for/ Potential for moderate to extensive tissue damage and edges can’t be brought  Wellness - readiness and enhancement/ achieve higher together i.e. Decubitus ulcer level of functioning  Syndrome – “syndrome” University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing  Possible – vague/ unclear – possible/probable 5. Charting by Exception (CBE) – only significant change is Prioritization of Nursing Diagnosis documented  Airway, breathing, circulation Case Management done with a Critical Pathway Variance – Comprehensive and make sure that it won’t legally be implicated PLANNING  Short Range PHYSICAL EXAM (Plan Order)  Long Range - Cephalo-caudal *Must be SMART (Specific, Measurable, Attainable, Realistic, Time o Inspect, palpation percussion, auscultation bound) o Inspection, auscultation, percussion, and Classify as dependent, interdependent, and collaborative palpation sequence on abdomen to prevent stimulation of peristalsis and for the patient to IMPLEMENTATION follow a more comfortable to least comfortable  Reassess if the patient still needs intervention examination  Determine if you need assistance  Carry out intervention, ensure that we have background Focused Assessment – on specific part/symptom  Document Process of implementing Bruit – normal if with AV fistula, abnormal in other since it may signify - Reassess client arterial occlusion - Determine nurses’ needs for assistance - Implementing nursing interventions Auscultate the scrotum in inguinal hernia since it may have bowel - Supervising the delegated care sounds - Documenting nursing activities Compare each body part to the other EVALUATION POSITIONING Purposes of evaluation  Sitting Determine the:  High Fowlers (90%) - Client’s progress or lack of progress  Orthopneic position (leaning on a table, hands extended) - Overall quality of care provided  Supine, Back Lying, Dorsal, Horizontal Recumbent - Promote nursing accountability  Flat on Bed – no pillow Guidelines for evaluation  Dorsal Recumbent – legs flexed to relax abdominal - Systemic process muscles, abdominal palpation/ exam – followed by - On-going basis diagonal draping  Standing/Errect – curvature of the spine Revision of the plan of care when needed  Prone/ Face – lying position - - Involve the client, significant others, and other  Sim’s Position, Left lateral, Side-lying members of the health team – Rectal exam, suppository insertion, enema administration - Must be documented  Knee Chest position/ Geno-pectoral position/ Jack Knife Process - nurse position Structure - system – Rectal exam, dysmenorrhea Outcome – patient  Kraaske – inverted V  Lithototomy – stirrups DOCUMENTATION or CHARTING  Trendelenburg – foot up; head down  STAT – now  Reverse trendelenburg – head up, foot down  Ad lib – as desired  Modified trendelenburg – only 1 leg up for shock: L  PRN – as required  OD – right eye/ once a day MCNAP – training to perform internal examination  OS – left eye  OU – both Chest  AD – right ear - Pectus excavatum – funnel chest (congenital);  AS – left ear compression of heart and breathing  AU – both ears - Pectus carinatum – pigeon chest – deformity for rickets (Vit  Ss – half D deficiency); AP diameter decreased ERROR: draw a straight line, signature, initials Posture - Kyphosis Types of Documentation - Lordosis 1. Source Oriented Recording – narrative account by nurse; - Scoliosis – lateral all the sheets in the patient’s chart (Standing Order, Skin Physician’s Order etc.) - Capillary refill test = 1-2 seconds 2. Problem Oriented Recording (POR) – problems ranked - Icteric sclera according to priority by the health care team, date - Cyanosis – late sign of oxygen deprivation dissolved, progress notes, problem list - Vitiligo a. FDAR – Focus, Data, Action, Response (patient) - Erythema b. SOAPIER – subjective, objective, assessment, - Pallor planning, implementation, evaluation, revision 3. Computer Assisted Recording – problem with privacy Nail Beds 4. Flow Chart - Clubbing - Beyond 180 degree due to dec. oxygen University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing - Koilonychia -Spoon shaped nail due to iron deficiency Gurgles (rhonchi) – Continuous, low-pitched, course, gurgling, harsh anemia sounds with moaning / snoring quality - Onycholysis/Oncolysis – separation of nail - rubbing hair in wide airway - Paronychia – severe inflammation of nail Friction rub – Superficial grating or creaking sounds - Unguis incartatus - ingrown toenail Vocal (tactile) fremitus – Faintly perceptible vibration felt through the chest wall when the client speaks PALPATION Stridor – noisy breathing - Light (indentation half an inch) Stertor – laryngeal spasm o Fontanels, buldges, pulses, lymph nodes, thyroids, Cardiac Sounds symmetry, neck veins, edema - 5th ICL MCL at the PMI - Deep - Llllleft – Pulmonic valve - Rrrrrr- Aortic valve NPH – Ntrmediate IE is a form of palpation Humulin R- rapid Chest expansion must be symmetrical Glargular – rapid Tactile fremitus - sound that is palpable Bowel Sounds - Increase in consolidation, pneumonia - Normoactive: 5-30 bowel sounds per minute - Decrease in pneumothorax - Wait 3-5 mins before concluding that bowel sounds are Thrill – palpable murmur absent Edema – on dependent area and may occur in legs - Hyperactive – Borborygmus - Pitting/Non-Pitting - Paralytic ileus – paralysis after surgery Anasarca – generalized edema Peri-orbital edema – about the eye Voice Transmitted Sounds - Egophony – say “E” but hears “A” PERCUSSION - Whispered Pertoriloquy – whisper but we hear it loudly, - Touch and healing secondary to consolidation - Vocal fremitus Tuning Fork Shifting dullness to check for ascites - Weber’s test/ Lateralization test – conduction hearing - Rhinne’s Test – bone-air conduction LABORATORY EXAMS - Properly collect the specimen Indirect Palpation - Give instructions correctly - Flexor – Hiitting - Pleximeter – Receiving Urinalysis Sounds - Color: Amber, tea-colored (biliary d/o), urobilinogen - Dull – organ - Odor: Aromatic/ Ammoniacal (decomposed urine) - Flat – bones, muscles - pH: Acidic – does not favor bacterial growth - Tympany – abdoment - Specific gravity: 1.050-1.025, if elevated urine is - Resonant – lungs concentrated, suspect dehydration - Hyperresonance – abnormal (emphysema) - Phosphates/Urates: Normal - Glycosuria – Diabetes (BS is more than 200mg) Typanism – “kabag” - Hematuria – Stones, BPH, renal diseases, UTI DTR - +2: NORMAL, above it hyper resonant, below it is hyporesonant - Albuminemia – protein in urine, eccampsia - Pyuria – UTI Parts of the Stethoscope - Cyllinduria – cast in urine (stones) Diaphragm – high pitched; lung sounds - First voided urine, mid-stream to clean the urethra first Bell – low pitched; heart sounds - Sterile specimen - Indwelling catheter – wait in the end of the catheter for 30 Adventitious breath sounds – no abnormal sounds mins - Indwelling catheter – aspirate from 10ml syringe Respiratory Sounds - Wee bag (*) Normal Breath Sounds Vesicular – Soft intensity, low pitched Urine Culture & Sensistivity Test - T5 onward - Exact microbe - Peripheral lung, base of the lung - Result is final only after 5-7 days Bronchovesicular – Moderate intensity, moderate pitch - Same collection process but less amount - T3-T5 - Ideal is catheterized cath - Between scapulae lateral to the sternum Bronchial – High pitch, loud harsh sounds Chemical Tests for Urine - T1-T3 - Clinitest – way to determine sugar in urine (glycosuria) - Anteriorly over the trachea - Benedict’s test – used Benedict’s solution then heat to check for potency: must remain blue; if not blue, discard Adventitious Breath Sounds - NO BOILING Wheeze – Continuous, high-pitched, squeaky musical sounds o Then add 3-10 drops of urine then heat - narrowed airway; asthma, bronchitis o Negative results Crackles (rales) – Fine, short, interrupted crackling sounds o Negative: Blue - rubbing hair in small airways; retained secretions; o +1 - Green o +2 - Yellow University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing o +3 – Orange - prick at the side since low blood vessels o +4 - Red o Collected before meals Thoracentesis - Heat and Acetic Acid Test – test of albuminuria; divide into - aspiration of pleural fluid through a needle 3 parts then add 2/3 urine, then 1/3 acetic acid - orthopneic position - informed consent - Fluid - 7-8 or 8-9 in intercostal posterior axillary line o Turbid/Cloudy – positive - Air - 2-3, 3-4 in intercostals o Not reliable since no microscopic instruments - Needs chest x-ray were used - Positioned lying on unaffected side o Done mostly in the community, NO BOILING Thoracostomy Quantitative Urine Exam - to return to negative pressure - 24-hour Urine Collection – HCG, urinary amylase, urinary catecholamines, urinary creatinine, urine albumin, Abdominal Paracentesis corticosteroids - Aspiration of peritoneal fluid in ascites o 6pm order, discard urine on 6pm, start on 6:01pm - Semi-sitting/sitting position o Whole amount of urine, need not be midstream - Void before procedure o Preserve in ice – cold storage - May be therapeutic or diagnostic o Leeway of 15-30mins; get urine after deadline as - Watch out for hypovolemia long as not too far - Fractional Urine Collection – shorter span; time determined Lumbar Puncture/ Tap by doctor - L3, L4, L5, subarachnoid space - Paralysis risk low Fecalysis - Fetal position – widens the angle of the lumbar spine - Color of stool is influenced by stercobilin - 50-200mm – normal CSF pressure - Clay colored = acholic stool = biliary track obstruction - Prepare 4 test tubes since every test requires a different - Hematochezia = red = lower GI bleeding test tube - Melena = blood = upper GI bleeding - Label test tubes and seal with appropriate cover; not with - Steatorrhea = fat = gall bladder rpoblem cotton - Foul smelling – indole and skatole - Xanthochromic – hemolyzed blood; yellowish discoloration - Soft/formed - Flat on bed after procedure (6-8 hours) to prevent spinal - Dead bacteria, fibers, amorphous phosphates – normal headache - Live bacteria – abnormal - After 1 hour, the stool cannot be used for fecalysis Diagnostic Exams - Collect abnormal looking feces, not the one which is well - Visualization procedures formed - Endoscopy o direct visualization; lighted instrument Stool Culture and Sensitivity - X-Ray – graphy - Determining exact microorganism o Contraindicated in pregnant women due to - Result also final after 5-7 days terratogenic effect - Sterile container - Transformed o Ultrasound/ Sonogram Guiac Test - Occult blood test Electroencephalography (EEG) - No meat, highly colored food, iron preparation, Vit. C in - Shampoo hair before and after procedure diet - Sedative must be withheld - 3 days occult blood sample - Determining seizure disorders - Sputum Exam Electrocardiography (ECG) - Done in early morning since secretions already pooled - Sputum C &S – may give oral hygiene to remove mouth Electromyogram (EMG) bacteria - Invasive - Acid Fast Bacilli – 3 consecutive days - Phase 2 – insertion of needle into muscle - Sputum Cytology – cancer cells - Eosinophil determination – to determine allergic reaction CBC needs a heparinized syringe - If unconscious, suction may be done: mucus trap Magnetic Resonance Imaging Blood Examinations - CI: steel implant and pace maker - FASTING - Some ortho implants/prosthesis are allowed o Triglyceride (1-12 hours), BUN (6-8 hours), HDL, - Assess for claustrophobia LDL, FBS, Total Protein, Albumin Globulin ration, - Needs consent since it’s expensive uric acid - With contrast in special procedures - NON FASTING - NPO – to avoid aspiration in case of untoward reaction o Crea, Na, K, Ca, CBG (but pre meals) Computed Tomography Scan CBG - Lesion must be bigger - before meals - Dye and NPO University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing - Enema to evacuate barium to prevent fecal impaction Positron Emission Tomography - Radioactive glucose (Fluorine) Lower GI Series - Cancer cells have strong affinity for glucose; detect - Barium enema cancer sites of metastasis - Outline of colon - Laxative and cleansing enema until it is clean - Pink phosposoda (oral cleansing enema) Nuclear Medicine Thyroid Scan - Evacuate barium through enema to prevent fecal - Nodule/tumor on thyroid impaction For abdominal scans laxative, (castor oil/ Dulcolax) and NPO may be necessary Excretory Urography - Intravenous Pyelography Opthalmoscopy o Hypaque- - made from iodine substance; check - Opthalmoscope for allergy for seafoods - Used in determining cataract o Laxative + NPO - Dim the light and focus light of opthalmoscope in the eye o Given through IV port and the xray series is made - Fundoscopy may be determined o Assesses kidney’s ability to filter o Assesses presence of stones Otoscopy o If reverse, retrograde pyelography - Otoscope - Oral Cholecystography - A cannula is inserted in the external auditory canal o Iapanoic acid (Telepaque) – taken every 5-10 - No need for written consent minute interval; 6 tablets - 3 y/o above – up & back o Low fat meal the day before the exam - 3 y/o below – down & back o Laxative + NPO Rhinoscopy Ultrasound/ Sonogram - Rhinoscope - US Brain - Hyperextend the neck - US Heart (2D ECHO, Echocardiography) o Regurgitation Endoscope o Stenosis - Can be used for surgery, biopsy - US Lungs - Pharyngoscopy - US Breast/ Sonomamogram - Bronchoscopy o Needs tranducer - Langyngoscopy - US Abdomen - Esophagogastroduedenoscopy o Colon – laxative, NPO - Anoscopy o Kidney – KUB - Proctoscopy – rectum o Pelvic ultrasound – drink 6-8 glasses to have a full - Sigmoidoscopy bladder; do not allow to void - Coloscopy – anus to ileum o Gallbladder ultrasound o Cleansing enema until clear - Transvaginal Ultrasound - Remove dentures o Will outline fallopian tube, uterus and ovaries - Remove gag reflex by local anesthetic agent and check o consent gag reflex - Transrectal Ultrasound - Resume food only when gag reflex is present o Consent - Consent and NPO o Empty the bladder for comfort and good - Urethroscopy visualization - Cystoscopy – bladder, written consent, cystoclysis set up o Visualization of uterus/ prostate (continuous flow of sterile water which also exits) - Colposcopy – vaginal examination, needs vaginal ADMITTING A CLIENT speculum Types of Bed o Shirodkar – tying the cervix so that miscarriage is - Closed – in anticipation for an admission avoided; incompetent cervix - Open - Post-Op/ Surgical/ Anesthetic/ Heater bed Roentgenography - Occupied - Electromagnetic radation photography - Xray but without contrast medium Principle of Bed-making - Chest X-Ray - Body Mechanics: Bed from knees, wide base of support o Not definitve of TB - Obtain help - Mammography - Asepsis, do not let linen touch uniform o Examination of breast - Do not let the linen fall into ground - Scout Film of Abdomen - Finish one side of bed first - KUB - Remove wrinkles to have aesthetic value o Top sheet – excess linen in foot part Upper GI Series o Bottom sheet – excess linen in head part - Esophagus, stomach, duodenum CHANGING GOWN - Barium swallow (dye) – outline the GI system, flavored, has - Remove with free arm first in changing gown constipating effect – inc. fluid - If both with contraption, any arms - Uses laxative, NPO ORIENTING THE CLIENT University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing ASSESSMENT  Course / Plateau phase: absence of chills, feels warm, up HISTORY TAKING HR, RR, thirtst PHYSICAL EXAM  Abatement phase: flushed skin, sweating, reduced VITAL SIGNS shivering DOCUMENT - chief complaint only found on admission sheet Average: 36˚ - 38˚ degrees DISCHARGE OF PATIENT Hypothermia: 36˚ degrees below - may be against medical advice (DAMA) but it needs Death: 34˚ degrees doctor’s order - health instruction Types of Fever - Illegal detention (false imprisonment) Intermittent – fluctuates from febrile to afebrile Remittent – febrile, temperature fluctuation is minimal VITAL SIGNS Relapsing – fluctuates in days Children – Respiratory Rate, Pulse Rate, Temperature Constant / Continuous – febrile, temperature fluctuation is wide (+2) * Blood Pressure can also be obtained in children Heat Stroke – depletion of fluid, hypothalamus does not regulate Hypothermia – induced (surgery), extreme temperature Nursing interventions Feels chilled – provide extra blankets TEMPERATURE Feels warm – remove excess blankets; loosen clothing Types of Temperature Adequate nutrition and fluids Core temp. – more important; can’t be affected by environment Reduce physical activity Surface temp. – more important in children since hypothalamus not Oral hygiene yet developed Tepid Sponge Bath – increase heat loss (conduction, convection, evaporation) Poikilothermia – temp is same with environment; newborn Homeothermia – different with the environment Unexpected Situation and Associated Interventions During rectal temperature assessment, the patient reports feeling Factors that affect Body Temperature lightheaded or passes out  Remove the thermometer 1. Age immediately. Quickly assess the patient’s BP and HR. Notify 2. Ovulation – temp is higher; progesterone physician. Do not attempt to take another rectal temperature on 3. Activity – inc. BMR this patient. 4. Environment Temperature conversion PULSE C-F multiply 1.8 + 32 - Temporal F-C subtract 32/ 1.8 - Carotid – cardiac arrest - Apical Methods of taking body temperature - Brachial - Oral – contraindicated in brain damage, mental illness, - Radial – thumb site retarded, problem with nose and mouth, tooth extraction, - Femoral contraption in nose and mouth, altered LOC, dyspnea, - Popliteal seizures, 7 y/o below o 2 mins under the tongue Affected by the following: - Rectal – contraindicated in imperforate anus, rectal 1. Age – the younger, the faster polyps, hirschprung’s disease, diarrhea, increase ICP, 2. Activity cardiac disease (may cause vagal stimulation) 3. Stres o Not safe since it can cause rectal trauma 4. Drugs o 1 min  Increase – anticholinergic, sympathomimetic - Axillary – 3mins  Decrease – cardiac glycoside - Tympanic – external ear. contraindicated in otitis, ear surgery; most Palpation accurate Pattern of Beat (Rhythm) - Temporal Scanner - done in temporal; most convenient - Regular (60 – 100 bmp) - Irregular (arrhythmia) Temperature can be checked every 30 mins since hypothalamus o Bigeminal pulse – 1, 2, disappear can only fluctuate the temperature every 30 mins o Trigeminal pulse – 1, 2, 3, disappear Spot Vital Signs – HR, RR, BP Pulse Strength = pulse volume Thermopacifier – for crying babies +1 – collapsible. thready Plastic strip Thermometer – Amitemp +2 – normal +3 – full Alterations in body temperature +4 – full, bounding Hyperpyrexia: 41˚ degrees + Pyrexia: 37.5˚ - 38˚ degrees + Corrigan pulse/ Waterhammer pulse – thready and with full  Onset / Chill phase: up HR, up RR, shivering, cold skin, expansion followed cessation of sweating by sudden collapse. University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing Auscultation Apical (PMI) Kinds  3rd – 4th ICS MCL (below 7 years old) - Direct – venous pressue, CVP, invasive, cutdown (5-  4th - 5th ICS MCL (7 years old and aboe) 12mmHg) Unexpected Situations and Associated Interventions - Indirect The pulse is irregular  Monitor the pulse for a full minute. If the pulse o Palpatory is difficult to assess, validate pulse measurement by taking the o Ausultatory apical pulse for 1 minute. If this is a change for the patient, notify the physician. Pulse pressure – 40 mmHg Pulse deficit (systolic - diastolic) You cannot palpate a pulse  Use a portable ultrasound Doppler to Mean Arterial Pressure ([2D+S]/D) assess the pulse. If this is a change in assessment or if you cannot find the pulse sing an ultrasound Doppler, notify the physician. Classification SBP DBP Lifestyle mmHg mmHg Modification RESPIRATION Normal: 16-20 bpm Optimal 100 YES  Intact thoracic cavity Stage 3 HPN > 180 Or > 110 YES  Compliance and recoil Diffusion – movement of gases from higher to lower concentration Choose the higher BP  Adequate concentration of gases Sources of error is BP Assessment  Normal lung tissue High BP reading Perfusion – circulation of the oxygenated blood to the different  Bladder cuff too narrow tissues of the body  Arms unsupported  Insufficient rest before the assessment Inhalation / Inspiration – 1 to 1.5 seconds  Repeating reassessment too quickly Exhalation / Expiration – 2 to 3 seconds  Deflating cuff too slowly  Assessing immediately after a meal or while client smokes Alterations in Breathing Patterns or has pain Rate Low BP reading Tachypnea – fast breathing  Bladder cuff too wide Bradypnea – slowed breathing  Deflating cuff too quickly Apnea – absence of breathing  Arm above the level of the heart Eupnea – normal breathing  Failure to identify auscultatory gap Rhythm Biot’s – shallow breathing with periods of apnea OXYGENATION Cheyne-Strokes – deep breathing with apnea Kussmaul’s – deep, rapid breathing (If with respiratory acidosis – to Respiratory Modalities blow off excess carbon dioxides) Abdominal (diaphragmatic) and purse-lip breathing Volume  Semi / high fowlers position Hyperventilation – leads to respiratory alkalosis  Slow deep breath, hold for a count of 3 then slowly exhale Hypoventilation – leads to respiratory acidosis through mouth and pursed lip  5 – 10 slow deep breaths every 2 hours on waking hours Ease of effort Dyspnea – difficulty of breathing Coughing exercise Orthopnea – difficulty of breathing within supine position  Upright position (best position for this is orthopneic position)  Contraindicated: post brain, spinal or eye surgery Katupnea - Difficulty of breathing while in sitting position  Take two slow deep breaths; on the third breath, hold for Trepopnea - ease when in side-lying position dew seconds, cough twice without inhaling in between Hyperpnea – inc. rate and depth of respiration  May splint surgical incisions  Every 2 hours while awake BLOOD PRESSURE Factor’s Affecting Blood pressure Incentive spirometry - Age, Gender  A breathing device that provides visual feedback that - Activity, exercise, stress encourages patient to sustain deep voluntary breathing - Time of the day and maximum inspiration.  10 times every 1 to 2 hours Korotkoff sounds Phase 1 – sharp tapping (systolic) Chest Physiotherapy Phase 2 – swishing or wooshing sound  Postural drainage Phase 3 – thump softer than the tapping in phase 1  Percussion Phase 4 – softer blowing muffled sound that fades (end = diastolic)  Vibration Phase 5 – silence University of Santo Tomas – College of Nursing / JSV Downloaded by Ding Dong ([email protected])  lOMoARcPSD|35501984 Fundamentals of Nursing  Positioning > percussion > vibration > removal of secretions  Safety precuations: “NO SMOKNG” and “O2 IN USE” signs by coughing or suction at the door o Contraindications:  ICP more than 20mmHg, head and neck injury, Nasal Cannula (approx. 20-40% of oxygen) active hemorrhage, recent spinal surgery, active  1L/min = 24% hemoptysis, pulmonary edema, confused or  2L/min = 28% anxious patients, rib fracture  3L/min = 32%  4L/min = 36% Postural Drainage  5L/min = 40%  When = morning, at bedtime, 30 minutes – 1 hour before or  6L/min = 40% 1-2 hours after meal Priority nursing interventions:  Each position = assumed for 10 – 15 minutes o Check frequently that both prongs are in the patient’s  Entire treatment should last only for 30 minutes nares. o Encourage the patient to breathe through the nose, Percussion with mouth closed.  Rhythmical force provided by clapping the nurse’s o May be limited to no more than 2-3L/min to patient cupped hands against the client’s thorax with chronic lung disease.  Over affected segment for 1-2 minutes Face mask Simple face mask (approx. 40-60%) Vibration  5-6L/min = 40%  Perform by contracting all the muscles in the nurse’s upper  7-8L/min = 50% extremities to cause vibration while applying pressure to  10L/min = 60% the client’s chest wall Priority nursing interventions:  One hand over the other o Monitor patient frequently to check the placement of the mask. Suctioning o Support patient if claustrophobia is a concern. Purposes o Secure physician’s order to replace mask with nasal  Maintain patent airway cannula during meal time  Promote adequate exchange of O2 and CO2  Substitute for effective coughing Partial rebreather mask (approx. 60-80%) Size  6-10L/min = up to 80%  Adult: Fr 12-18 Priority nursing interventions:  Child: Fr 8-10 o Set flow rate so that mask remains two-thirds full during  Infant: Fr 5-8 inspiration Length o Keep reservoir bag free of twists or kinks.  From tip of nose to earlobe (5 in.)  Nasopharyngeal = 5-6 inches Nonrebeather mask  Oropharyngeal = 3-4 inches  10L/min = 80-100%  Nasotracheal = 8-9 inches Priority nursing interventions:  ET = lenth of ET + 1 inch o Maintain flow rate so reservoir bag collapses only slightly  Tracheostomy = length of trachea + 1 cm during inspiration. Suctioning o Check that valved and rubber flaps are functioning  Duration of suction: 5-10 seconds properly (open during expiration and closed during  Intermittent suctioning upon withdrawal using rotating inhalation) motion o Monitor SaO2 with pulse oximeter.  If to repeat: 1-2 mins interval  Limit suctioning in a total of 5 minutes Venturi mask (most accurate and precise