Narrative Report On Second Sem Syllabus
Narrative Report On Second Sem Syllabus
Narrative Report On Second Sem Syllabus
INTERVENTION
Nursing Intervention Classification
Types: Independent, Dependent, and Interdependent
Health Education
A. Procedures Basic to Nursing Care
1. Asepsis and Infection Control
2. Safety, security, and emergency
3. Complementary and alternative therapies
4. Medication
B. Nursing Interventions to Promote Healthy Physiologic Responses
1. Hygiene
2. Skin integrity
3. Mobility
4. Rest and Sleep
5. Pain Management
6. Nutrition
7. Urinary elimination
8. Bowel elimination
9. Oxygenation
10. Fluid Electrolyte and Acid Base Balance
C. Nursing Interventions to Promote Healthy Psychosocial Responses
1. Self-concept
2. Stress and Adaptation
3. Loss, Grief and Dying
4. Sensory Functioning
5. Sexuality and Gender
6. Spirituality
II. EVALUATION
Types: Planned, On-going, and Purposeful
A. Documentations and Reporting
1. Guidelines/Protocols/Tools in documentations related to client care
2. Subjective Information, Assessment, Plan, Implement and Evaluate (SOAPIE)
3. Focus, Data, Action, Response (FDAR)
4. Electronic Health Record (EHR)
5. Problem-Oriented Medical Record
B. Guidelines/Protocols/Tools in Reporting Related to Client Care
1. Identity, Situation, Background, Assessment, Recommendation, Read Back (ISBARR)
2. Change of Shift Report
3. Incident Report
4. Referral System
5. Health Care Electronic Databases
III. EVIDENCE-BASED PRACTICE IN NURSING
A. Research Related Roles and Responsibilities
IV. CONCEPTS AND PRINCIPLES OF PARTNERSHIP, COLLABORATION, AND TEAMWORK
A. Development of Teamwork and Collaboration
B. Tools for facilitating Teamwork
C. Roles of the Nurse
V. CONCEPTS OF LEADERSHIP AND MANAGEMENT
A. Role of the Nurse as Leader/Manager
B. Positive Practice Environment
VI. CONCEPTS OF CONTINUING PROFESSIONAL DEVELOPMENT
A. Life-long learning
B. Career Path/Development Map
VII. FILIPINO CULTURE, VALUES AND PRACTICES IN RELATION TO HEALTH CARE
VIII. ETHICO-MORAL AND LEGAL CONSIDERATIONS IN THE PRACTICE OF NURSING
A. Phil. Nursing Law of 2012: RA 9173 Art of IV, Sec 28: Scope of Nursing Practice
B. National Nursing Core Competency Standards
C. Patient’s Bill of Rights
D. Informed Consent
E. Data Privacy Law
F. Code of Ethics for Nurses
Philippine Professional Nursing Roadmap
INTERVENTION
Nursing interventions are identified and written during the planning step of the nursing
process; however, they are actually performed during the implementation phase. A taxonomy of
nursing interventions referred to as the Nursing Interventions Classification (NIC) taxonomy,
developed by the Iowa Intervention Project, was first published in 1992 with three levels that includes:
level 1, domains; level 2, classes; and level 3, interventions.
Domains Classes
Domain 1 Physiological: Basic A. Activity and Exercise Management: Interventions to
Care that supports physical organize or assist with physical activity and energy
functioning conservation and expenditure
B. Elimination Management: Interventions to establish and
maintain regular bowel and urinary elimination patterns and
manage complications due to altered patterns
C. Immobility Management: Interventions to manage
restricted body movement and the sequelae
D. Nutrition Support: Interventions to modify or maintain
nutritional status
E. Physical Comfort Promotion: Interventions to promote
comfort using physical techniques
F. Self-Care Facilitation: Interventions to provide or assist
with routine activities of daily living
Domain 2 Physiological: Complex G. Electrolyte and Acid-Base Management: Interventions
Care that supports homeostatic to regulate electrolyte/acid-base balance and prevent
regulation complications
H. Drug Management: Interventions to facilitate desired
effects of pharmacological agents
I. Neurologic Management: Interventions to optimize
neurologic functions
J. Perioperative Care: Interventions to provide care before,
during, and immediately after surgery
K. Respiratory Management: Interventions to promote
airway patency and gas exchange
L. Skin/Wound Management: Interventions to maintain or
restore tissue integrity
M. Thermoregulation: Interventions to maintain body
temperature within a normal range
N. Tissue Perfusion Management: Interventions to optimize
circulation of blood and fluids to the tissue
Domain 3 Behavioral O. Behavior Therapy: Interventions to reinforce or promote
Care that supports psyschosocial desirable behaviors or alter undesirable behaviors
functioning and facilitates lifestyle P. Cognitive Therapy: Interventions to reinforce or promote
changes desirable cognitive functioning or alter undesirable cognitive
functioning
Q. Communication Enhancement: Interventions to facilitate
delivering and receiving verbal and nonverbal messages
R. Coping Resistance: Interventions to assist another to
build on own strengths, to adapt to a change in function, or to
achieve a higher level of function
S. Patient Education: Interventions to facilitate learning
T. Psychological Comfort Promotion: Interventions to
promote comforts using psychological techniques
Domain 4 Safety U. Crisis Management: Interventions to provide immediate
Care that supports protection against short-term help in both psychological and physiological crisis
harm V. Risk Management: Interventions to initiate risk-reduction
activities and continue monitoring risks over time
Domain 5 Family W. Childbearing Care: Interventions to assist in
Care supports the family unit understanding and coping with the psychological and
physiological changes during the childbearing period
Z. Childbearing Care: Interventions to assist in child rearing
X. Lifespan Care: Interventions to facilitate family unit
functioning and promote and health and welfare of the family
members throughout the lifespan
Domain 6 Health System Y. Health System Mediation: Interventions to facilitate the
Care that supports effective use of interface between patient/family and the health care system
the health care delivery system Ya. Health System Management: Interventions to provide
and enhance support services for the delivery of care
Domain 7 Community Yb. Information Management: Interventions to facilitate
Care that supports the health of the communication among health care providers
community Yc. Community Health Promotion: Interventions that
promote the health of the whole community
Yd. Community Risk Management: Interventions that assist
in detecting or preventing health risks to the whole community
Health Education
Health education involves giving information and teaching individuals and communities how
to achieve better health, a common role within nursing.
HEALTH MAINTENANCE
Health maintenance is a guiding principle in health care that emphasizes health promotion
and disease prevention rather than the management of symptoms and illness. It includes the full
array of counselling, screening, and other preventive services designed to minimize the risk of
premature sickness and death and to assure optimal physical, mental, and emotional health
throughout the natural life cycle.
Health promotion is an important component of nursing practice. It is a way of thinking that
revolves around a philosophy of wholeness, wellness, and well-being.
Disease prevention/health protection as a behavior motivated by a desire to actively avoid
illness, detect it early, or maintains functioning within the constraints of illness.
Levels of Prevention
a. Primary Prevention
Focuses on health promotion and protection against specific health problems
The purpose of primary prevention is to decrease the risk or exposure of the
individual or community to disease.
b. Secondary Prevention
Focuses on early identification of health problem
Prompt intervention to alleviate health problems
Its goal is to identify individuals in an early stage of a disease process and to
limit future disability
c. Tertiary Prevention
Focuses on restoration and rehabilitation with the goal of returning the
individual to an optimal level of functioning.
DIFFERENCES BETWEEN HEALTH PROMOTION AND HEALTH PROTECTION
Health Promotion Disease Prevention/Health Protection
-Not disease oriented -Illness or injury specific
-Motivated by personal, positive “approach” to -Motivated by “avoidance” of illness
wellness
-Seeks to expand positive potential for health -Seeks to prevent the occurrence of insults
to health and well-being
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
PROCEDURES BASIC TO NURSING CARE
Infection is an invasion of body tissue by microorganisms and their growth there. Such
microorganism is called an infectious agent. If the microorganism produces no clinical evidence of
disease, the infection is called asymptomatic or subclinical. A detectable alteration in normal tissue
function is called disease.
CHAIN OF INFECTION
1. Etiologic Agent
Any microorganism that is capable of producing an infectious process.
2. Reservoir
Any sources of microorganisms
Carrier (a person or animal reservoir of specific infectious agent that usually does
not manifest any clinical signs of disease.
3. Portal of Exit from Reservoir
Route where the microorganism must pass through to exit the reservoir
4. Method of Transmission
Microorganisms need a means of transmission to reach another person or host
through a receptive portal of entry.
TYPES OF TRANSMISSION
Direct Transmission
Involves immediate and direct transfer of microorganisms from person to
person through touching, biting, kissing, or sexual intercourse.
Droplet spread is also a form of direct transmission but can only occur if
the source and the host are within 3 feet of each other.
Indirect Transmission
Vehicle-borne Transmission
o A vehicle is any substance that serves as an intermediate means
to transport and introduce an infectious agent into a susceptible
host through a suitable portal of entry.
Vector-borne Transmission
o A vector is an animal or flying or crawling insect that serves as an
intermediate means of transporting the infectious agent.
o May occur by injecting the salivary fluid during biting or by
depositing feces or other materials on the skin.
Airborne Transmission
May involve droplets or fine dust
Droplet nuclei (residue of evaporated droplets emitted by an infected
host.
Dust particles containing the infectious agent can be transmitted by air
currents to a suitable portal of entry.
5. Portal of Entry to the Susceptible Host
Any route suitable for the infectious agent to enter.
Commonly, break in the skin can readily serve as a portal of entry.
Microorganisms can also enter the body of the host by the same route they used to
leave the reservoir.
6. Susceptible Host
Any person who is at risk for infection
Compromised Host (a person at increased risk)
b) Cell-Mediated Defenses
Cellular immunity
Occur in the T-cell system
On exposure to antigen, the lymphoid tissues release large numbers of
activated T-cells into the lymph system.
These T-cells pass into the general circulation
MAIN GROUPS OF T-CELLS:
Helper T-cells
o Help in the function of the immune system
Cytotoxic T-cells
o Attack and kill microorganisms
o Sometimes attack the body’s own cells
Suppressor T-cells
o Suppress the functions of the helper t-cells and the cytotoxic
T-cells
Boiling Water
o Most practical and inexpensive method of sterilizing.
o Spores and some viruses are not killed by this method
Radiation
o Ionization (alpha, beta, x-rays) and Nonionization (UV
light)
PERSONAL PROTECTIVE EQUIPMENT
1. Gloves
They protect the hands when the nurse is likely to handle any body substances.
Reduce the likelihood of nurses transmitting their own endogenous microorganisms to
individuals receiving the care.
Reduce the chance that the nurse’s hands will transmit microorganisms from one
client to another client.
2. Gowns
Worn during procedures when the nurse’s uniform is likely to become soiled.
3. Face Masks
Worn to reduce the risk for transmission of organisms by the droplet contact and
airborne routes, and by splatters of body substances.
4. Eyewear
Worn when there is a possible splatter of body substances and protects the eyes.
References:
Berman, Snyder, Kozier, & Erb. (2008). Kozier & Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
2. Safety, security, and emergency
Nurses need to be aware of what constitutes a safe environment for a particular person or for
a group of people in home and community settings. This is why it has become a fundamental
concern of nurses that extends from the bedside to the home to the community, is prevention of
accidents and injury, as well as assisting the injured.
FACTORS THAT INCREASE THE RISK OF HUMAN ERROR IN A HEALTH CARE SETTING
1. Limited Short-term Memory
Nurses have rapidly changing information coming at them continuously in busy hospital
environments. Systems that rely on human memory are prone to failure.
2. Being late or in a hurry
People start cutting corners when they are late or in a hurry. This may get the work
done quicker; however. it also contributes to the possibility of missing an important detail or
piece of information that could cause client harm.
3. Limited ability to multitask
People perform better at a single task.
4. Interruptions
Many interruptions occur in complex environments such as a hospital. It is more difficult
to get back on task or to remember what you were thinking with frequent interruptions.
5. Stress
Stress causes anxiety, and anxiety affects performance.
6. Fatigue and other physiological factors
Studies show that fatigue affects a person’s ability to process complex information.
7. Environmental factors
Heat, noise, distractions, visual stimuli, and lighting can affect performace and lead to
mistakes.
RESTRAINING CLIENTS
Restraints are protective devices used to limit the physical activity of the client or a part of the
body.
The purpose of restraints is to prevent the client from injuring self or others.
CLASSIFICATION OF RESTRAINTS
1. Physical Restraints
These are manual method or physical or mechanical device, material, or
equipment attached to the client’s body.
They cannot be removed easily and they restrict the client’s movement.
2. Chemical Restraints
These are medications such as neuroleptics, anxiolytics, sedatives, and
psychotropic agents used to control socially disruptive behaviour.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
3. Complementary and alternative therapies
The term alternative medicine or complementary medicine are use to describe as many
as 1,800 other therapies practiced all over the world. Many of these have been handed down over
thousands of years, orally and in written records. They are based on the medical systems of
ancient people.
BOTANICAL HEALING
1. Herbal Medicine
Conventional primary care providers use plant-derived products and even some medicine
are derived from plants.
2. Aromatherapy
It is the therapeutic use of essential oils of plants in which the odor or fragrance plays an
important part.
3. Homeopathy
It is a self-healing system, assisted by small doses of remedies or medicines, which is
useful in a variety of acute and chronic disorders.
4. Naturopathy
Naturopathic medicine is not only a system of medicine but also a way of life.
The goal of the treatment is the restoration of health and normal body function, rather than
the application of a particular therapy.
MIND-BODY THERAPIES
1. Yoga
Yoga has been practiced for thousands of years in India.
For Indians, it is a way of life that includes ethical models for behaviour and mental and
physical exercises aimed at producing spiritual enlightenment.
2. Meditation
Relaxing the body and easing the mind.
It is a process that anyone can use to calm themselves, cope with stress, and, for those
with spiritual inclinations, feel as one with God or the universe.
3. Hypnotherapy
It is the application of hypnosis in a wide variety of medical and psychological disorders.
Hypnosis is a trance state or an altered state of consciousness in which an individual’s
concentration is focused and distraction is minimized.
It can be used to help people gain self-control, improve self-esteem, and become more
autonomous.
4. Guided Imagery
Guided Imagery is a state of focused attention that encourages changes in attitudes,
behaviour, and physiologic reactions.
It can help stop troublesome thoughts and focus on images that help the client relax.
5. Biofeedback
It is a method for learned control of physiologic responses of the body.
It is a relaxation technique that uses electronic equipment to amplify the electrochemical
energy produced by body responses.
6. Qigong and T’ai Chi
Qigong is a Chinese discipline consisting of breathing and mental exercises combined with
body movements.
T’ai Chi, which arose form Qigong, is a discipline that combines physical fitness,
meditation, and self-defense.
Both disciplines consist of soft, slow, continuous movements that are circular in nature. The
slowness of movements requires attentive control that quiets the mind an develops one’s
powers of awareness and concentration.
7. Pilates
It is a method of physical movement and exercise designed to stretch, strengthen, and
balance the body, in particular the core or center including the abdominal region.
SPIRITUAL HEALING
1. Faith and Prayer
Faith refers to our beliefs and expectations about life, ourselves, and others. It refers to a
belief in a Supreme Being who listens and responds to people and cares about their well-
being.
Prayer is most often defined simply as a form of communication and fellowship with the
Deity or Creator.
MISCELLANEOUS THERAPIES
1. Music Therapy
Music is often used in healing, from the ancient sounds of the drum, rattle, bone flute, and
other primitive instruments to the use of current music as a prescription for health.
Often used to relax and distract clients in operative settings, ICU, birthing rooms,
rehabilitation and physical therapy units, and sleep induction units.
2. Humor and Laughter
In Nursing, it helps the client to perceive, appreciate, and express what is funny, amusing,
or ludicrous in order to establish relationships, relieve tension, release anger, facilitate
learning, or cope with painful endings.
3. Bioelectromagnetics
Magnets are used to relieve joint pain and headaches, to speed up healing of wounds by
increasing blood flow, and to improve bone repair.
4. Infrared Photoenergy Therapy
It is a safe and effective treatment to improve sensory impairment associated with
peripheral neuropathy.
It is believed that the treatment works by increasing energy inside cells and improving
blood circulation.
5. Detoxifying Therapy
Belief that physical impurities and toxins must be cleared from the body to achieve better
health.
1. Hydrotherapy (the use of water as a healing treatment)
2. Colonics (procedure for washing the inner wall of the colon by filling it with water or
herbal solutions and then draining it)
3. Chelation Therapy (introduction of chemicals into the bloodstream that bind with
heavy metals in the body)
6. Animal-Assisted Therapy
The use of specifically selected animals as a treatment modality in health and human
service settings.
7. Horticultural Therapy
Healing garden
It is an adjunct therapy to occupational and physical therapy.
It stimulates the five senses, provides leisure activities, improves motor function, provides
sense of achievement, and improves self-esteem.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
4. Medication
PARENTERAL MEDICATIONS
Parenteral administration of medications is commonly done because some medications like
intradermal (ID), subcutaneously, intramuscularly (IM), or intravenously (IV) are absorbed more
quickly than oral medications and are irretrievable once injected.
*EQUIPMENT NEEDED
Syringes
Have three parts: the tip, which connects with the needle; the barrel, which the
scales are printed; the plunger, which fits inside the barrel.
KINDS OF SYRINGES
1) Hypodermic Syringe
2) Insulin Syringe
3) Tuberculin Syringe
Needles
These are made of stainless steel, and most are disposable
Has three discernible parts: the hub, which fits onto the syringe; the cannula or
shaft, which is attached to the hub; the bevel, which is the slanted part at the tip
of the needle.
Ampules and Vials
An ampule is a glass container usually designed to hold a single dose of a drug
and has distinctive shape with a constricted neck.
A vial is a small glass bottle with a sealed rubber cap.
1. Intradermal Injections
It is the administration of a drug into the dermal layer of the skin just beneath the epidermis.
This method of administration is frequently used for allergy testing and tuberculosis
screening.
Common sites: inner lower arm, upper chest, back beneath the scapulae
2. Subcutaneous Injections
Usually for vaccines, insulin, and heparin.
Common sites: outer aspect of the upper arms and the anterior aspect of the thighs.
3. Intramuscular Injections
Injections into the muscle tissue are absorbed more quickly than subcutaneous injections
because of the greater blood supply to the body muscles.
Ventrogluteal Site
Vastus Lateralis Site
Dorsogluteal Site
Deltoid Site
Rectus Femoris Site
4. Intravenous Medications
This is appropriate because it enters the client’s bloodstream directly via veins and has a
rapid effect.
This is also done when medications are too irritating to tissues to be given by other routes.
Large-volume infusion of IV fluid
Intermittent IV infusion
Volume-controlled infusion
IV push or bolus
Intermittent injection ports
TOPICAL MEDICATIONS
A topical medication is applied locally to the skin or to mucous membranes in areas such as
the eye, external ear canal, nose, vagina, and rectum. Most topical medications used therapeutically
are not absorbed well, completely, or predictably when applied to intact skin.
A particular type of topical or dermatologic medication delivery system is the transdermal
patch. This system administers sustained-action medications via multi-layered films containing the
drug and an adhesive layer.
1. Skin Applications
Include ointments, pastes, creams, lotions, powders, sprays, and patches.
2. Ophthalmic Medications
Medications may be administered to the eye using irrigations or instillations.
Eye irrigation is administered to wash out the conjunctival sac to remove secretions or
foreign bodies or to move chemical that may injure the eye.
3. Otic Medications
Consist of instillations or irrigations of the external auditory canal and are generally
carried out for cleaning purposes.
4. Nasal Medications
Usually instilled for their astringent effect, to loosen secretions and facilitate drainage, or
to treat infections of the nasal cavity or sinuses.
5. Vaginal Medications
This are inserted as creams, jellies, foams, or suppositories to treat or to relieve vaginal
discomfort.
6. Rectal Medications
Rectal medication is a convenient and safe method of giving certain medications.
Advantages include: avoids irritation of the upper gastrointestinal tract, when
medication has an objectionable taste or odor, when the drug is released at a
slow but steady rate, and it provide higher bloodstream levels.
RESPIRATORY INHALATION
Nebulizers deliver most medications administered through the inhaled route. A nebulizer is
used to deliver a fine spray of medication or moisture to a client.
There are two kinds of nebulization: atomization and aerosolization. In atomization, a device
called atomizer produces rather large droplets for inhalations. In aerolosolization, the droplets are
suspended in a gas, such as oxygen.
1. Large-volume Nebulizer
Provides a heated or cool mist that can be used for long-term therapy, such as
tracheostomy.
2. Ultrasonic Nebulizer
Provides 100% humidity and can provide particles small enough to be inhaled deeply
into the respiratory tract.
3. Metered-dose Inhaler (MDI)
A handheld nebulizer which is pressurized container of medication that can be used by
the client to release the medication through a nosepiece or mouthpiece.
IRRIGATIONS
Irrigation is the washing out of a body cavity by a stream of water or fluid that may or may not
be medicated.
To clean the area, that is, to remove a foreign object or excessive secretions or
discharge
To apply heat or cold
To apply a medication such as an antiseptic
To reduce inflammation
To relieve discomfort
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
NURSING INTERVENTIONS TO PROMOTE HEALTHY PHYSIOLOGIC RESPONSES
1) Hygiene
Hygiene is the science of health and its maintenance. Personal hygiene is the self-care by
which people attend to such functions as bathing, toileting, general body hygiene, and grooming.
Hygiene is a highly personal matter determined by individual values and practices.
HYGIENIC CARE
1. Early Morning Care
This is provided to clients as they awaken in the morning.
2. Morning Care
This is often provided after clients have breakfast and sometimes before having
breakfast.
3. Hour of Sleep (HS)/ PM Care
This is provided to clients before they retire for the night.
4. As-needed (prn) Care
This is provided as required by the client.
BATHING
Bathing removes accumulated oil, perspiration, dead skin cells, and some bacteria. Bathing
also stimulates circulation and also produces a sense of well-being. It is refreshing and relaxing and
frequently improves morale, appearance, and self-respect.
CATEGORIES OF BATH
1. Cleaning Baths
Complete bed bath
The nurse washes the entire body of a dependent client in bed.
Self-help bed bath
Clients confined to bed are able to bathe themselves with help from the nurse for
washing the back and perhaps the feet.
Partial bath
Only the parts of the client’s body that might cause discomfort or odor are
cleaned for this type of bath.
Bag Bath
This bath is a commercially prepared product that contains 10 to 12 presoaked
disposable washcloths that contain no-rinse cleanser solution.
Tub Bath
This are often preferred to bed baths because it is easier to wash and rinse in a
tub.
Sponge Bath
This is suggested for the newborn because daily tub baths are not considered
necessary.
Shower
Many ambulatory clients are able to use shower facilities and require only
minimal assistance from the nurse.
2. Therapeutic Baths
These are given for physical effects, such as to soothe irritated skin or to treat an area.
Medications may be placed in the water.
PERINEAL-GENITAL CARE
Perineal-genital care is also referred to as perineal care or pericare. Perineal care as part of
bed bath is embarrassing for many clients and so as nurses, particularly with clients of the opposite
sex. Most clients who require a bed bath from the nurse are able to clean their own genital areas with
minimal assistance.
HAIR CARE
The appearance of the hair often reflects a person’s feelings of self-concept and
sociocultural well-being. Patient's hair can be washed with shampoo and conditioner in the shower,
bathtub and in bed with a special bed tray or dry shampoo. Patients should also be encouraged to
comb or brush their hair a couple of times a day.
ORAL HYGIENE
Oral hygiene is done at least twice a day and more often as needed. Oral hygiene consists
of brushing the teeth, flossing the teeth, and rinsing the mouth. Partial and full dentures are also
brushed and rinsed.
NAIL CARE
Client nail care is another important area of hygiene and client's nails need to be checked
daily, to observe them for any irregularities. To provide care the nurse needs a nail cutter or sharp
scissors, a nail file, an orange stick to push back the cuticle, hand lotion or mineral oil to lubricate any
dry tissue around the nails and a basin of water to soak the nails if they are particularly thick and
hard.
FOOT CARE
Feet are washed with the bath and more often as needed. Diabetics and other patients at
risk for infections should get special foot and toenail care and monitoring. For example, the feet must
be completely cleaned and dried and examined daily for any signs of skin breakdown, corns,
bleeding, broken, chipped or absent nails, as well as blue or pale nail beds.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
2) Skin Integrity
Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds. The
appearance of the skin and skin integrity are influenced by internal factors such as genetics, age,
and the underlying health of the individual as well as external factors such as activity.
TYPES OF WOUNDS
1. Intentional Wounds
This occurs during therapy.
2. Unintentional Wounds
A person may fracture an arm in an automobile collision.
DEGREE OF WOUND CONTAMINATION
1. Clean Wounds
These are uninfected wounds in which minimal inflammation is encountered and the
respiratory, alimentary, genital, and urinary tracts are not entered.
2. Clean-contaminated Wounds
These are surgical wounds in which the respiratory, alimentary, genital, or urinary tract
has been entered.
3. Contaminated Wounds
These include open, fresh, accidental, wounds involving a major break in sterile
technique or a large amount of spillage from the gastrointestinal tract.
4. Dirty or infected Wounds
These include wounds containing dead tissue and wounds with evidence of a clinical
infection, such as purulent drainage.
WOUND HEALING
This is also referred to as regeneration of tissues. Healing can be considered in terms of
types of healing, having to do with the caregiver’s decision on whether to allow the wound to seal
itself or to purposefully close the wound, and phases of healing, which refer to the steps in the body’s
natural processes of tissue repair.
TYPES OF WOUND HEALING
1. Primary Intention Healing
Occurs where the tissue surfaces have been approximated and there is minimal or no
tissue loss.
Characterized by the formation of minimal granulation tissue and scarring.
2. Secondary Intention Healing
A wound that is extensive and involves considerable tissue loss, and in which the
edges cannot or should not be approximated.
Secondary intention healing differs from the primary one because its repair time is
longer, the scarring is greater, and the susceptibility to infection is greater.
1. Bandages
These are strips of cloth used to wrap some part of the body. There are many types of
materials used for bandages. Gauze is one of the most commonly used because it is light,
porous and inexpensive which it can be used to retain dressings on wounds and to bandage
the fingers, hands, toes, and feet. Elasticized bandages are applied to provide pressure to an
area.
*Basic Turns for Roller Bandages
Circular Turns
Spiral Turns
Spiral Reverse Turns
Recurrent Turns
Figure-Eight Turns
2. Binders
A binder is a type of bandage designed for a specific body part. This is used to support
large areas of the body and is simple to use, inexpensive and customizable using plain
material.
Triangular Arm Sling
Straight Abdominal Binder
Securing Peritoneal Dressing
PRESSURE ULCERS
A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to
underlying tissue. Pressure ulcers are a problem in both acute care settings and long-term care
settings, including homes.
NURSING INTERVENTIONS
Supporting Wound Healing
Preventing Pressure Ulcers
Treating Pressure Ulcers
Dressing Wounds
Cleaning Wounds
Supporting and Immobilizing Wounds
Heat and Cold Applications
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
3) Mobility
Mobility is the ability to move freely, easily, rhythmically, and purposefully in the environment.
People often define their health and physical fitness by their activity because mental well-being
and the effectiveness of body functioning depend largely on their mobility status, The ability to
move without pain also influences self-esteem and body image, thus, creating a sense of
independence on individuals.
ELEMENTS OF A BODY MOVEMENT
1. Alignment and Posture
Proper body alignment and posture bring the body parts into position in a manner that
promotes optimal balance and maximal body function whether the person is standing, sitting,
or lying down.
2. Joint Mobility
Joints are the functional units of the musculoskeletal system and are responsible for
movements such as bending of knees and lifting of arms.
3. Balance
This mechanisms involved in maintain balance and posture are complex and involve
informational inputs from the inner ear, vision, and receptors of muscles and tendons.
4. Coordinated Movement
Balanced, smooth, purposeful movement is the result of proper functioning of the
cerebral cortex, cerebellum, and basal ganglia.
FACTORS AFFECTING BODY ALIGNMENT AND ACTIVITY
Growth and Development
Nutrition
Personal Values and Attitudes
External Factors
Prescribed Limitations
EFFECTS OF IMMOBILITY
Musculoskeletal System
Disuse Osteoporosis
Disuse Atrophy
Contractures
Stiffness and pain in the joints
Cardiovascular System
Diminished cardiac reserve
Increased use of the Valsalva maneuver
Orthostatic hypotension
Venous vasodilation and stasis
Dependent edema
Thrombus Formation
Respiratory System
Decreased respiratory movement
Pooling of respiratory secretions
Atelectasis
Hypostatic pneumonia
Metabolic System
Decreased Metabolic Rate
Negative Nitrogen balance
Anorexia
Negative calcium balance
Urinary System
Urinary stasis
Renal calculi
Urinary retention
Urinary infection
Gastrointestinal System
Decreased peristalsis and colon motility
Integumentary System
Reduced Skin turgor
Skin breakdown
Psychoneurologic System
Low self-esteem
EXERCISE
Physical activity is bodily movement produced by skeletal muscle contraction that increases
energy expenditure. Exercise is a type of physical activity defined as a planned, structured, and
repetitive bodily movement performed to improve or maintain one or more components of physical
fitness.
TYPES OF EXERCISES
1. Isotonic Exercises- are those in which the muscle shortens to produce muscle contraction
and active movement.
2. Isometric Exercises- are those in which there is muscle contraction without moving the joint.
3. Isokinetic Exercises- involve muscle contraction or tension against resistance.
4. Aerobic Exercises- are those during which the amount of oxygen taken in the body is greater
than that used to perform the activity.
5. Anaerobic Exercises- involves activities in which the muscles cannot draw out enough
oxygen from the bloodstream, and anaerobic pathways are used to provide additional energy
for a short time.
BENEFITS OF EXERCISE
Musculoskeletal System
Size, shape, and tone of muscles are maintained
Bone density and strength are maintained
Increases joint flexibility, stability and ROM
Cardiovascular System
Increased cardiac output
Prevents stroke and cardiovascular diseases
Improved oxygen uptake
Improved circulation
Respiratory System
Improving gas exchange
Elimination of toxins with deeper breathing
Prevents pooling of secretions in the bronchi and bronchioles
Enhances oxygenation and circulation
Metabolic System
Stabilizes blood sugar
Increases the use of triglycerides
Increases the production of body heat and waste products and calorie use
Urinary System
Promotes efficient blood flow
Gastrointestinal System
Improves appetite
Increases GI tract tone and facilitating peristalsis
Relieves constipation
Psychoneurologic System
Elevating mood and relieving stress
NURSING INTERVENTIONS
Using Body Mechanics
Preventing Back Injury
Positioning Clients
Moving and Turning Clients in Bed
Transferring Clients
Using a Hydraulic Lift
Providing ROM Exercises
Ambulating Clients
Using Mechanical Aids for Walking
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
TYPES OF SLEEP
1. NREM Sleep (Non-rapid-eye-movement)
NREM sleep occurs when activity in the reticular activating system (RAS) is inhibited and
about 75% to 80% of sleep during the night is NREM.
Stage I is the stage of very light sleep and lasts only a few minutes. During this stage the
person feels drowsy and relaxed, eyes roll from side to side, and respiratory and heart
rates slightly drop.
Stage II is the stage of light sleep during which the body processes continue to slow down.
The eyes are still, the heart and respiratory rates decrease slightly, and body temperature
falls. This lasts for 10 to 15 minutes but constituents to 40% to 55% of total sleep.
Stage III and IV are the deepest stages of sleep, differing only in the percentage of delta
waves recorded during a 30 second period. The heart and respiratory rates drop 20% to
30% below those exhibiting during waking hours. The sleeper is difficult to arouse and not
disturbed by sensory stimuli, skeletal muscles are very relaxed, reflexes are diminished,
and snoring is most likely to occur.
Physiologic Changes during NREM Sleep
Arterial blood pressure falls
Pulse rate decreases
Peripheral blood vessels dilate
Cardiac Output decreases
Skeletal muscles relax
Basal metabolic rate decreases 10 % to 30%
Growth hormone levels peak
Intracranial pressure decreases
2. REM Sleep (Rapid-eye-movement)
REM sleep usually recurs about every 90 minutes and lasts 5 to 30 minutes.
Most dreams take place during REM sleep but usually will not be remembered unless the
person arouses briefly at the end of the REM period.
During REM sleep, the brain is highly active, and brain metabolism may increase as much
as 20%
Distinctive eye movement occur, voluntary muscle tone is dramatically decreased, and
deep tendon reflexes are absent.
In this phase, sleeper may be difficult to arouse or may wake spontaneously.
Gastric secretions increase, and heart and respiratory rates often are irregular.
FUNCTIONS OF SLEEP
Restores normal levels of activity
Normal balance among parts of the nervous system
Necessary for protein synthesis
5) Pain Management
Pain is an unpleasant and highly personal experience that may be imperceptible to other,
while consuming all parts of the person’s life. Pain, by definition, “is an unpleasant sensory and
emotional experience associated with actual or potential tissue damage, or described in terms of
such damage”.
TERMS DESCRIBING THE TYPES OF PAIN
Location
Classification of pain based on where it is in the body may be useful in determining the
client’s underlying problem or needs.
Duration
When pain lasts only through the expected recovery period, it is called acute pain.
Chronic pain is a prolonged recurring or persisting for over 6 months or longer and may
interfere with functioning.
Intensity
Categorization of pain according to intensity has become a useful way to identify pain.
By using a 0 to 10 pain scale where: 1-3 is considered mild pain, rating 4-6 is moderate
pain, and pain reaching 7-10 is ranked severe pain.
Etiology
Designation of the types of pain through etiology is done under broad categories of
physiological and neuropathic pain.
CATEGORIES OF PAIN BY ETIOLOGY
1. Physiological pain
This is experienced when an intact, properly functioning nervous system sends
signals that tissues are damaged, requiring attention and proper care.
Somatic Pain (originates in the skin, muscle, bone, or connective tissue)
Visceral Pain (poorly located, and may have cramping, throbbing, pressing, or
aching quality)
2. Neuropathic pain
This is experienced by people who have damaged or malfunctioning nerves.
Peripheral neuropathic pain (follows damage and/or sensitization of peripheral
nerves)
Central neuropathic pain (results from malfunctioning nerves in the central
nervous system)
Sympathetically maintained pain (occurs occasionally when abnormal
connections between pain fibers and the sympathetic nervous system perpetuate
problems with both the pain and sympathetically controlled functions)
*Pain Tolerance is the maximum amount of painful stimuli that a person is willing to withstand
without seeking avoidance of the pain or relief.
*Pain threshold is the least amount of stimuli that is needed for a person to label a sensation as
pain.
FACTORS AFFECTING THE PAIN EXPERIENCE
Ethnic and Cultural Values
Developmental Stage
Environment and Support People
Past Pain Experiences
Meaning of Pain
Pain management is the alleviation of pain or a reduction in pain to a level of comfort that is
acceptable to the client. It includes two basic types of nursing interventions: pharmacologic and
nonpharmacologic.
PAIN ASSESSMENT (COLDERR Mnemonic)
Character : describe the sensation
Onset : when it started, how it has changed
Location : where it hurts
Duration : constant versus intermittent in nature
Exacerbation : factors that make it worse
Relief : factors that make it better
Radiation : pattern of shooting/spreading/location of pain away from its origin
INDIVIDUALIZING CARE FOR CLIENTS WITH PAIN
Establish a trusting relationship.
Consider the client’s ability and willingness to participate actively in pain relief measures.
Use a variety of pain relief measures.
Provide measures to relieve pain before it becomes severe.
Use pain-relieving measures that the client believes are effective.
The selection of pain relief measures should be aligned with the client’s report of the pain.
If a pain relief measure is ineffective, encourage the client to try it again before giving up.
Maintain an unbiased attitude about what may relieve the pain.
Keep trying.
Prevent harm to the client.
Educate the client and caregivers about pain.
NURSING INTERVENTIONS
PHARMACOLOGIC PAIN MANAGEMENT
This involves the use of opioids (narcotics), nonopioids/nonsteroidal anti-inflammatory drugs
(NSAIDs), and conanalgesic drugs. The principles of modern analgesic use are built on a foundation
established by the World Health Organization (WHO).
1. Nonopioids/NSAIDS
Nonopiods include acetaminophen and NSAIDs such as ibuprofen or aspirin. NSAIDs
have anti-inflammatory, analgesic and antipyretic effects, whereas acetaminophen has
only analgesic and antipyretic effects.
2. Opioids
Full agonists
These are pure opioid drugs that are bind tightly to mu receptor sites, producing
maximum pain inhibition, an agonist effect. These include morphine, and
hydromorphone.
Mixed agonists-antagonists
These are drugs that can act like opioids and relieve pain when given to a client
who has not taken any pure opioids.
Partial agonists
Partial agonists have a ceiling effect in contrast to a full agonist. These drugs
such as buprenorphine block the mu receptors or are neutral at that receptor but bind at
a kappa receptor site.
3. Coanalgesics
A coanalgesic agent is a medication that is not classified as pain medication but has
properties that may reduce pain alone or in combination with other analgesics to relieve
other discomforts, potentiate the effect of pain medications, or reduce the pain
medication’s side effects.
NONPHARMACOLOGIC PAIN MANAGEMENT
Nonpharmacologic pain management consists of a variety of physical, cognitive-behavioral,
and lifestyle pain management strategies that target the body, mind, spirit, and social interactions.
1. Physical Interventions
The goals of physical interventions include providing comfort, altering physiologic
responses to reduce pain perception, and optimizing functioning.
Cutaneous Stimulation
This provides effective temporary pain relief wherein it distracts the client and
focuses attention on the tactile stimuli, away from the painful sensations, thus reducing
pain perception.
massage
application of heat or cold
acupressure
contralateral stimulation
Immobilization/Bracing
Immobilizing or restricting the movement of a painful body part may help to
manage episodes of acute pain. Splint or supportive devices should hold joints in the
position of optimal function and should be removed regularly depending on the agency
protocol.
Transcutaneous Electrical Nerve Stimulation
This is a method of applying low-voltage electrical stimulation directly over
identified pain areas, at an acupressure pint, along peripheral nerve areas that
innervate the pain area, or along the spinal column.
2. Cognitive-Behavioral Interventions
The goals of cognitive-behavioral intervention include providing comfort, altering
psychologic responses to reduce pain perception, and optimizing functioning.
Distractions
Eliciting the Relaxation Response
Repatterning Unhelpful Thinking
Facilitating Coping
Selected Spiritual Interventions
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
6) Nutrition
Nutrition is the sum of all the interactions between an organism and the food it consumes. It
is what a person eats and how the body uses it. Nutrients are organic and inorganic substances
found in foods that are required for body functioning and metabolisms.
ESSENTIAL NUTRIENTS
WATER
The body’s most basic nutrient need; it serves as a medium for metabolic reactions
within cells and a transporter of nutrients, waste products and other substances.
MACRONUTRIENTS
Include carbohydrates, fats and proteins that are needed in large quantities.
1. Carbohydrates
Carbohydrates are composed of the elements carbon, hydrogen, and oxygen.
The primary sources of these are plant.
Types of Carbohydrates
a. Simple (sugars) such as glucose, galactose, and fructose
SPECIAL DIETS
Clear Liquid Diet
Limited to water, tea, coffee, clear broths, ginger ale, or other carbonated beverages,
strained and clear juices, and plain gelatin.
Full Liquid Diet
Contains liquids or foods that turn to liquid at body temperature, such as ice cream.
Full liquid diets are often eaten by clients who have gastrointestinal disturbances or are
otherwise unable to tolerate solid or semisolid foods.
Soft Diet
The soft diet is easily chewed and digested.
It is often ordered for clients who have difficulty chewing and swallowing.
It is a low-residue diet containing very few uncooked foods.
Diet as Tolerated
Diet as tolerated is ordered when the client’s appetite, ability to eat, and tolerance for
certain foods may change.
Modification for Disease
Many special diets may be prescribed to meet requirements for disease process or
altered metabolism.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
7) Urinary Elimination
Urinary elimination depends on effective functioning of the upper urinary tract: kidneys and
ureters, and the lower urinary tract: urinary bladder, urethra, and pelvic floor. This is usually taken
for granted until a problem arises and aware people of their urinary habits and any associated
symptoms.
Micturition, voiding, and urination all refers to the process of emptying the urinary bladder.
FACTORS AFFECTING MICTURITION
Developmental Factors
Children only gain bladder control between 2-5 years old
Mentally disabled people may not have the control of urine elimination.
Enuresis: bed wetting
Psychosocial Factors
Some people who experience stress void smaller amounts of urine at more frequent
intervals.
Stress can also interfere with the ability to relax the muscles and sphincter, and the
person may have the urge to void but it becomes difficult.
Fluid and Food Intake
Dehydrated: kidneys reabsorb fluids; the urine produced is more concentrated and
decreased in amount.
Fluid overload: kidneys excrete a large quantity of diluted urine.
Alcohol produces a diuretic effect: increase urine production.
Foods and beverages with high sodium content cause sodium and water reabsorption:
decrease urine formation.
Foods such as asparagus and onions may affect the odor of the urine.
Beets affect the color of the urine: red
Medications
Sedatives and tranquilizers may diminish awareness of the need to urinate.
Diuretics: usually to treat HTN, prevents reabsorption of water and certain electrolytes in
tubules. This increases urine production and dilute urine.
Cholinergic medications: stimulate contraction of detrusor muscle, producing urination.
Analgesics and tranquilizers: supress CNS and diminish effectiveness of neural reflex.
Nephrotoxic medication: capable of causing kidney damage.
Muscle Tone
Exercise increases urine production and elimination
Immobility may result to poor urine production and elimination.
Pathologic conditions
Multiple sclerosis
Hematuria
UTI
HTN
Heart and circulatory disorders
High fever
Hypertrophy of the prostate gland
Surgical and Diagnostic Procedures
The urethra may swell after a cystoscopy and other surgical procedures on any part of
the urinary tract.
Spinal anesthetics can affect the passage of urine because they decrease the client’s
awareness of the need to void.
Surgery on the structure near the urinary tract can also affect urination because of
swelling in the lower abdomen.
ALTERED URINE PRODUCTION
Polyuria (production of abnormally large amounts of urine by the kidneys)
Polydipsia (excessive fluid intake)
Oliguria (low urine output)
Anuria (lack of urine production)
ALTERED URINE ELIMINATION
Urine frequency (voiding at frequent intervals)
Nocturia (voiding two or more times at night)
Urgency (sudden strong desire to void though there may not be a great deal of urine in the
bladder)
Dysuria (voiding that is either painful or difficult)
Enuresis (involuntary urination in children beyond the age when voluntary bladder control is
normally acquired)
Urinary incontinence (involuntary urination suggesting a symptom not a disease)
Urinary retention (accumulation of urine in the bladder that over distends)
Neurologic bladder (impaired neurologic function that interfere with the normal mechanisms
of urine elimination)
URINARY INCONTINENCE
Urinary incontinence or involuntary urination, is a symptom, not a disease. It can have significant
impact on the client’s life, creating physical problems such as skin breakdown and possibly leading to
psychosocial problems such as embarrassment, isolation, and social withdrawal.
TYPES OF URINARY INCONTINENCE
Transient
Appears suddenly and lasts for 6 months or less
Caused by treatable factors such as confusion secondary to acute illness, infection, and
as a result of medical treatment.
Stress
Involuntary loss of urine related to an increase in intra-abdominal pressure.
Occurs during coughing, sneezing, laughing, or other physical activities, childbirth,
menopause, obesity, or straining from chronic constipation.
Urge
Involuntary loss of urine that occurs soon after feeling an urgent need to void.
Mixed
Urine loss with features of two or more types of incontinence
Overflow
Voluntary loss of urine associated with over distention and overflow of bladder.
Chronic retention of urine
May be due to a secondary effect of some drugs, fecal impaction or neurologic
conditions.
Functional
Urine loss caused by the inability to reach the toilet because of environmental barriers,
physical limitation, loss of memory or disorientation
Reflex
Emptying of the bladder without sensation of need to void.
Spinal cord injuries can lead to this type of urinary incontinence.
Total
Continuous, unpredictable loss of urine resulting from surgery, trauma or physical
malformation.
MANAGING URINARY INCONTINENCE
Introduce continence training
Pelvic muscle exercises
Maintaining skin integrity
Applying external urinary drainage devices
URINARY CATHETERIZATION
Urinary catheterization is the introduction of a catheter into the urinary bladder. This is usually
performed only when absolutely necessary, because the danger exists of introducing microorganisms
into the bladder.
TYPES OF CATHETER
Indwelling urethral catheter
Catheter than remains in place for continuous urine drainage.
Intermittent urethral catheter
Catheter that is used to drain the bladder for shorter periods.
Suprapubic catheter
Catheter that is used for long term continuous drainage.
External condom catheter
A soft, pliable sheath made of silicone material applied externally to the penis.
URINARY IRRIGATIONS
An irrigation is a flushing or washing-out with a specified solution.
Bladder irrigation is carried out on a primary care provider’s order, usually to wash out
the bladder and sometimes to apply a medication to the bladder lining.
Catheter irrigation may be performed to maintain or restore the patency of the catheter,
for example, to remove pus or blood clots blocking the catheter.
ASSESSMENT
History and Urinary Status
Physical Assessment
Measuring Urinary Output
Measuring Residual Urine
NURSING INTERVENTIONS
1. MAINTAINING NORMAL URINARY ELIMINATION
Promoting Fluid Intake
Maintaining Normal Voiding Habits
Assisting with Toileting
2. PREVENTING URINARY TRACT INFECTIONS
Drink eight 8-ounce glasses of water per day to flush the bacteria out of the urinary
system.
Practice frequent voiding.
Avoid using harsh soaps, bubble bath, powder, or sprays in the perineal area.
Avoid tight0fitting pants or other clothing that creates irritation to the urethra and
prevents ventilation of the perineal area.
Wear cotton rather than nylon underclothes.
Girls and women should always wipe the perineal area from front to the back to
prevent introduction of gastrointestinal bacteria into the urethra.
Take showers instead of tub baths because bacteria present in the water can readily
enter the urethra.
Refences
(n.d.). Retrieved May 25, 2020, from Studocu: http://www.studocu.com/en-us/document/nova-
southeastern-university/foundations-of-professional-nursing/summaries/1-ch-36-urinary-
elimination/1078888/view
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
8) Bowel Elimination
Bowel elimination or defecation is the expulsion of feces from the anus and rectum. The
frequency of defecation is highly individual, varying from several times per day to two to three
times a week.
FACTORS AFFECTING DEFECATION
Developmental Factors
Infants- characteristics of stool and frequency depend on formula or breast feedings.
Toddler- physiologic maturity is first priority for bowel training.
Child, Adolescent, Adult- defecation patterns vary in quantity, frequency, and
rhythmicity.
Older Adults- constipation is often a chronic problem; diarrhea and fecal incontinence
may result from physiologic or lifestyle changes.
Diet
Sufficient bulk (cellulose, fiber) in the diet is necessary to provide fecal volume.
Certain foods are difficult or impossible for some people to digest.
Spicy foods can produce diarrhea and flatus in some individuals.
Gas-producing foods
Laxative-producing foods
Constipation-producing foods
Fluid
Healthy fecal elimination usually requires a daily fluid intake of 2,000 to 3,000 mL.
Activity
Activity stimulates peristalsis, thus facilitating the movement of chyme along the colon.
Psychologic Factors
People who are anxious or angry experience increased peristaltic activity and
subsequent nausea or diarrhea.
People who are depressed may experience slowed intestinal motility, resulting in
constipation.
Defecation Habits
Bowel habits may affect the frequency of defecating.
Ignoring the urge to defecate may result to lost defecation.
Medications
Some drugs have side effects that can interfere with normal elimination.
Diagnostic Procedures
Before certain diagnostic procedures, such as visualization of the colon, the client is
restricted from ingesting food or fluid.
Anesthesia and Surgery
General anesthetics cause the normal colonic movements to cease or slow by blocking
parasympathetic stimulation to the muscles of the colon.
Surgery that involves direct handling of the intestines can cause temporary cessation of
the intestinal movement.
Pathologic Conditions
Spinal cord injuries and head injuries can decrease the sensory stimulation for
defecation.
Impaired mobility may limit the client’s ability to respond to the urge to defecate and the
client may experience constipation.
Pain
Clients who experience discomfort when defecating often suppress the urge to
defecate to avoid the pain.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
9) Oxygenation and Perfusion
Respiration is the process f gas exchange between the individual and the environment.
Oxygenation on the other hand, is the mechanism that facilitates or impairs the body’s ability to
supply oxygen to all cells of the body.
PROCESS OF OXYGENATION
1. Ventilation
The process of moving gases into and out of the lungs.
2. Diffusion
The movement of gases or other particles from an area of greater pressure or
concentration to an area of lower pressure concentration.
3. Perfusion
The ability of the cardiovascular system to pump oxygenated blood to the tissues
and return deoxygenated blood back to the lungs.
FACTORS AFFECTING RESPIRATORY FUNCTION
Age
Changes in aging affect the respiratory system by infection, physical or emotional stress,
surgery, anesthesia, or other procedures.
Environment
Altitude, heat, cold, and air pollution affect oxygenation.
Lifestyle
Physical exercise or activity increases the rate and depth of respirations and hence the
supply of oxygen in the body.
Health Status
Diseases of the respiratory system can adversely affect the oxygenation of the blood.
Medications
A variety of medications can decrease the rate and depth of respirations.
Stress
When stress and stressors are encountered, both psychologic and physiologic responses
can affect oxygenation.
ALTERATIONS IN RESPIRATORY FUNCTION
Hypoxia
This is a condition of insufficient oxygen anywhere in the body, from the inspired gas to the
tissues.
Hypercabia is a condition that suggests an accumulation of carbon dioxide in the blood.
Hypoxemia refers to reduced oxygen in the blood and is characterized by a low partial
pressure of oxygen in arterial blood or low haemoglobin saturation.
Altered Breathing Patterns
Breathing patterns refer to the rate, volume, rhythm, and relative case or effort of
respiration.
Eupnea is the normal respiration that is quiet, rhythmic, and effortless.
Tachypnea is the rapid rate observed with fevers, metabolic acidosis, pain and
hypercabia or hypoxemia.
Bradypnea is an abnormally slow respiratory rate, which may be seen in clients who have
taken drugs such as morphine, who have metabolic alkalosis, or who have increase
intracranial pressure.
Apnea is the cessation of breathing.
Orthopnea is the inability to breathe except in an upright or standing position.
Dyspnea is the difficulty or uncomfortable breathing.
Obstructed Airway
A completely or partially obstructed airway can occur anywhere along the upper or lower
respiratory passageways.
ASSESSMENT FOR OXYGENATION
Current Respiratory Problems
History of Respiratory Disease
Lifestyle
Presence of Cough
Description of Sputum
Presence of Chest Pain
Presence of Risk Factors
Medication History
NURSING INTERVENTIONS
Promoting Oxygenation
Sit straight and stand erect to permit full lung expansion
Exercise regularly
Breathe through the nose
Breathe in to expand the chest fully
Do not smoke cigarettes, cigars, or pipes
Eliminate or reduce the use of household pesticides and irritating chemical substances.
Do not incinerate garbage in the house
Use building materials that do not emit vapors
Make sure furnaces, ovens, and wood stoves are correctly ventilated
Support a pollution-free environment
Deep Breathing and Coughing
The nurse can facilitate respiratory functioning by encouraging deep breathing
exercises and coughing to remove secretions from the airways.
When coughing raises secretions high enough, the client may either expectorate or
swallow them.
Hydration
Adequate hydration maintains the moisture of the respiratory mucous membranes,
Medications
A number of types of medication can be used for clients with oxygenation problems.
Bronchodilators, anti-inflammatory drugs, expectorants, and cough suppressants are
some medications that may be used to treat respiratory problems.
Incentive Spirometry
Incentive spirometers also referred to as sustained maximal inspiration devices (SMIs),
measure the flow of air inhaled through the mouthpiece and are used to: improve
pulmonary ventilation, counteract the effects of anesthesia or hypoventilation, loosen
respiratory secretions, facilitate respiratory gaseous exchange, and expand collapsed
alveoli.
Percussion, Vibration, and Postural Drainage
Percussion is the forceful striking of the skin with cupped hands. Cupping the hands
trap the air against the chest and cause vibrations through the chest wall to the
secretions.
Vibration is a series of vigorous quiverings produced by hands that are placed flat
against the client’s chest wall.
Postural drainage is the drainage by gravity of secretions from various lung segments. A
wide variety of positions is necessary to drain all segments of the lungs, but not all are
required for every client.
Oxygen Therapy
Clients who have difficulty ventilating all areas of their lungs, those whose gas
exchange is impaired, or people with heart failure may benefit from oxygen therapy to
prevent hypoxia.
Oxygen therapy is prescribed by the primary care provider, who species the
concentration, method of delivery, and depending on the method, liter flow per minute.
Oxygen Delivery Systems
A number of systems are available to deliver oxygen to the client.
The choice of system depends on the client’s oxygen needs, comfort, and
developmental considerations.
Types of Oxygen Delivery System
Cannula
Face Mask
Face Tent
Artificial Airways
Artificial airways are inserted to maintain a patent air passage for clients whose airway
have become or may become obstructed.
A patent airway is necessary so that air can flow to and from the lungs.
Types of Artificial Airways
Oropharyngeal and Nasopharyngeal Airways
Endotracheal Tubes
Tracheostomy
Suctioning
When clients have difficulty handling their secretions or an aorway is in place,
suctioning may be necessary to clear air passages.
Suctioning is aspirating secretions through a catheter connected to a suction machine
or wall suction outlet.
Chest Tubes and Drainage Systems
Chest tubes may be inserted into the pleural cavity to restore negative pressure and
drain collected fluid or blood.
When the chest tubes are inserted, they must be connected to a sealed drainage
system or a one-way valve that allows air and fluid to be removed from the chest cavity
but prevents air from entering from the outside.
The respiratory and cardiovascular systems are closely linked and dependent on one another
to deliver oxygen to the tissues of the body. Perfusion is the ability of the cardiovascular system to
pump oxygenated blood into tissues and return deoxygenated blood to the lungs.
NURSING INTERVENTIONS
Promoting Circulations
Changing position frequently, ambulating and exercising usually maintain adequate
cardiovascular functioning.
Medications
Many classes of medication are administered to clients with cardiovascular disorders.
Drugs such as nitrates, calcium channel blockers, and angiotensin-converting enzyme
inhibitors reduce the workload of the heart and prevent vasoconstrictions.
Preventing Venous Stasis
Preventing venous stasis is an important nursing intervention to reduce the risk of
complications following surgery, trauma, or major medical problems. Sequential compression
devices are additional measures to help prevent venous stasis.
Cardiopulmonary Resuscitation
This is a combination of oral resuscitation, which supplies oxygen to the lungs, and
external cardiac massage, which is intended to re-establish cardiac function and blood
circulation.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
10)Fluid, Electrolyte, and Acid-Base Balance
In good health, a moderate balance of fluids, electrolytes, and acids and bases is
maintained in the body. This balance, or physiologic homeostasis, depends on multiple
physiologic processes that regulate fluid intake and output and the movement of water and the
substances dissolved in it between the body compartments.
BODY FLUIDS AND ELECTROLYTES
Water is vital to health and normal cellular function, serving as:
A medium for metabolic reactions within cells.
A transport for nutrients, waste products, and other substance.
A lubricant.
An insulator and shock absorber.
One means if regulating and maintaining body temperature.
Electrolytes are charged ions capable of conducting electricity and are present in all body
fluids and fluid compartments.
Distribution of Body Fluids
The body’s fluid is divided into two major compartments, intracellular and extracellular.
Intracellular Fluid (ICF) is found within the cells of the body and constitutes
approximately two-thirds of the total body fluid in adults.
Extracellular Fluid (ECF) is found outside the cells and accounts for about one-
third of the total body fluid.
Intravascular fluid, or plasma, accounts for approximately 20% of the
ECF and is found within the vascular system.
Interstitial fluid, accounting for approximately 75% of the ECF, surrounds
the cells.
Composition of Body Fluids
Extracellular and Intracellular fluids contain oxygen from the lungs, dissolved nutrients
from the gastrointestinal tract, excretory products of metabolism such as carbon dioxide, and
charged particles called ions
Electrolytes
Cations
Anions
Movement of Body Fluids and Electrolytes
The body fluid compartments are separated from one another by cell membranes and
the capillary membrane. While these membranes are completely permeable to water, they are
considered to be selectively permeable to solutes.
Osmosis is the movement of water across cell membranes, from the less
concentrated solution to the more concentrated solution.
Diffusion is the continual intermingling of molecules in liquids, gases, or solids
brought about by the random movement of the molecules.
Filtration is a process whereby fluid and solutes move together across a
membrane from one compartment to another and the movement is from an area
of higher pressure to one of lower pressure.
Active Transport is the process where substances can move across cell
membranes from a less concentrated solution to a more concentrated one.
Regulating Body Fluids
In a healthy person, the volumes and chemical composition of the fluid compartments
stay within narrow safe limits.
Fluid Intake
Water as a by-product of food metabolism accounts for most of the remaining
fluid volume required. This quantity is approximately 200mL per day for the
average adult.
Fluid Output
Fluid losses from the body counterbalance the adult’s 2500mL average daily
intake of fluid.
Maintaining homeostasis
The volume and composition of the body’s fluids is regulated through several
homeostatic mechanisms.
Kidneys
Antidiuretic Hormone
Renin-Angiotensin-Aldosterone System
Atrial Natriuretic Factor
Regulating Electrolytes
Most electrolytes enter the body through dietary intake and are excreted in the urine.
Some electrolytes, such as sodium and chloride, are not store by the body but must be
consumed daily to maintain normal levels
Sodium
Potassium
Calcium
Magnesium
Chloride
Phosphate
Bicarbonate
ACID-BASE BALANCE
An important part regulating the chemical balance or homeostasis is of body fluids is regulating
their acidity or alkalinity. An acid is a substance that releases hydrogen ions in solution. Bases or
alkalis have a low hydrogen ion concentration and can accept hydrogen ions in solution.
Regulation of Acid-Base Balance
Body fluids are maintained within a narrow range that is slightly alkaline. The normal pH
of arterial blood is between 7.35 and 7.45.
Buffers prevent excessive changes in pH by removing or releasing hydrogen
ions.
Respiratory Regulation helps regulate acid-base balance by eliminating or
retaining carbon dioxide, a potential acid.
Renal Regulation
NURSING INTERVENTIONS
Promoting Wellness
Enteral Fluid and Electrolyte Replacement
Parenteral Fluid and Electrolyte Replacement
Blood Transfusions
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
NURSING INTERVENTIONS TO PROMOTE HEALTHY PSYCHOSOCIAL RESPONSES
1. Self-Concept
Self-concept is one’s mental image of oneself. A positive self-concept is essential to a
person’s mental and physical health. However, a person with a negative self-concept may express
feelings of worthlessness, self-dislike, or even self-hatred.
Self-concept is a complex idea that influences the following:
How one thinks, talks, and eat
How one sees and treats other people
Choices one makes
Ability to give and receive love
Ability to take action and to change things
FOUR DIMENSIONS OF SELF-CONCEPT
Self-knowledge: the knowledge that one has about oneself. Including insights into one’s
abilities, nature, and limitations
Self-expectation: what one expects of oneself; may be a realistic or unrealistic expectation
Social Self: how a person is perceived by others and society
Social Evaluation: the appraisal of oneself in relationship to others, events, or situation
*Global self refers to the collective beliefs and images one holds about oneself. It is the most
complete description that individuals can give of themselves at any one time.
COMPONENTS OF SELF-CONCEPT
Personal Identity
Personal identity is the conscious sense of individuality and uniqueness that is
continually evolving throughout life. It also includes beliefs and values, personality, and
character.
Body Image
This is how a person perceives the size, appearance, and functioning of the body and
its parts. Body image has both cognitive and affective aspects. The cognitive is the knowledge
of the material body; the affective includes the sensations of the body, such as pain, pleasure,
fatigue, and physical movement.
Role Performance
A role is a set of expectations about how the person occupying one position behaves.
Role performance relates what a person in a particular role does to the behaviors expected of
that role.
Self-Esteem
Self-esteem is one’s judgment of one’s own worth that is how that person’s standards
and performances compare to others and to one’s ideal self.
Global Self-esteem is how much one likes oneself as a whole.
Specific Self-esteem is how much one approves of a certain part of oneself.
NURSING INTERVENTIONS
Identifying Areas of Strength
Enhancing Self-Esteem
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
2. Stress and Adaptation
Stress is a universal phenomenon. It is a condition in which the person experiences changes
in the normal balanced state. A stressor is any event or stimulus that causes an individual to
experience stress. When a person faces stressors, responses are referred to as coping strategies,
coping responses, or coping mechanisms.
SOURCES OF STRESS
Internal stressors originate within a person, for example, infection or feelings of depression.
External stressors originate outside the individual, for example, a move to another city, a
death in the family, or pressure from peers.
Developmental stressors occur at predictable times throughout an individual’s life.
Situational stressors are unpredictable and may occur at any time during life.
MODELS OF STRESS
1. Stimulus-Based Models
In this model, stress is defined as a stimulus, a life event, or a set of
circumstances that arouses physiologic and/or psychologic reactions that may
increase the individual’s vulnerability to illness.
2. Response-Based Models
Stress may also be considered as a response. The term stressor to denote any
factor that produces stress and disturbs the body’s equilibrium.
The initial reaction of the body is the alarm reaction, which alerts the body’s
defenses. This stage is divided by two parts: the shock phase and the
countershock phase.
During the shock phase, the stressor may be perceived consciously or
unconsciously by the person.
The countershock phase, is when the body’s adaptation takes place.
Stage of resistance: when the body’s adaptation takes place and the body
attempts to cope with the stressor and to limit the stressor to the smallest area of
the body that can deal with it.
Stage of exhaustion: the adaptation that the body made during the second
stage cannot be maintained and means that the ways used to cope with the
stressor have been exhausted.
3. Transaction-Based Models
Transactional theories of stress states that the stimulus theory and the response
theory do not consider individual differences.
This encompasses a set of cognitive, affective, and adaptive responses that
arise out of person-environment transactions.
INDICATORS OF STRESS
1. Physiologic Indicators
Clinical Manifestations Stress
Pupils dilate to increase visual perception when serious threats to the
body arise.
Sweat production (diaphoresis) increases to control elevated body heat
due to increased metabolism.
Heart rate and cardiac output increase to transport nutrients and by-
products of metabolism more efficiently.
Skin is pallid because of constriction of peripheral blood vessels an effect
of norepinephrine.
Sodium and water retention increase due to release of mineralocorticoids,
which increases blood volume.
Rate and depth of respirations increase because of dilation of the
bronchioles, promoting hyperventilation.
Urinary output decreases.
Mouth may be dry.
Peristalsis of the intestines decreases, resulting in possible constipation
and flatus.
For serious threats, mental alertness improves.
Muscle tension increases to prepare for rapid motor activity or defense.
Blood sugar increases because of release of glucocorticoids and
gluconeogenesis.
2. Psychologic Indicators
Anxiety and Fear
Anxiety is a state of mental uneasiness, apprehension, dread, or
foreboding or a feeling of helplessness related to an impending or anticipated
unidentified threat to self or significant relationships.
Fear is an emotion or feeling of apprehension aroused by impending or
seeming danger, pain, or another perceived threat.
Anger
Anger is an emotional state consisting of a subjective feeling of animosity
or strong displeasure.
Depression
Depression is an extreme feeling of sadness, despair. Dejection, lack of
worth, or emptiness, affects millions of Americans a year.
Ego Defense Mechanisms
Ego defense mechanisms are unconscious psychologic adaptive
mechanisms or, mental mechanisms that develop as the personality attempts to
defend itself, establish compromises among conflicting impulses, and calm inner
tensions.
3. Cognitive Indicators
Cognitive indicators of stress are thinking responses that include problem
solving, structuring, self-control or self-discipline, suppression, and fantasy.
Problem solving involves thinking through the threatening situation, using
specific steps to arrive at a solution.
Structuring is the arrangement or manipulation of a situation so that threatening
events do not occur.
Self-control is assuming a manner and facial expression that convey a sense of
being in control or in charge.
Suppression is consciously and wilfully putting a thought or feeling out of mind.
Fantasy is likened to make-believe.
4. Coping
Coping may be described as dealing with change – successfully or
unsuccessfully. A coping strategy is a natural or learned way of responding to a
changing environment or specific problem or situation.
Types of Coping Strategies
a. Problem-focused coping refers to efforts to improve a situation by making
changes or taking some action.
b. Emotion-focused coping includes thoughts and actions that relieve emotional
distress.
c. Long-term coping strategies can be constructive and realistic.
d. Short-term Coping strategies can reduce stress to a tolerable limit temporarily
but are ineffective ways to permanently deal with reality.
e. Adaptive coping helps the person to deal effectively with stressful events and
minimizes distress associated with them.
f. Maladaptive coping can result in unnecessary distress for the person and
others associated with the person or stressful event.
NURSING INTERVENTIONS
Encouraging Health Promotion Strategies
Minimizing anxiety
Mediating Anger
Using Relaxation Techniques
Crisis Intervention
Stress Management for Nurses
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
Grief is the total response to the emotional experience related to loss. And this is manifested
in thoughts, feelings, and behaviors as sociated with overwhelming distress or sorrow. Bereavement
is the subjective response experienced by the surviving loved ones after the death of a person with
whom they have shared a significant relationship. Mourning is the behavioural process through
which grief is eventually resolved or altered.
STAGES OF GRIEVING
1. Denial Stage
Refuses to believe that loss is happening.
Is unready to deal with practical problems.
May assume artificial cheerfulness to prolong denial.
2. Anger Stage
Client or family may direct anger at nurse or staff about matters that normally
would not bother them.
3. Bargaining
Seeks to bargain to avoid loss.
May express feelings of guilt or fear of punishment for past sins, real or
imagined.
4. Depression
Grieves over what has happened and what cannot be.
May talk freely or may withdraw.
5. Acceptance
Comes to terms with loss.
May have decreased interest in surroundings and support people.
May wish to begin making plans.
Death is a fundamental loss, both for the dying person and for those who survive. Death can
be viewed as the dying person’s final opportunity to experience life in ways that bring significance
and fulfilment.
RESPONSES TO DYING AND DEATH
Grieving
Fear
Hopelessness
Powerlessness
NURSING INTERVENTIONS
Helping Clients Die with Dignity
Hospice and Palliative Care
Meeting the Physiologic Needs of the Dying Client
Providing Spiritual Support
Supporting the Family
Postmortem Care
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
4. Sensory Functioning
An individual’s senses are essential for growth, development, and survival. Sensory stimuli
give meaning to events in the environment and any alteration in a person’s sensory function can
affect their ability to function within the environment.
SENSORY ALTERATIONS
Sensory Deprivation is generally thought of as a decrease in or lack of meaningful stimuli.
Sensory Overload generally occurs when a person is unable to process or manage the
amount or intensity of sensory stimuli.
Sensory Deficits is impaired reception, perception, or both, of one or more of the senses.
FACTORS AFFECTING SENSORY FUNCTION
Developmental Stage
Culture
Stress
Medications and Illness
Lifestyle and Personality
CLINICAL MANIFESTATIONS SENSORY DEPRIVATION
Excessive yawning, drowsiness, sleeping
Decreased attention span, difficulty concentrating, decreased problem solving
Impaired memory
Periodic disorientation, general confusion, or nocturnal confusion
Preoccupation with somatic complaints, such as palpitations
Hallucinations or delusions
Crying, annoyance over small matters, depression
Apathy, emotional lability
NURSING INTERVENTIONS
Promoting Health Sensory Function
Adjusting Environmental Stimuli
Managing Acute Sensory Deficits
Sensory Aids
Promoting the Use of Other Senses
Communicating Effectively
PREVENTING SENSORY OVERLOAD
Minimize unnecessary light, noise, and distraction. Provide dark glasses and earplugs as needed.
Control pain as indicated at the level desired by the client, on a scale of 0 to 10.
Introduce yourself by name, and address the client by name.
Provide orienting cues, such as clocks, calendars, equipment, and furniture in the room.
Provide a private room.
Limit visitors.
Plan care to allow for uninterrupted periods for rest or sleep.
Schedule a routine of care so the client knows when and what to expect.
Speak in a low tone of voice and in an unhurried manner.
Provide new information gradually to enable the client to process the meaning.
Describe any test and procedures to the client beforehand.
Reduce noxious odors.
Take time to discuss the client’s problems and to correct misinterpretations.
Assist the client with stress-reducing techniques.
PREVENTING SENSORY DEPRIVATION
Encourage the client to use eyeglasses and hearing aids.
Address the client by name and touch the client while speaking if this is not culturally offensive.
Communicate frequently with the client and maintain meaningful interactions.
Provide a telephone, radio and/or TV, clock, and calendar.
Provide murals, pictures, sculptures, and wall hangings.
Have family and friends bring freshly cut flowers and plants.
Consider having a resident pet.
Include different textured objects to feel.
Increase tactile stimulation through physical care.
Encourage social interaction through activity groups or visits by family and friends.
Encourage the use of crossword puzzles or games to stimulate mental function.
Encourage environment changes.
Encourage the use of self-stimulation techniques.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
VARIETIES OF SEXUALITY
Sexual Orientation
This is referred to as one’s attraction to people of the same sex, other sex, of both
sexes.
Gender Identity
This is deeply committed to the idea that there are only two sexes.
Intersex is a condition in which there are contradictions among chromosomal
gender, gonadal gender, internal organs, and external genital appearance.
Transsexuals are those who have a condition called gender dysphoria or
gender identity disorder.
Cross-Dressers are typically those who cross-dress to express either their
feminine side or manliness side of their personality.
Erotic Preferences
These are sexual activities which serves as a common sexual outlets for women and
men, single and couples persons, and heterosexual, gay/lesbian, and bisexual persons.
NURSING INTERVENTIONS
Promoting Sexual Health Teaching
Counselling for Altered Sexual Function
Dealing with Inappropriate Sexual Behavior
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
6. Spirituality
Spirituality refers to that part of being human that seeks meaningfulness through intra-, inter-,
and transpersonal connection. Spiritually generally involves a belief in a relationship with some higher
power, creative force, divine being, or infinite source of energy.
Spiritual health or spiritual well-being is manifested by a feeling of being “generally alive,
purposeful, and fulfilled” (Ellison, 1983).
Spiritual Distress refers to a challenge to the spiritual well-being or to the belief system that
provides strength, hope, and meaning to life.
CHARACTERISTICS OF SPIRITUAL DISTRESS
Expresses lack of hope, meaning and purpose in life, forgiveness of self
Expresses being abandoned by or having anger toward God
Refuses interaction with friends and family
Sudden changes in spiritual practices
Requests to see a religious leader
No interest in nature, reading spiritual literature
SPIRITUAL DEVELOPMENT
1. 0-3 years
Neonates and toddlers are acquiring fundamental spiritual qualities of trust, mutuality,
courage, hope and love.
Transition to next stage of faith begins when child’s language and thought begin to allow
use of symbolism.
2. 3-7 years
Make-believe is experienced as reality influenced by examples, moods, and actions.
3. 7-12 years, even into adulthood
Child accepts stories and beliefs literally.
Ability to learn the beliefs and practice of the culture and religion.
4. Adolescence
Generally conform to the beliefs of those around them; begin to examine beliefs
objectively, especially in late adolescence.
5. Young Adulthood
Develops independent commitments, lifestyle, beliefs, and attitudes.
Begins to develop personal meaning for symbols of religion and faith.
6. Mid-Adulthood
Newfound appreciation for the past.
Increased respect for inner voice.
More aware of myths, prejudices, and images that exist because of social background.
7. Mid-to late Adulthood
Able to believe in, and live with a sense of participation in, a nonexclusive community.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
EVALUATION
Evaluating is a planned, ongoing, and purposeful activity in which clients and health care
professionals determine (a) the client’s progress toward achievement of goals/ outcomes and (b) the
effectiveness of the nursing care plan. Evaluation is an important aspect of the nursing process
because conclusions drawn from the evaluation determine whether the nursing interventions should
be terminated, continued, or changed.
Evaluation is continuous. Evaluation done while or immediately after implementing a nursing
order enables the nurse to make on-the-spot modifications in an intervention.
TYPES OF EVALUATION
Planned
Evaluation performed at specified intervals which shows the extent of progress toward
goal achievement which then enables the nurse to correct any deficiencies and modify the
care plan needed.
Ongoing
Evaluation done during an intervention. The nurse uses his/her senses to observe any
result of the intervention.
Purposeful
Evaluation done to gain information whether the intervention has become successful
and if there are any modification to be done.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
DOCUMENTATION AND REPORTING
DOCUMENTATION METHODS
Kardexes
This is a widely used, concise method of organizing and recording data about client,
making information quickly accessible to all health professionals. The system consists of a
series of cards kept in a portable index.
Flow Sheets
A flow sheet enables nurses to record nursing data quickly and concisely and provides
an easy-to-read record of the client’s condition over time.
Graphic Record
Indicates body temperature, pulse, respiratory rate, blood pressure,
weight, and, in some agencies, other significant clinical data such as admission
or postoperative bowel movements, appetite, and activity.
Intake and Output Record
All routes of fluid intake and all routes of fluid loss or output are measured
and recorder on this form.
Medication Administration Record
Medication flow sheets usually include designated areas for the date of
the medication order, the expiration date, the medication name and dose, the
frequency of administration and route, and the nurse’s signature.
Skin Assessment Record
A skin or wound assessment is often recorded on a flow sheet such as the
one shown.
Progress Notes
Provides information about the progress a client is making toward achieving desired
outcomes. These include information about client problems and nursing interventions.
Referral Summaries
A discharge note and referral summary are completed when the client is being
discharged and transferred to another institution or to a home setting where a visit by a
community health nurse is required.
References
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
3. Incident Report
An incident report is a form that filled up in order to record the details of accidents, patient
injury and other unusual events that occur in a health care facility such as a hospital or nursing home.
It is also called an accident report which documents the exact details of the accident or unusual
event while the information is still fresh in the minds of those who witness the event.
Written at the first opportunity after the incident so that the details are not blurry or
forgotten.
Written with a pen (ink) not pencil. Information written using a pencil can be erased.
Details should be complete and accurate. The patient should be identified with the
following details:
o Full name
o Hospital bed number
o Hospital ID
o Patients diagnosis
o Patient’s condition before and after the incident
4. Referral Systems
These are different level of health care provided by health care professionals and facilities.
When a certain case isn’t curable or no equipment are available, then referring to a higher health
care facility takes place, thus, the referral system.
LEVEL 1
Primary Health Care Clinic
A Primary Health Care Clinic is the first step in the provision of health care and offers
services such as immunisation, family planning, anti-natal care, and treatment of common
diseases, treatment and management of Tuberculosis, HIV/AIDS counselling, amongst other
services.
Community Health Care Centre
A Community Health Care Centre is the second step in the provision of health care
but can also be used for first contact care. A Community Health Care Centre offers similar
services to a Primary Health Care Clinic with the addition of a 24 hours maternity service,
emergency care and casualty and a short stay ward.
District Hospital
This is the third step in the provision of health care. These hospitals will normally
receive referral from and provide generalist support to community health centers and clinics
such as diagnostic, treatment, care, counselling and rehabilitation services. Clinical services
include Surgery, Obstetrics & Gynaecology, Out-Patients Department, Medicine, Paediatrics,
Mental Health, Geriatrics, Casualty and Clinical Forensic Medical Services amongst other
services.
LEVEL 2
Regional Hospital
This is the second level of health care. These hospitals will normally receive referral
from and provide specialist support to a number of district hospitals.
LEVEL 3
Provincial Tertiary Hospital
These hospitals will receive referral from and provide sub-specialist support to a number
of regional hospitals and is the third level of health care. These hospitals are staffed by
specialists and generalists and offer services such as neurosurgery, neurology, Plastic &
reconstructive surgery, Cardiology, Urology, Paediatric surgery, maxillio-facial surgery,
Psychiatry, Occupational health and Orthopaedics amongst other services.
LEVEL 4
Central Hospitals
The fourth and highest level of health care. These hospitals will consist of very highly
specialised referral units which together provide an environment for multi-speciality clinical
services, innovation and research. People are referred to these hospitals by Provincial Tertiary
Hospitals.
Specialised Hospital
These hospitals will provide care only for certain specialised groups of patients. They
will include chronic psychiatric and TB hospitals, as well as specialised spinal injury and acute
infectious disease hospitals.
References
(2019, November 26). Retrieved May 25, 2020, from http://www.kznhealth.gov.za/Referral-
system.htm
Edwards, K. J. (2016). ISBARR Communication Workshop and its Effect on Novice Baccalaureate
Nursing Students’ Self-Confidence.
1. SBAR tool
The SBAR communication tool, used in many NHS trusts, structures communication in four
stages:
S: situation; Hello, this is Peter Jones. I am a staff nurse on Ward 25. I am calling about Mr
Smith.
B: background; Mr Smith is 92. He was admitted yesterday with chest pain. He has had two
MIs in the past and has heart failure.
A: assessment; I have assessed him today and I am worried – he looks very unwell. His
respiration rate is 34 and his oxygen saturations are 86% on 15L. His NEWS is eight.
R: recommendation; I would like you to come and see him now please.
2. Checklists
As well as maintaining our situational awareness and sharing observations with colleagues,
we need to be aware of our own vulnerability and potential for making errors. This can be done
through a simple self-checking exercise using either the I’M SAFE checklist or the ‘three bucket’
model.
The I’M SAFE checklist, which is a Team tool, stands for:
I: illness;
M: medication;
S: stress;
A: alcohol and drugs;
F: fatigue;
E: eating and elimination.
3. Safety huddles
A safety huddle is a brief coming together of staff, once or more in a shift, aimed at
maintaining situational awareness, sharing observations and going through risks: which patients
are causing concern? Is anyone at risk of deterioration? How is staffing? How is workload?
Anyone can take part or lead the safety huddle, whether they are nurses, doctors,
physiotherapists, housekeepers or ward clerks.
4. Closed-loop communication
Closed-loop communication is a technique that reduces the risk of errors arising from
misunderstandings and wrong assumptions. It is a good idea for team leaders to use closed-loop
communication in their communication with the team. This role modelling will encourage staff to
adopt the same good practice.
5. Readback
Readback is similar to closed-loop communication. It involves reading back to the sender
information they have given to you in order to check you have correctly understood it. Readback
can also help clarify who is responsible for what, as this can be unclear at handover and important
interventions might thus be missed or delayed.
Effective communication is critical for a collaborative care plan to work; nurses are
trained to have adaptability, empathy, and communication skills, which allows for them to be
excellent leaders and members of a care team.
Nurses’ ability to understand and assess a patient’s clinical, emotional, and social
needs can help them to call upon available resources and create a patient-focused care plan. As
nurses are offering direct patient care around the clock, they have a unique and focused view of
how that care should be provided. Nurses can be role models in their honest and open
communication with team members about the quality of patient care which is being provided and
the work environment.
Establish Team Goals
Examples of common health care goals can include improving patient care, shortening
response times, and decreasing waste. Setting a team goal provides every team member a
focused objective to work toward, which helps create team unity and provides space for feedback.
Without setting common goals, individuals on a team may have different outcomes in mind, which
can only serve to hinder progress.
Assign Roles Within a Team
Nurses interact with many health care professionals, both within their own team and across
departments. It is crucial then, to understand key roles within individual teams to achieve greater
collaboration. If clear roles are not assigned, team members may duplicate efforts in some areas
while leaving gaps in others. This not only wastes time but could cause patient harm.
Allow for Open Communication
Because nurses interact with many people, from patients to practitioners, they must
develop keen listening skills. Those working alongside nurses may have their individual feedback,
suggestions, or questions, making active listening an important aspect of team operations. On the
other hand, team members whose input and successes are verbally acknowledged to the greater
team are more likely to contribute their ideas, which builds team cohesion and efficiency.
Promote Mutual Respect
Mutual respect is critical in health care settings, not just within the team but across
collaborative departments. Team members who are not feeling respected can become defensive,
foster hidden agendas, demonstrate a lack of engagement, and worse. Building mutual respect
comes through a common, focused goal; an understanding that each individual’s work is valuable
and an acknowledgment of the efforts of others.
Handle Conflict Proactively
Effective teamwork and collaboration in nursing exist with the understanding that some
conflict is inevitable. By allowing for open communication and listening to team members’
concerns, nurses can encourage productive conflict resolution in its early stages.
Be an Effective Leader
The field of health care is filled with leaders, and nursing is no exception. Specialized nurse
practitioners frequently assume leadership roles, taking charge of teamwork and collaborative
efforts. The best leaders can adapt to different circumstances based on the team, patient care
goals, and the needs of the health care organization. Quality leaders must be flexible while
helping their team members and other departments in an open and respectful manner.
References
Nursing Times. (2016, December 12). Retrieved May 24, 2020, from
http://www.nursingtimes.net/clinical-archive/patient-safety/tools-and-techniques-to-improve-
teamwork-and-avoid-patient-harm-12-12-2016/
Advisory Board. (n.d.). Retrieved May 24, 2020, from http://www.advisory.com/research/physician-
executive-council/prescription-for-change/2015/03/dyad-leadership-slides
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
NSW . (n.d.). Retrieved May 24, 2020, from
http://www.health.nsw.gov.au/healthone/Pages/multidisciplinary-team-care.aspx
Wiley Online Library. (n.d.). Retrieved May 24, 2020, from
http://www.onlinelibrary.wiley.com/doi/abs/10.1111/nhs.12671
References
SHRM. (n.d.). Retrieved May 26, 2020, from http://www.shrm.org/resourcesandtools/tools-and-
samples/toolkits/pages/developingemployeecareerpathsandladders.aspx
Filipino older adults tend to cope with illness with the help of family and friends, and by faith in
God. Complete cure or even the slightest improvement in a malady or illness is viewed as a miracle.
Filipino families greatly influence patients’ decisions about health care. Patients subjugate personal
needs and tend to go along with the demands of a more authoritative family figure in order to
maintain group harmony. Before seeking professional help, Filipino older adults tend to manage their
illnesses by self-monitoring of symptoms, ascertaining possible causes, determining the severity and
threat to functional capacity, and considering the financial and emotional burden to the family.
COPING STYLES
Coping styles common among elderly Filipino Americans in times of illness or crisis include:
• Patience and Endurance (Tiyaga): the ability to tolerate uncertain situations
• Flexibility (Lakas ng Loob): being respectful and honest with oneself
• Humor (Tatawanan ang problema): the capacity to laugh at oneself in times of adversity
• Fatalistic Resignation (Bahala Na): the view that illness and suffering are the unavoidable
and predestined will of God, in which the patient, family members and even the physician
should not interfere
• Conceding to the wishes of the collective (Pakikisama) to maintain group harmony
A. Phil. Nursing Law of 2012: RA 9173 Art of IV, Sec 28: Scope of Nursing Practice
NURSING PRACTICE SEC. 28. Scope of Nursing.
A person shall be deemed to be practicing nursing within the meaning of this Act when
he/she singly or in collaboration with another, initiates and performs nursing services to individuals,
families and communities in any health care setting. It includes, but not limited to, nursing care during
conception, labor, delivery, infancy, childhood, toddler, pre-school, school age, adolescence,
adulthood and old age.
As independent practitioners, nurses are primarily responsible for the promotion of health
and prevention of illness. As members of the health team, nurses shall collaborate with other health
care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health,
alleviation of suffering, and when recovery is not possible, towards a peaceful death. It shall be the
duty of the nurse to:
a. Provide nursing care through the utilization of the nursing process.
b. Establish linkages with community resources and coordination with the health team;
c. Provide health education to individuals, families and communities;
d. Teach, guide and supervise students in nursing education programs including the
administration of nursing services in varied settings such as hospitals and clinics; undertake
consultation services; engage in such activities that require the utilization of knowledge and
decision-making skills of a registered nurse; and
e. Undertake nursing and health human resource development training and research,
which shall include, but not limited to, the development of advance nursing practice;
Provided:
That this section shall not apply to nursing students who perform nursing functions under the
direct supervision of a qualified faculty.
That in the practice of nursing in all settings, the nurse is duty-bound to observe the Code of
Ethics for nurses and uphold the standards of safe nursing practice.
That the program and activity for the continuing professional education shall be submitted to
and approved by the Board.
B. National Nursing Core Competency Standards
I. SAFE AND QUALITY NURSING CARE
CORE COMPETENCY 1:
Demonstrate knowledge based on health/illness status of individual/ groups
Indicators :
Identifies health needs of patients/groups
Explains patient/group status
CORE COMPETENCY 2:
Provides sound decision making in care of individual/groups considering their beliefs,
values
Indicators :
Problem identification
Data gathering related to problem
Data analysis
Selection appropriate action
Monitor progress of action taken
CORE COMPETENCY 3:
Promotes patient safety and comfort
Indicators :
Performs age-specific safety measures and comfort measure in all aspects of
patient care
CORE COMPETENCY 4:
Priority setting in nursing care based on patients’ needs
Indicators :
Identifies priority needs of patients
Analysis of patients’ needs
Determine appropriate nursing care to be provided
CORE COMPETENCY 5:
Ensures continuity of care
Indicators :
Refers identified problems to appropriate individuals/ agencies
Establish means of providing continuous patient care
CORE COMPETENCY 6:
Administers medications and other health therapeutics
Indicators :
Conforms to the 10 golden rules in medication administration and health
therapeutics
CORE COMPETENCY 7:
Utilizes nursing process as framework for nursing. Performs comprehensive,
systematic nursing assessment
Indicators :
Obtains consent
Complete appropriate assessment forms
Performs effective assessment techniques
Obtains comprehensive client information
Maintains privacy and confidentiality
Identifies health needs
CORE COMPETENCY 8:
Formulates care plan in collaboration with patients, other health team members
Indicators :
Includes patients, family in care planning
States expected outcomes in nursing interventions
Develops comprehensive patient care plan
Accomplishes patient centered discharge plan
CORE COMPETENCY 9:
Implements NCP to achieve identified outcomes
Indicators :
Explain interventions to patient, family before carrying them out
Implement safe, comfortable nursing interventions
Acts according to client’s health conditions, needs
Performs nursing interventions effectively and in timely manner
CORE COMPETENCY 10:
Implements NCP progress toward expected outcomes
Indicators :
Monitors effectiveness of nursing interventions
Revises care plan PRN
CORE COMPETENCY 11:
Responds to urgency of patient’s condition
Indicators :
Identifies sudden changes in patient’s health conditions
Implements immediate, appropriate interventions
CORE COMPETENCY 2:
Develops Health Education plan based on assessed and anticipated needs.
Indicators:
Considers nature of the learner in relation to social, cultural, political, economic,
educational, and religious factor
CORE COMPETENCY 3:
Develops learning material for health education
Indicators:
Involves the patient, family and significant others and other resources
Formulates a comprehensive health educational plan with the following
components , objectives, content and time allotment
Teaching-learning resources and evaluation parameters
Provides for feedback to finalize plan
CORE COMPETENCY 4:
Implements the health Education Plan
Indicators:
Provides for conducive learning situation in terms of timer and place
Considers client and family preparedness○ Utilize appropriate strategies
Provides reassuring presence through active listening, touch and facial
expression and gestures
Monitors client and family’s responses to health education
CORE COMPETENCY 5:
Evaluates the outcome of health Education
Indicators:
Utilizes evaluation parameters
Documents outcome of care
Revises health education plan when necessary
V. LEGAL RESPONSIBILITY
CORE COMPETENCY 1:
Adheres to practices in accordance with the nursing law and other relevant
legislation including contract and informed consent.
Indicators:
Fulfill legal requirements in Nursing Practice
Holds current professional license
Acts in accordance with the terms of contract of employment and other rules and
regulation
Complies with the required CPE
Confirms information given by the doctor for informed consent
Secures waiver of responsibility for refusal to undergo treatment or procedures
Check the completeness of informed consent and other legal forms
CORE COMPETENCY 2:
Adheres to organizational policies and procedures, local and national
Indicators:
Articulates the vision and mission of the institution where one belongs
Acts in accordance with the established norms and conduct of the institution/
organization
CORE COMPETENCY 3:
Document care rendered to patients.
Indicators:
Utilizes appropriate patient care records and reports
Accomplish accurate documentation in all matters concerning patient care in
accordance with the standard of nursing practice.
VII. RESEARCH
CORE COMPETENCY 1:
Gathers data using different methodologies
Indicators:
Identifies researchable problems regarding patient care and community health
Identifies appropriate methods of research for a particular patient/community
problem
Combines quantitative and qualitative nursing design thru simple explanation on
the phenomena observed
Analyzes data gathered
CORE COMPETENCY 2:
Recommends actions for implementation
Indicator:
Based on the analysis of data gathered, recommends practical solutions
appropriate for the problem
CORE COMPETENCY 3:
Disseminates results of research findings
Indicators:
Communicates results of findings to colleagues/patients/family and to others
Endeavors to publish research
Submits research findings to own agencies and others as appropriate
CORE COMPETENCY 4:
Applies research findings in nursing practice
Indicators:
Utilizes and findings in research in the provision of nursing care to
individuals/groups/communities
Makes use of evidence-based nursing to ameliorate nursing practice
IX. COMMUNICATION
CORE COMPETENCY 1:
Establishes rapport with patients, significant others and members of the health
team.
Indicators:
Creates trust and confidence
Listens attentively to client’s queries and requests
Spends time with the client to facilitate conversation that allows client to express
concern.
CORE COMPETENCY 2:
Identifies verbal and non-verbal cues
Indicator:
Interprets and validates client’s body language and facial expression
CORE COMPETENCY 3:
Utilizes formal and informal channels
Indicator:
Makes use of available visual aids
CORE COMPETENCY 4:
Responds to needs of individuals, family, group and community
Indicator:
Provides re- assurance through therapeutic, touch, warmth and comforting words
of encouragement
Readily smiles
CORE COMPETENCY 5:
Uses appropriate information technology to facilitate communication
Indicator:
Utilizes telephone, mobile phone, email and internet, and informatics
Identifies a significant other so that follow up care can be obtained
Provides “holding” or emergency numbers of services
References
Official Gazette. (2002, October 21). Retrieved May 28, 2020, from
http://www.officialgazette.gov.ph/2002/10/21/republic-act-no-9173/
The Nursing Profession. (2009, September 13). Retrieved May 27, 2020, from
http://www.thenursingprofession.blogspot.com/2009/09/11-core-competencies.html?m=1
American Nurses Association. (2014). The Code of Ethics for Nurses with Interpretive Statements.
Berman, Snyder, Kozier, & Erb. (2008). Kozier and Erb's Fundamentals of Nursing, 8th ed. Vol. 1.
Pearson Education, Inc.
National Privacy Commission . (2016). Implementing Rules and Regulations of Republic Act No.
10173, known as the "Data Privacy Act of 2012".
Saint Anthony Mother and Child Hospital. (n.d.). Retrieved May 28, 2020, from
http://www.samch.doh.gov.ph/index.php/patients-and-visitors-corner/patients-rights