Fundamentals of Nursing
Fundamentals of Nursing
Fundamentals of Nursing
FUNDAMENTALS OF NURSING maintaining and promoting health and preventing illness and
caring for and rehabilitating the sick and disabled (Rogers)
4 Major concepts central in nursing: Levels of prevention:
1. Person/Client – recipient of care; first foundational concept in Primary
nursing Secondary – disease prevention
2. Health Tertiary
3. Environment o Helping or assisting service to persons who are wholly or
4. Nursing – attributes, characteristics, actions of the nurse partly dependent, when they, their parents and guardians, or
other adults responsible for their care are no longer able to
CONCEPTS OF MAN AND HIS BASIC HUMAN NEEDS give or supervise their care (Orem)
Concepts of man o Protection, promotion and optimization of health and abilities,
Man is a biopyschosocial and spiritual being who is in prevention of illness and injury, alleviation of suffering
constant contact with the environment through the diagnosis and tx of individual, families,
o Biological: Man is like all other man (Callista Roy) communities (ANA)
o Spiritual: Man is like all other man; there is a supreme
higher being (Callista Roy) Historical Development of Nursing
o Social: Man is like some other man (Callista Roy) Intuitive – nursing is by instinct
o Psychological: Man is like no other man (Callista Roy) Apprentice – nursing is without formal education but directed
Man is an open system in constant interaction with a changing by more experienced person
environment Educated – Florence nightingale; 1860
Man is a unified whole composed of parts which are Contemporary – end of World War II up to the present time
interdependent and interrelated with each other
o All body parts, systems functions collaboratively Current trends in Nursing
Man is composed of parts which are greater than and Evidence-based practice
different from the sum of all his parts Community-based nursing – primary prevention
Man is composed of subsystems and suprasystems Decreased length of hospital stay
o Subsystem: within; systems in the body Aging population
o Suprasystem: outside; “ang tao ay parte ng isang Increased in chronic care conditions
pamilya”; family, friends etc Independent nursing practice
Culturally competent care
Characteristics of basic human needs
Universal Nursing theories
Met in different ways JOHHNN PARROLL
Stimulated by external and internal factors J-ohnson: Behavioral Systems Model
Priorities may be altered O-rem: Self Care Deficit Theory
H-all: Core, Care, Cure
May be deferred
H- enderson: 14 Fundamental Needs of Man
May be interrelated N- ightingale: Environmental Theory
Unmet human need results in disruption of normal body N- ewman: Help System Model
activities and frequently leads to eventual illness P- eplau: Interpersonal Relations Model/ Psychodynamic Model of
Nursing
*Maslow’s hierarchy of human needs A- bdellah: 21 Nursing Problems
Physiologic – base of the pyramid R- oy: Adaptation Model
High priority needs – life threatening needs R- ogers: Science of Unitary Human Being
O- rlando: Dynamic Nurse-Patient Relationship model/ Nursing Process
Medium priority needs– help threatening needs
Model
Low priority needs– developmental needs L- eininger: Transcultural Nursing
L- evine: Four Principles of Conservation/ Conservation model
Safety and Security
Physical safety and security – e.g. keep sharp objects, bedrails, Dorothy Johnson
etc. o Behavioral systems model
Psychological safety and security – e.g. explain before doing any o Man is composed of subsystems and these systems exist in
procedure (observe verbal/nonverbal communication) dynamic stability
o 7 subsystems
Love and belonging Dorothea Orem
Self-esteem o Self care and self care deficit theory of nursing
Self – promote independence; self-control o Based on the concepts of:
Others – recognition/praises from others Self care – activities that a person must perform
Self care agency
Self actualization
Self care agent
Concepts of Nursing
Nursing Dependent care agent – nurse is totally doing the
o act of utilizing the environment of the patient to assist him in care for the patient
his recovery (Nightingale) Self care requisites: demands for self care
o Theoretical system of knowledge that prescribes a process of Universal
analysis and action related to the care of the ill person (Roy) Developmental
Health deviation: mother doesn’t know how to
properly care for baby
Therapeutic self care demand: needs of the person
Lydia Hall o Total Person Model
o Core, Care, Cure o Also known as health systems model
o Three aspects of nursing: o Attainment and maintenance of maximal level of total
Therapeutic use of self: motivation of pt to recover and wellness by purposeful interventions
energy to promote healing Patricia Benner
Bodily care: nurses o Novice to Expert theory
Cure: doctors Expert
Proficient
Virginia Henderson Competent
o The Nature of Nursing Model Advanced beginner
Novice
o 14 fundamental needs of the person
Nursing Functions
Florence Nightingale Independent
o Environmental theory Dependent
o Linked health with 5 environmental factors
Interdependent/Collaborative
Hildegard Peplau
o Interpersonal Relations Model/ Psychodynamic Model Health, Disease and Illness
o Rel bet the nurse and pt must be significant and Health
therapeutic A state of complete physical, mental and social well-being, and
o Identified 4 phases of nurse-client rel: not merely the absence of disease or infirmity (WHO, 1948)
Orientation Smith’s 4 Models of Health:
Identification o Clinical model: healthy if with/without signs and
Exploitation symptoms; narrowest definition
Resolution o Role performance model: healthy if able to perform ADLs
Faye Abdellah and roles
o 21 Nursing problems o Adaptive model: health is a very dynamic; healthy if able to
o It is from the client’s needs that the our nursing problems adapt and adjust to env’t
originated from o Eudaemonistic model: healthy if able to reach the apex of
o Patient-centered approaches to Nursing Model Maslow’s hierarchy of needs; very comprehensive view
o Nursing as having a problem-solving approach, with key about health
nursing prob –solving approach Leavell and Clark Model
Sister Callista Roy o Agent-host Environment model: absence of (-) agent and
o Adaptation Model presence of (+) agent; (-) microorganisms; (+) health
o Viewed humans as biopsychosocial beings who o Ecologic Model
constantly interact with their env’t Dunn’s high level Wellness grid (copy from Raj)
Martha Rogers Travis’s Illness/Wellness Continuum (copy)
o Science of Unitary Human beings
o Unitary man is an energy field in constant interaction
with the env’t
o Human beings are more than diff from the sum of their
parts Premature High level
Ida Jean Orlando death Neutral point wellness
o Dynamic Nurse-patient relationship model
o Nursing process theory Illness
o Nursing as a process involved in interacting with an ill Personal state wherein the physical, mental and social aspects
individual to meet an intermediate need of well-being is thought to be diminished
o 4 practices basic to nursing o Acute: sudden, short period of time; may or may not
o Dynamic: forever changing relationship require intervention
Madeleine Leininger o Chronic: remission & exacerbation; more on the
o Transcultural Nursing Model rehabilitation
o Cultural care diversity Suchman Five stages of illness:
Myra Levine o Symptoms experience
o 4 Conservation Principles: o Assumption of sick role
Conservation of energy o Medical care contact
Conservation of structural integrity of the body o Dependent client role
Conservation of personal integrity o Recovery or rehabilitation
Conservation of social integrity
Jean Watson Disease
o Human Caring theory Alteration in body functions that may result in a reduction of
o 10 Carative factors capacities or a shortening of the normal life span
o Nursing is an innate personality of the nurse; something
Stages of Health behaviour change:
personal or within
Pre-contemplation: patient is without the intention to change; it
Imogene King
could be that the patient is misinformed or under informed
o Goal attainment theory
Contemplation: patient acknowledge that there is a problem and
o Nurses purposefully interact with patient and mutually
there’s an intention to change but may take him/her months or
set, explore and agree to means to achieve goals
years to change
Betty Newman
Preparation: patient is planning to have a behavioural change 2. Validation of data
Action: there is an observable behavioural modification 3. Organization of data
Maintenance: patient is able to integrate the new behaviour into 4. Categorizing or identifying patterns of data
his/her lifestyle but needs to prevent relapses 5. Making influences or impressions
Termination : it’s as if the unhealthy behaviour did not exist and 6. Recording/reporting of data
there is no possibility for relapse
Diagnosis
Nursing Process Medical diagnosis Nursing diagnosis
Characteristics: Focuses on illness, injury and Focuses on response to actual
Cyclic and dynamic nature dse process or potential health prob
Critical-thinking skills Remains constant until cure is Changes as the client’s
effected response or health prob
Decision making change
Client-centered Indentifies condition that Identifies situation
Interpersonal and collaborative practitioners is licensed and
Universally applicable qualified to treat
Active
Done by patient himself w/o assistance
from the nurse
Active-assistive
Performed independently by the client
which is then continued or assisted by the
nurse for the patient to complete the ROM
passive
Exercise done the pt with the complete
assistance from the nurse
Resistive
Pt moves or tenses his muscles against a
resistance
Sulcular technique – 45 degree angulation
Types of massage:
Effleurage – relaxes the muscles
Petrissage
Martha Rogers
FUNDAMENTALS OF NURSING Man as a unitary being
Elizabeth Cortez, RN, MAN
Nutrix – latin words; to nourish Imogene King
NURSING Interacting systems framework
Is an art and science
total patient care Betty Neuman
focuses on environment Total person model theory
individual, family, community 3 types of stressors: intra-personal, extra personal,
interpersonal
THEORETICAL FOUNDATIONS OF NURSING Primary, secondary, tertiary levels of prevention
Theory – set of concepts to explain a phenomenon
Paradigm - pattern Parse
4 Metaparadigms of Nursing Theory of Human Becoming
Person
emphasizes how individual chose and bear responsibility for
Health patterns of personal health
Environment
Nursing Patricia Benner
Novice of expert theory
NURSING THEORISTS Stage 1: Novice
Florence Nightingale Stage 2: Advance beginner
May 12, 1830 – August 13, 1910
Stage 3: Competent (2-3 years)
Environmental sanitation Stage 4: Proficient (3-5 years)
Stage 5: Expert
Hildegard Peplau
Skills acquisition
Interpersonal process
Psychodynamic theory of Nursing
Joyce Travelbee
Phases of Nurse-patient relationship: Orientation (client seeks
Human to human relationship
), Identification (independence, dependence), Exploitation
(accept service of nurse), and Resolution
Ernestein Weidenbach
Clinical Nursing: A Helping Art
Virginia Henderson
1897-1996
Pender
14 fundamental needs
Health promotion model
Faye Abdellah FILIPINO NURSING THEORISTS
March 13, 1919 Carmencita Abaquin
Typology of 21 Nursing problems Chairman of Board of Nursing
Patient-centered approach PREPARE ME intervention
P – presence which in
Lydia Hall RE – reminisce therapy
Core (therapeutic use of self), Care (nursing function), Cure P - prayer
(medical)
Re - relaxation
Jean Watson
ME - medication
10 Carative factors
Nursing process Sr. Caroline Agravante
The CASAGRA Transformative Leadership model
Ida Jean Orlando-Pelletier
5 C’s for Transformational leadership: creative, caring, critical,
Dynamic nurse-patient relationship contemplative, collegial
Madeleine Leininger Carmelita Divinagracia
Transcultural theory of nursing COMPOSURE Behavior for wellness
COMpetence
Myra Levine Presence of Prayer
4 Principles of Conservation
Open mindedness
Entergy, structural integrity, social integrity, and personal
Stimulation
integrity
Understanding
Respect
Sister Callixta Roy
Relaxation
Adaptation model of Nursing
Empathy
4 mode of adeptatiton
Role function, interdependence, physiological, self concept
Mila Delia Llanes
Dorothea Orem
Conceptual model on Core Competency Development
Self-Care model
Universal self care requirement (nutrition, oxygenation),
Ma. Irma Bustamante
developmental self care requirement (developmental tasks),
The effects of the Nursing Self-Esteem Enhancement (NurSe)
health care deviation self care requirement
Program to the Self-Esteem of Filipino Abused Women
3 Nursing systems: wholly compensatory ,partially
compensatory, supportive-educative compensatory
Sr. Letty Kuan
Retirement and Role Discontinuity
Dorothy Johnson
Behavioral theory of Nursing
T. Fliedner – founder of the first organized school of nursing
Rose Nicolet – helped establish the first school of nursing in the Normal Hall in PNU is used as training ground – same instruction (central
Philippines school idea) for 6 months then go back to hospital
Lilian Wald- founder of Public Health Nursing Act 2493 (1915) – Medical act which included Sec.7 & 8 about nursing
practice which mandated registration and examination
HISTORICAL DEVELOPMENT OF NURSING Act 2808 (1919)
Intuitive - First true nursing law
- Out of love, sickness caused by black spirits, based on instinct - Board of Examiner for Nurses (BEN)
- Shamans, spells, rituals - 1 Doctor and 2 Nurses
- 1920 – First board examination
Trephining – boring a hole into a skull without anesthesia to release evil - Anna Dulgent – first board exam topnotcher
spirits
Egyptians – art of embalming, anatomy and physiology GN Program (Graduate Nurse) – 1 year
Moses – Father of Sanitation, asepsis, art of circumcision After World War II, BSN degree for four years was given by UST (1946).
China – material medica – book of pharmacology Managerial, teaching and supervision position. Equal to Master’s degree
Babylonians – Bill of Rights, Code of Hammurabi (made by King
Hammurabi which include freedom to refuse treatment), medical fee RA 877 – BEN is composed of BSN
India – Shushurutu – list of function of the nurse – combination of 1966 – Master’s degree needed
masseur, caregiver RA 6136 – can administer intravenous meds as long as physician, violaion
Romans – Fabiola – a rich matron who contributed her home to serve as of professional autonomy; did not materialize but instead nurse prepared
first hospital medication and doctor administered until 1992 but it had conflict with
Apprentice the drug administration principle of “administer what you prepare”
- Experienced (through trial and error) nurse teaches new 1960s – 5-year curriculum
volunteer nurses who usually came from religious orders 1976 – 4-year curriculum; GN program was phased out, practicing GNs
- Nursing the sick and wounded from the wars must go back to 4th year to earn a BSN degree but they won’t take board
- Charles Dickens – novel “Martin Chuzzlewit” about Sairy Gump exam anymore since they are already licensed
and Betsy Prag (exemplification of nurses in the Dark Period of 1980 – overlapping of 4 and 5 year curriculum graduates
Nursing) RA 7164 (1992) – IV training for nurses by ANSAP, signed by Cory
- Pastor Theodore Fliedner (Protestant) – first training school Aquino, valid only after 2 months
for Nursing, “Deaconess School of Nursing”, 6 months program RA 9173 (2002) – New Nurse Practice Act
at Kaiserswerth,Germany
Labor laws least likely affect supply and demand for nurses abroad
Educated RECEIPIENT OF CARE
Florence Nightingale Concept of Man
- First theory author, first nurse-researcher - Biological
- Lady with a Lamp/ Mother of Modern Nursing o Anatomy
- 3 months of study from Kaiserswerth - Emotional/Psychological
- Developed her own training “Nightingales System of Nursing o Id, Ego, Superego
Education” which is implemented in St. Thomas Hospital in - Socio-Cultural
London o Norms and practices
- Correlate theory and practice, updates, continuing education, - Spiritual
research, self supporting nursing school (separate from
hospital) Holism – consider the multi-factorial nature of man
- Changed image of nursing, revolutionized practice Maslow’s Hierarchy of Needs
- Professionalized as a nursing - Physiological, safety and security, love and belongingness, self-
- Notes of Nursing: What it is, What it is not, Notes on Hospitals esteem, self-actualization
- Ranked according to how critical need is to survival
Nursing as a profession is not as old as mankind but nursing as an act
itself is. Richard Kelish
Contemporary - Emphasized stimulation needs after physiological needs before
- Modern nursing practice safety and security
- Sex, exploration, manipulation
Anastacia Giron-Tupas Calling the name of the patient – self esteem need
- grand lady of Philipine Nursing Suctioning of baby’s mouth – physiologic
- Founded PNA Fulfillment – self-actualization
Needs are interrelated and must all be met
Hilaria Aguinaldo – development of Red Cross Satisfy one need and satisfy others
Loreto Tupas – Florence Nightingale of Iloilo All needs have a stimulus; universal; and can be deferred/delayed to a
Melchora Aquino – Tandang Sora certain extent
Sex is important to the survival of the race, not the person.
History of Nursing in the Philippines
Pre-Spanish SAMPLE QUESTIONS
- Spaniards colonized the Philippines 1. Mans energy is limitless – FALSE
2. As a psychosocial organism, man is like all other men – FALSE
First hospital – Hospital de Real de Manila (1577) 3. The intellect allows man to choose what he likes or longs to do
1578 – San Lazaro Hospital, Intramuros – leprosy and mental illness – FALSE, Will allows you to choose
Hospital de San Gabriel – Chinese General Hospital
Aliping sagigilid and aliping namamahay – first volunteer nurses who HEALTH, DISEASE, AND ILLNESS
served as apprentice in the first hospitals
1878 – Escuela de Practicantes (UST) – first school for Nursing (short- Health – complete and optimum wellbeing and not only the absence of
lived) disease or infirmity; a process
1906 – Iloilo Mission Hospital School for Nursing – 6 months training, no
board exam (NON-EXISTENT) Models of Health
Mission Hospital (1901) – still existent Judith Smith
1907 – PGH Hospital, St. Lukes Hospital, St. Paul Hospital Clinical Model
- Absence of signs and symptoms of disease
- Narrowest Body adapts to the changes in the environment which leads to
Homeostasis (Walter B. Cannon)
Role Performance Model Cloud Bernard - called homeostasis as “therapeutic milieu”
- Able to perform job Adaptation - change to maintain integrity of the environment
Modes of Adaptation
Adaptive Model - Biogical/Physiological – homeostatic mechanism
- Capable of adjusting - Emotional/Psychological
- Although there is infirmity, he is able to find ways to cope - Socio-cultural
- Technological
Eudaemonistic Model
- Maximization of potential and mission in life Principles of Homeostatic Mechanisms
- Fulfillment of his purpose in life - Automatic, self-regulatory
- Compensatory
Levell and Clark - Negative feedback except for uterine contraction during labor
Ecologic Model of Health - Has limits
- Epidemiological triad –agent, host, environment
- Any of these triad must be manipulated or enhanced to One physiologic error is corrected by several homeostatic mechanisms
maintain health STRESS RESPONSE
Lazarus’ Stress Response Theory
Multiple Causation Theory of Disease General Adaptation Syndrome (GAS) - a physiological response is a
- health is affected by different factors in the environment systemic response
Local Adaptation Syndrome (LAS) - Only a part of the body
Rosenstock Bekker’ s Health Belief Model GAS Stages
- Individual perception affect modifying factors which may Alarm
influence likelihood of action - Awareness of stressor
- Increase in vital signs
Travis’Illness-Wellness Continuum - Mobilization of defense
Health is in a spectrum which moves into polarity of directions - Decreased body resistance
Dunn’s High Level Wellness Grid - Increased hormone level
- health axis “Favorable/Unfavorable environment” Resistance
- Repel of stressor; overcome
Quadrants: - Adaptation
- High level wellness in a favorable environment - Normalization of hormone levels and vital signs
- Emergent high levels in Level Wellness in an unfavorable - Increase in body resistance
environment - Going back to pre-stress state
- Poor Health in an Unfavorable Environment Exhaustion
- Poor health in a favorable environment - Unable to overcome stressor
- - Decreased energy level
- Breakdown in feedback mechanism
Disease – defect/abnormality/dysfunction in structure and function - Organ/tissue damage; decreased physiological
(physically) function
Illness – broad; may involve issues other than physical - Exaggeration of
“I have the disease but not ill” – TRUE
“I am ill but I have no disease” (schizophrenia, etc) – TRUE General Adaptation Response
Socio-cultural illnesses – manana culture, Sympathoadreno-medullary Response (SAMR)
Spiritually ill – not following the church, not going to mass - activation of sympathetic system which stimulated adrenal
medulla
Schumann’s Stages of Illness Behaviors - Release of epinephrine and norepinephrine ---- > inc.
1. Symptom experience physiological activities
2. Assumption of sick role - Sympathetic stimulation (inc. HR, RR, BP, visual perception,
3. Medical care contact metabolism – glycogenolysis in liver, dec. GI, GU)
4. Dependent client role - Propanolol (Inderal) – bronchoconstriction
5. Convalescence/ Rehabilitation
Adrenocortical Response
Opposite of health is illness, not disease Anterior pituitary gland Adreno corticotropic hormone adrenal
STRESS cortex
- Response Based Model - Physiological involved (1) release of aldosterone kidneys increase Na reabsorption
- Transaction-based Model - Cognitive, psychological (2) release of cortisol fats & CHON catabolism glucose
- Stimulus Based Model – live events/ change
- Adaptation Model – anxiety provoking stimulus Neurohypophyseal Response
Posterior pituitary gland release
CRISIS (1) Antidiuretic hormone kidneys inc. Na, H2O reabsorption
- disequilibrium, not merely psychological but physiologic as dec. urine output, inc. blood volume, inc. BP
well (shock) (2) Inc. oxytocin (aids in ejaculation/sperm motility) uterine
- spontaneous resolution is 6 weeks contraction
- grieving process: 4 years
Methods to decrease stress:
Stressor - Progressive relaxation – muscle tension
- Internal/ intrinsic - Benzon relaxation method – dimming the light, music
- External - Yoga, meditation
- Developmental/ Maturational - Ventilation of feelings
- Situational
Local Adaptation Syndrome
Eustress – helpful stress Inflammatory Response
Distress – harmful to health All infections cause an inflammatory response
Not all tissue damage results to inflammation
Inflammation can heal spontaneously as long as the body can manage Risk for/ Potential for
Wellness - readiness and enhancement/ achieve higher level of
I. Vascular Stage functioning
(1) vasoconstriction which limits injury and contain damage Syndrome – “syndrome”
(transient) Possible – vague/ unclear – possible/probable
(2) Release of chemical mediators – kinins
a. Bradykinin – most potent vasodilator/ universal Prioritization of Nursing Diagnosis
pain stimulus, inc. chemical activity warmth Airway,breathing, circulation
(calor), redness (rubor)
b. Prostaglandin PLANNING
(3) Capillary permeability swelling (tumor), pain (dulor), Short Range
temporary loss of function (function laesa)
Long Range
II. Cellular Stage
*Must be SMART (Specific, Measurable, Attainable, Realistic, Time
(1) Neutrophils – bands and segmenters in differential count; first
bound)
one to arrive. If elevated, it suggests acute infection
Classify as dependent, interdependent, collaborative
(2) Lymphocytes, Monocytes, or Macrophages – suggests chronic
IMPLEMENTATION
infection.
Reassess if the patient still needs intervention
(3) Eosinophils – allergy
Determine if you need assistance
(4) Basophils - healing
Carry out intervention, ensure that we have background
III. Exudating Document
Types of Exudate
Serous – plasma - waterry EVALUATION
Sanguinous/hemorrages – blood Process - nurse
Serosaguinous - pink Structure - system
Pus – purulent/ suppurative Outcome – patient
Catarrhal - mucin
Fibrin fibers - fibrinous DOCUMENTATION OR CHARTING
STAT – now
Ad lib – as desired
IV. Reparative
PRN –as required
Phagocytosis – ingestion of foreign substances
OD – right eye/ once a day
Macrophages Monocytes
OS – left eye
Chemotaxis – movement of substances to a chemical signal
OU – both
Healing methods:
AD – right ear
Cold compress for first hours then warm compress after
AS – left ear
Nutrition and fluid intake AU – both ears
Ss – half
NURSING PROCESS ERROR: draw a straight line, signature, initials
A – Assessment
D - Diagnosis Types of Documentation
P – Planning 1. Source Oriented Recording – narrative account by nurse
I - Implementation 2. Problem Oriented Recording (POR) – problems ranked
E – Evaluation according to priority by the health care team, date dissolved,
An overlapping of process can be noted since it is cyclic progress notes, problem list
ASSESSMENT a. FDAR – Focus, Data, Action, Response (patient)
Data Collection – first step in assessment b. SOAPIER – subjective, objective, assessment,
Primary/ Secondary planning, implementation, evaluation, revision
Object (over)/ Subjective (covert) 3. Computer Assisted Recording – problem with privacy
4. Flow Chart
Methods of Gathering Data 5. Charting by Exception (CBE) – only significant change is
Interview documented
therapeutic and non communication
Health history Case Management done with a Critical Pathway
o Medical history – disease focused (physiological) Variance
o Nursing history – needs, psychosocial dimension, - Comprehensive and make sure that it won’t legally be implicated
spiritual aspects
PHYSICAL EXAM (Plan Order)
Observation - Cephalocaudal
Use of senses to gather data o Inspect, palpation percussion, auscultation
Clinical eye – comes with practice and experience o Inspection, auscultation, percussion, and palpation
sequence on abdomen to prevent stimulation of
Examination peristalsis and for the patient to follow a more
Inspection, Palpation, Percussion, Auscultation comfortable to least comfortable examination
After data collection, synthesis, analysis and validation are performed Focused Assessment – on specific part/symptom
DIAGNOSIS*
Problem + etiology +defining symptoms Bruit – normal if with AV fistula, abnormal in other since it may signify
*Guided by the NANDA arterial occlusion
Knowledge deficit – kulang sa kaisipan
Knowledge deficiency – ku SMARlang sa kaalaman (preferred) Auscultate the scrotum in inguinal hernia since it may have bowel sounds
Self care deficit - acceptable
Types of Nursing Diagnosis Compare each body part to the other
Actual
POSITIONING - Flat – bones, muscles
- Sitting - Tympany - abdoment
- High Fowlers (90%) - Resonant - lungs
- Orthopneic position (leaning on a table, hands extended) - Hyperresonance – abnormal (emphysema)
- Supine, Back Lying, Dorsal, Horizontal Recumbent
- Flat on Bed – no pillow Typanism – kabag
- Dorsal Recumbent – legs flexed to relax abdominal muscles,
abdominal palpation/ exam – followed by diagonal draping DTR - +2: NORMAL, above it hyper resonant, below it is hyporesonant
- Standing/Errect – curvature of the spine
- Prone/ Face-lying position Parts of the Stethoscope
- Sim’s Position, Left lateral, Side-lying – rectal exam, suppository Diaphragm – high pitched; lung sounds
insertion, enema administration Bell – low pitched; heart sounds
- Knee Chest position/ Geno-pectoral position/ Jack Knife position
– rectal exam, dysmenorrhea Adventitious breath sounds – no abnormal sounds
- Kraaske – inverted V
- Lithototomy – stirrups Respiratory Sounds
- Trendelenburg – foot up; head down Wheezing – narrowed airway; asthma, bronchitis
- Reverse trendelenburg – head up, foot down Crackles – rubbing hair in small airways; retained secretions;
- Modified trendelenburg – only leg up for shock: L Girgles (Rhonchi)- rubbing hair in wide airway
Stridor – noisy breathing
MCNAP – training to perform internal examination Stertor – laryngeal spasm
Factors that affect Body Temperature Corrigan pulse/ Waterhammer pulse –thready and with full expansion
1. Age followed by sudden collapse
2. Ovulation – temp is higher; progesterone
3. Activity – inc. BMR
4. Environment Respiration
Kinds:
Temperature conversion Internal
C-F multiply 1.8 + 32 External
F-C subtract 32/ 1.8
Normal: 16-20
Methods of taking body temperature
- Oral – CI in brain damage, mental illness, retarded, problem Eupnea – normal breathing
with nose and mouth, tooth extraction, contraption in nose and Bradypnea
mouth, altered LOC, dyspnea, seizures, 7 y/o below Tachypnea/Polypnea
o 2 mins Dyspnea
- Rectal – CI in imperforate anus, rectal polyps, hirschprung’s
disease, diarrhea, increase ICP, cardiac disease (may cause Katupnea - Difficulty of breathing while in sitting position
vagal stimulation) Trepopnea - ease when in side-lying position
o Not safe since it can cause rectal trauma Hyperpnea – inc. rate and depth of respiration
o 1 min Cheyne-stokes
- Axillary – 3mins Biot’s respiration –
- Tympanic – external ear. CI in otitis, ear surgery Kausmaul’s Breathing – hyperventilation, blow off excess CO2 which may
- Temporal Scanner - done in temporal lead to alkalosis
Heat Stroke – depletion of fluid, hypothalamus does not regulate Classification SBP DBP Lifestyle
Hypothermia – induced (surgery), extreme temperature mmHg mmHg Modification
EXTRA-ORAL FEEDING Constipation – hard stools; laxative; Psilium (bulk-formers), Castor oil (GI
- NGT/ Levine’s Tube irritant)
o French 12-18 (bigger)
o Endoscopic intubation Tenesmus – urge to but unproductive of stool
o Measure length
o Gavage/lavage Fecal impaction
o Drain by gravity; decompression - constipation and seepage of watery stools
Monitor for F&E imbalance - No enema
o Diagnostic procedure - Digital/Manual extraction with doctor’s order
- Monitor for vagal stimulation; stop if signs are noted
Check patency and position of NGT
- Aspirate gastric content Eructation/ Belching
- Place in water - Expulsion of gases through mouth
- Auscultate for gurgling sounds
- X-ray (1st) Flatulence/Typanism
- pH method (2nd) – pH of 6 and below, give feeding - Avoid gas forming foods: cauliflower, cola
- - Carminative enema – expel flatus
Withhold feeding if more than 100ml residue - Rectal tube insertion – inserted in anus then placed in water
for 20 mins; if need to be repeated wait for 2-3 mins. to
French is directly proportional to size prevent anal sphincter damage
Gauge is inversely proportional to size
Immobility
- Thrombus formation
- Edema
- Constipation
- Urinary stasis – stones- calculi