FUNDAMENTALS OF NURSING

Nursing
 Latin word “Nutrix” = nourish.
 An ART and SCIENCE.

ART SCIENCE History of Nursing in the Philippines

 Therapeutic use  Specific or  Philippine Revolution
of self. specialized o Doña Hilaria de
 Dexterity and body of Aguinaldo – founder of
skills. knowledge Filipino Red Cross.
1. Communication o Trinidad Tecson – mother
– charting and of Filipino Red Cross
nursing diagnosis
(Problem, Hospital and Schools of Nursing
Etiology, Sign (patterned to US)
and symptoms) 1. Iloilo Mission Hospital School of
2. Manual/hands nursing (Iloilo city, !906) – IMH
on 2. Philippine General Hospitals
3. Cognitive Skills School of Nursing (Manila, 1907) –
(decision making) UP manila
3. St. Paul’s School of Nursing
(Manila, 1907) -
 CARING/🌟COMPASSION =
Essence of nursing. College of Nursing in the Philippines
 Committed to: 1. University of Santo Tomas College
o promoting individual, of Nursing (1946)
family, community, and 2. Manila Central University College of
national health goals in the Nursing (1947)
manner.
o personalized services for all Nursing Leaders in the Philippines
persons without regard to 1. Anastacia Giron Tupas –
color, creed, or social or founder of PNA
economic status. 2. Cesaria Tan – first to receive
master’s degree abroad
If you take care of an individual, who 3. Rosa Militar – pioneer of school
will benefit? health nursing education
A individual R: if the individual 4. Loreto Tupaz – Florence
benefits, everybody will (umbrella nightingale of Iloilo & requested
effect) the first NLE outside Manila
B. Family
C. Community Who is the Florence N. of the
D. Nation Philippines?
Dean Julia Solejo (Code of Ethics)
What food is not included in the food
tray for ISLAM? What can be filed to Nurse?
Pork, alcohol beverages, shrimp, A. Criminal – violated RA (Liability of
crabs. criminal > imprisonment and civil >
R: Haram – forbidden (land) pay)
alimasag B. Civil – private person > TORT > Civil
Halal – allowed (sea) alimango (pay)
C. Administrative – Public office >
License will be revoked by the BON
D. All of the Above

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 FUNDAMENTALS OF NURSING

First "True” Nursing Law

 ACT 2808 (1919) which created
the BON.
 First NLE (1920) in Manila
 Lasted till 1935 Period of Apprentice Nursing
First Philippine Nursing Law  Most care delivered by members of
 RA 877 (1953) – everything after religious orders.
1935.  Pastor Theodor Fliedner and
 Law created by the people. Fredericia Fliedner.

Period of Intuitive Nursing Dark period of Nursing

 Prehistoric times among primitive  17th – 19th century.
tribes.  Nurses were women of less
 Out of Compassion for others. desirable members of society
 A function that belongs to women. (prostitutes).
 Illness caused evil spirits through
the use of magic or voodoo Period of Educate Nursing
(kulam).  Flo N. School of nursing opened at
 Medicine man or “Shaman” – uses
white magic. St. Thomas Hospital in London – 🌟
 Trephining. England (Country of modern
nursing).
Changes  Flo N. – mother of modern nursing
GCS – EVM o Also known as the lady with
MVA > respiratory > stabilize spine > the lamp – 1939 to 1945.
circulatory o Born on May 12, 1820 in
Anisocoria – uneven pupils
Florence Italy.
Dec. LOC > sleep – easily awaken >
o Entered the deaconess
immediately goes back to sleep
school at Kaiserswerth
o Took care of soldiers in
Pain (ICU)
Crimean war.
1. Sternal rub
o Published books – notes in
2. Nailbed pressure
3. Trapezius Squeeze nursing and notes in
*Removed the nipple pinching hospitals.

Period of Contemporary Nursing

Philippines
 Period of WWII to the present.
 Herbman
 Establishment of WHO.
 Mabuting Hilot
 Use of atomic energy for medical
IgG – transplacental Ig (passive natural diagnosis and treatment.
immunity)  Use of sophisticated equipment;
IgM – first Ig produced by the fetus; computers.
natural astringent (green tea extract)  Health is perceived as a
IgA – found in colostrum (postpartum fundamental human right.
10 days milk); tears; saliva  Development of the expanded role
IgD – serum (unknown) of the nurse.
IgE – increased during allergic reaction
(rhinitis) and presence of asthma Extracorporeal Membrane
Oxygenation (ECMO) – hyper
Parameters for diagnosis perfusion
IgG – chronic infection (old)
IgM
2 – acute infection (new onset)
 FUNDAMENTALS OF NURSING

assigned is not fluent to

Oral antiviral medication to prevent the Px language/dialect.
severed COVID (EUA > Paxlovid – same
o 🌟Unfamiliar with the
time every day > take within 5 days
after a positive COVID test) patient R:
confidentiality
Pfizer – Nimatrelvir 30 mg (COVID);
Ritonavir 100 mg (AIDS) – to prevent 3. Coordinator
the degradation of Nimatrelvir in the  Coordinates and plans care.
liver; 3 tabs 12 hrs apart.  Piece together fragmented
Side effects: care.
1. HPN  Prepares Px for discharge.
2. Bitter taste  Liaison in health care team.

WHO first line treatment: 4. Communicator

1. Paxlovid - tab  Establish rapport.
2. Remdesivir - inpatient  Helping relationship.
3. Molnupiravir – capsule (green); 800  Assertive commnunicator.
mg 2x a day for 5 days
5. Counselor
 Assist and guide Px in solving
Roles of a Professional Nurse problems or making decisions.
1. Caregiver  Utilize the interpersonal
 Functions as nurturer, (helping) relationship.
comforter, provider.  Promote self-determination.

 🌟 Mothering actions of the 6. Manager

nurse.  Plans – identify needs and
 Provides direct care and development of goals.
promotes comfort of client.  Organizes – identify resources
to meet goals.
2. Teacher  Directs – leading others in
reaching goals.
 🌟 Encourages compliance with  Controls – monitoring ongoing
prescribed therapy. evaluations.
 Educate Px to develop self-care  Delegates – Right task,
abilities. person, circumstances,
 Demonstrate needed skills. communication, & feedback.
 Provide knowledge to allow Px
to make informed decisions. 7. Leader
 Promotes healthy lifestyle – 30  Have visions to energize
mins a day, adjust for 2-3 mos others.
to max 60 mins due to  Motivates others to achieve
increased creatinine due to goals.
muscle movement.  Encourages others to do their
 Interprets information to the best.
client.  Works collaboratively.
 Have wider variety of roles
o 🌟Trained medical than managers.
interpreter must be
present if nurse 8. Team Player
 Nurses are part of a team.

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 Don’t work in isolation.  Cabbage  Bread/cakes

 Sayote  Milk tea
9. Motivator  Green leafy (added sugar
 Motivates the Px to make veggies bev.)
changes.  Strawberries  Mangoes
 Oatmeal (ripe)
10.Critical Thinker  Watermelon
 Looking at problems other than  Over ripped
the obvious. banana
 Open to new ideas.
Cruciferous food
 Cabbage
 Lettuce
11.Innovator  Broccoli
 Takes action to make things  Cauliflower
happen.  Bok Choy
 Initiates change.
 Sees a problem and looks for  🌟 Brussel sprouts
solutions.
 🌟 Kale
12.Researcher
 Collect data to improve nursing  🌟 Chopsuey
practice.
 Provide info for EBP. Oils
1. Olive
13.Advocate 2. Cannola
 Protect and support the Px.
 Representative for ALL PXs. Expanded Roles of a Professional
 Assertiveness. Nurse (7)
 Promote self-determination. 1. Clinical Specialists
 Master’s degree in specialty.
 Clinical expertise.
Heplock meds administration  Provides expert care to
(SASH): individuals.
1. Saline  Participates in educating
2. Administer medication health care professions and
3. Saline ancillary.
4. Heparin  Clinical consultant and
participates in research.
Diarrhea management:
H2 Blocker
Hyoscine 🌟Nursing Specialty Certificate
program
Aversion therapy for alcoholism –  10% RNs in hospital should
disulfiram (Antabuse) undergo training.
Cruciferous vegetables – anti colon  Free training sponsored by DOH
cancer (seizure) (e.g., NKTI, HC).
 Free funded by lotto (PCSO &
PAGCOR)
Low glycerin High glycerin  Why only few undergo training?
index index Required to serve to any PH

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 FUNDAMENTALS OF NURSING

hospital for a period of 2

YEARS. Asthma
- Young
Which of the following is not included in - Afebrile
the expanded roles of nurses in the Ph? - Non productive cough
A: Nurse Pediatrician - Wheezing

Pneumonia
🌟 Ladder of Clinical Proficiency – - Fever.
Patricia Benner: - Productive cough (yellow phlegm =
bacterial; white = virus).
Novice – 0-1 years’ experience RN (🌟 - Elderly > earliest sign = altered
rule governed behavior or strict > takot mental status with associated
matanggalan ng trabaho). dehydration; late sign is fever.

Advance Beginner - 1-2 years’ COPD (chronic bronchitis and

emphysema)
experience RN (🌟DM is based on - Elderly.
theory). - Hx of smoking.
- Assess current health activities.

Competent – 2-3 years (🌟DM is based Chronic bronchitis

on client’s needs). - Narrow airway with phlegm.
- Decreased O2 in the body
- Right sided failure (systemic).
Proficient – 3-5 years’ experience (🌟
- 🌟Peripheral edema.
DM is based on priorities).
- 🌟Weight gain.
Expert - >5 years of experience (🌟DM
- 🌟Blue bloaters = cyanotic.
is intuitive and instinctive).

2. Nurse Practitioner Pulmonary Emphysema

 Either as certificate program or - Lack of recoil = CO2 trapped.
a master’s degree, certified by
- 🌟Pursed lips = alleviate pain and
the appropriate specialty
organization. expels CO2.
 Skilled at making nursing - Barrel chest = trapped air in the
assessments, performing P.E., lungs.
counseling, teaching and - Lack of appetite = weight loss.
treating minor and self-limiting
- 🌟Pink puffers.
illness (Viral e.g. Varicella
zoster virus or chicken pox).
 Nurse has their own clinic. Which of the following is not done in
examining scrotum?
Tuberculosis (TSE = less than 20 years old)
- Night sweats (2 weeks cough) A. Palpation
- X-ray (extent of damage) B. Percussion
- Mantoux test (PPD test > exposure C. Inspection
to TB) D. Auscultation > R: rule out hernia
- Sputum test (check for active TB) (bruit)

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 FUNDAMENTALS OF NURSING

(eyebrows or temple)
Testes of infant is not in the scrotum - Lesions = vesicular vesicles =
before delivery, instead it is in the fluid filled > Dewdrop on a petal
abdominal area (kidney); Left always go pattern
down first “I don’t want to be LEFT - Virus is dormant in the posterior
BEHIND”. horn of the spinal cord (reactivated
due to poor immune system >
Undescended testicle is the number 1 Herpes Zoster).
cause for testicular cancer.
Bag of worms > varicocele (dead sperm Herpes Zoster aka Shingles
= infertility) - Appear unilateral.
- Elderly should take shingles shot.
Types of lung sounds: - Zebralike skin (red stripes)
Wheezing
- musical sound Common complain
- narrowed airway > administer - Posterior (sensory) portion of the
Bronchodilator (bronchodilators spinal cord > PAIN.
before steroids; R: how will the - DOC for pain > GABA helps calm
steroids enter if it is narrow). and inhibits nerves to decrease
pain.
Stridor
- wheeze but more intense Dopamine “Pag may DOPE may
- sign of obstruction > report Addiction”
immediately post bronchoscopy. - repetitive behavior and pleasure >
addiction
Crackles Acetylcholine
- bubbling - starts the muscle contraction.
- Coarse = phlegm > pneumonia - Low acetylcholine miastemia gravis.
- Fine = fluid > heart failure - excessive acetylcholine due to low
congestion > pulmonary edema dopamine > Parkinson’s.
Serotonin
Pleural Friction Rub - sleep cycle.
- Grating sound upon auscultation.
Herpes Simplex (STD)
Heart Valves Location (APTM 2245) - blister in the perineum or genital
- Aortic = 2nd ICS (right) area.
- Pulmonic = 2nd ICS (left) - CS for pregnancy.
- Tricuspid = 4th ICS (right/left R:
depending on the angle can be Types of Herpes Simplex
heard from both sides) - HSV1 = above waist.
- Mitral = 5th ICS (right) - HSV2 = below waist.

Heart sounds Human Papilloma Virus

S1 – closure of atrioventricular valves = - cervical cancer (HPV 16 & 18).
mitral + tricuspid.
S2 – closure of semilunar valves = Syphilis
aortic + pulmonic. - Bacterial (CA: Treponema Pallidum;
DOC: penicillin)
Varicella Zoster Virus aka Chicken - Cross reaction with penicillin >
Pox (DOC: acyclovir = limit lesion) cephalosporins (allergies)
- Scarring = pockmark, crater like

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 FUNDAMENTALS OF NURSING

True reaction of allergies with  A nurse who has an advanced

penicillin degree and manages health-
- Wheezing related business.
- Fever
- Rash
7. Nurse Administrator
Type of syphilis  A nurse who functions at
Primary - chancre sore > painless various levels of management
ulcer in health settings.
Secondary – Condyloma latum >
wartlike
Tertiary – Gummas > saclike lesion
Neurosyphilis – most fatal as it can Nursing Theories
lead to psychosis. 1. Environmental Theory –
Florence Nightingale
3. Nurse Midwife  Manipulate the environment to
 A nurse who has completed a facilitate recovery.
program in midwifery,  “Cleanliness”.
provides prenatal and
uncomplicated pregnancies.

4. Nurse Anesthetist
 A nurse who completed the
course of study in an
anesthesia school and carries
out pre-operative status of
client.

What is the recommended mode of

anesthesia for Episiotomy repair?
A. Local infiltration > Lidocaine (+
Antiarrhythmic medication > PVS)

(+) Atrial Fibrillation

- Asses the vital signs and
decrease of LOC > high risk for
clot.

5. Nurse Educator
 With advanced degree, who 2. 21 Nursing problems – Faye
teaches in clinical or education Glenn Abdellah
settings, teaches theoretical  To promote optimal activity:
knowledge, clinical skills and
exercise, rest, sleep.
conduct research.
 To promote safety by
 At least 1 year experience (RA
preventing accidents, injuries,
9173).
or other trauma and
 3 years of experience (RA preventing the spread of
9164). infection.
6. Nurse Entrepreneur

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- Level of potassium (6mEq/L)

 🌟To maintain good body
mechanics and prevent and Diabetes
correct the deformity.
- (️️)/absence of insulin
Ergonomic Principles (4)
 To facilitate the maintenance of a - - Wide
Cell base
starvation = (️
of support ️) feet
> glucose
widein
supply oxygen to all body cells. apart.
blood > need for insulin and
 To facilitate the maintenance - Bend on the to
potassium knees.
enter cell.
of nutrition for all body cells. - Be as close to the object being
- lifted
🌟Fatal problem with insulin
as possible.
 🌟To facilitate the maintenance
therapy > hypokalemia (banana
of elimination (2-3x/week). - 🌟Contract
or the gluteal,
Kalium abdominal,
Derule) and
arms, and leg muscles.
hypoglycemia
 🌟To facilitate the maintenance
of fluid and electrolyte - 🌟Snack for DM travel > raisins (️️)
balance. NA + K+
 To recognize the physiologic - Regular Insulin – administered
responses of the body to via IV.
disease conditions – - Ideally (SQ) slow release to
pathologic, physiologic, and prevent rebound hypotension.
compensatory.
- 🌟Open vial > stored at ROOM
Sodium (135-145 mg/dl) temperature (in reality na sa fridge
but must wait for 2 hours to
- (⬆) NA = Hypertension (HTN).
sustain room temp) > label the
- Average Na intake = 2,500 mg. date of opening (28-30 days/ 1
- Average Na intake with HPN = month viability).
1,500 mg/day.
- Instant Noodles 800mg/pack. - 🌟Unopen vial > Fridge.

- (️️) NA = cerebral edema >

Insulin + BURN
Alzheimer’s disease. - K+ is released in the cell when
there is a burn > Hyperkalemia.
Angiotensin Receptor Blocker
(ARB) - 🌟Laboratory parameter 24
- Management for hypertension (e.g. hours post burn > Potassium.
Losartan - potassium, Telmisartan).
- Eliminates the salt = hyponatremia. - 🌟Insulin facilitates the intracellular
movement of the Potassium inside
Potassium (3.5 – 5.2 mEq/dl) the cell (ipapasok niya).
- 90% excreted via urine > ihi ng ihi
= Hypokalemia Mixing insulin
- Syringe.
- Renal Failure > (️️) urine output =
- Neutral Protamine Hagedorn
hyperkalemia (cloudy) > air; Regular insulin
(clear) > air (5ml); R > withdraw ;
Qualification of Dialysis NPH > withdraw

- (️️) BUN (>20) + Creatine (>1.3). - 🌟“Clear first before cloudy”

- Fluid retention > edema.

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 FUNDAMENTALS OF NURSING

5. Goal Attainment Theory –

Heparin VS Warfarin Imogene King
“In heaven (heparin) there is peace, In  The model has three
war (warfarin) there is violence”. interacting systems: (1)
personal, (2) interpersonal,
Assessment: and (3) social.
Heparin – Protamine Sulfate (PTT)  The concepts for the
Warfarin – Vitamin K (PT) personal system >
perception, self-growth, and
3. 14 Basic Needs – Virginia development, body image,
Henderson space, and time.
 “Valentine’s Heart’s” or “basta o “GA: height is equal
Virgin, 14”. to arm span”.
 Maslow’s Hierarchy of human  The concepts for the
needs. interpersonal system >
interaction, communication,
transaction, role, and stress.
 The concepts for the social
system > organization,
authority, power, status, and
decision-making.

Anorexia Nervosa
- Weight is downhill.
- Fixed body disturbance

Bulimia Nervosa
- “Saw tooth ang weight”.
- Concious
4. Behavioral System Model –
Dorothy Johnson 6. Transcultural Nursing Theory –
 “Behaviors affect health”. Madeleine Leininger
 She also identified four goals  “Ethno Nursing”.
of nursing, which are to assist  Respect the individual’s
the patient: culture, practices, and beliefs.
o Whose behavior is in
proportion with social
demands.
o Who is able to modify his
behavior in order to
support biological
imperatives.
o Who is able to benefit to
the fullest extent during
illness from the physician’s
knowledge and skill.
o Whose behavior does not
give evidence of Scenario: You’re handling a HIV patient,
unnecessary trauma as a what is the most important
consequence of illness. responsibility of the nurse?
A. Tell the Px that he is HIV +. R:

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 FUNDAMENTALS OF NURSING

you’re now allowed to give result - White > frontal

interpretation as a nurse.
B. Remind the PC that AIDS can be 9. Self-Care Deficit Theory -
transmitted through urine, blood, Dorothea Orem
and semen. R: urophilia (drinking  Wholly compensatory – Px
the urine) who are bed ridden and
comatose.
7. Four Conservation Principles –  Partially compensatory –
Myra Levine assistance.
 Conservation of Energy > eat. o Semi-dependent Px –
 Conservation of Structural cannot walk but can dress
Integrity > continuity of skin themselves. Nurse will
+ mucous membranes gather the
 Conservation of Personal clothes/equipment. Can
integrity > ego/self-worth, button or unzip Px
dignity. clothes.
 Conservation of Social  Supportive – educative –
integrity >. Health teaching.

Log roll > for Px that underwent

laminectomy od the cervical spine.

Vitamin A + measles
- Protect the mucous membrane of
the eyes.
- Boosting the immune system.
- Prevent night blindness.

Zinc
- Boost immune system.
- Toddler with diarrhea for 14 days. Bed bath > firm long strokes > (️️)
venous return

Nitroglycerin patch (chest – clip

hair or shave) > (️️) venous return due

to vasodilation
8. Health Care System Model –
Betty Neuman
Why do we increase venous return?
 Intra Stress – within the
> prevent deep vein thrombosis >
individual (e.g., Pain, Fever).
Virchow’s Triad
 Inter Stress – between
persons.
 Extra Stress – environment. Virchow’s Triad
- Hypercoagulability of the blood
(e.g., DM, smoker, Combined oral
Type of Dental Filling
Contraceptives).
Amalgam
- Venous blood stasis (e.g., lithotomy
- silver or gray in color
-cystoscopy, prolonged sitting).
- Strong > molar
- Injury to the blood vessel wall.
Lite Cure
Anticoagulant > prevent further clot.

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 FUNDAMENTALS OF NURSING

Thrombolytics > dissolves clot (e.g.,

Urokinase, Streptokinase, tissue
Plasminogen Activator (tPAs) – 3-6
hours for stroke).

Types of Intracerebral Hematoma

2. 🌟Remittent Fever
 Within 24 hours, Fever
fluctuates but never goes down
to normal.
 Common with Px with
Infective Endocarditis
(heart).

10. Interpersonal Model –

Hildegard Peplau
 “Levels of anxiety”.
 4 phases:
o Orientation – establish
rapport.
o Identification – Px is
cooperative.
o Exploitation – Px, will
🌟What type of fever fluctuates ABOVE
take advantage of the
nurse “gagawin kang normal?
katulong”. A: Remittent fever
o Resolution – discharge.
3. Relapsing Fever
 Within days, usually 2-3 days,
temperature fluctuates from
Normal to fever.
 Common with Lyme Disease,
Dengue fever (Saddleback
Fever).

Types of Fever 4. Constant Fever

1. Intermittent Fever  Continuously 40-41 Celsius
 Within 24 hours, temperature fluctuations do not exceed 1
fluctuates from Normal to Celsius.
Fever.  Unresponsive to antipyretics.
 Common in Leptospirosis,  Common with KAWASAKI
Schistosomiasis, Pyrogenic disease (autoimmune).
infection. o Vasculitis > strawberry
tongue.

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 FUNDAMENTALS OF NURSING

Ice and Fever Criteria

o (️️) temperature > 1. Emergency and high BMR due to
Inflammation > constant excessive consumption of O2 that could
fever >DOC: Incids. lead to hypoxia and anaerobic
metabolism.
Kawasaki Disease
Med mgt: IVIG – autoimmune. 2. Neuroleptic malignant syndrome
- Complication of antipsychotics.
DOC: Aspirin > (️️) fever; but not given
to Pxs with Viral infection to prevent 3. Malignant hyperthermia
Reye’s syndrome > damage to liver and - Hereditary; react to gas anesthetics
brain.
(GA) > rapid muscles spasms > (️️)
friction > heat.

- 🌟DOC: muscle relaxant –

Dantrolene Sodium.

Colostomy/Ileostomy
- Bag is attached inside the OR.
- Expect loose and bloody drainage
for 10 days.

Nursing Action make assessment

Decline of Fever first > NEVER ANSWER CALL A
1. Lysis DOCTOR Exemption:
1. Pain > active bleeding (e.g., post
 Gradual (️️) of fever. cataract extraction and renal biopsy)

2. Crisis Methods of Temperature taking

1. Oral
 Sudden (️️) of fever.  Under the tongue, beside the
frenulum (highly vascular >
Nursing intervention for Client with blood).
Fever  Contraindications:
o Nausea and Vomiting.
1. (️️) Fluid intake. o Cough.
2. Full diet due to high Basal o Infant (mouth breathers).

Metabolic Rate ((️️) BMR > o (️️) LOC.

consumes O2 > anaerobic
o (️️) 5 years old > febrile
metabolism > (️️) lactid acid > lactic seizure.
acidosis). o O2 therapy.
3. Oral care due sordes (dead cells in
the mouth) leading to bitter taste. 2. Rectal
4. TSB – 28 - 30 degree celsius >  Most accurate.
tapping or patting motion to avoid  Insert 0.5-1.5 inch.
friction which induces heat > long  Use water base lubricant (KY
strokes. jelly).
 Contraindications:

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 FUNDAMENTALS OF NURSING

o Hemorrhoids
o Diarrhea
🌟Pitting Edema
o Cardiac Disease (Vagus
stimulation > bradycardia > +1 = barely detectable up to 2mm.
MI) +2 = 2mm – 4mm
+3 = 4mm – 7mm | 5mm – 7mm
o (️️) ICP (Monro-Kellie +4 = 7mm – above | 8mm and above
Doctrine)

Salem Sump Tube

- To relieve post-op distention.

Monro-Kellie Doctrine Constants:

1. Brain volume Factors affecting pulse rate
2. CSF  (️️) age, (️️) pulse.
3. Intracerebral blood

3. Axillary Inotropic
 Safest and most non-invasive. - Force/strength of cardiac
 Constraints: contraction.
o Lesions.
o CVA (false low result) > Chronotropic
take temperature in the - Heart.
unaffected side. E.g.
o Amputation. (+) ino = (️️) force/strength of heart
contraction
Homonymous Hemianopsia
- Side of the brain attack is opposite (-) chrono = (️️) HR
to homonymous hemianopsia.
Interpretation: “lumalakas ang
contraction pero bumabagal ang pintig”
Left homonymous Hemianopsia
(left sided neglect)
- Blind at the Left. Medications:
- Beta Blockers
- 🌟Put call light to right. - Digitalis

- Digoxin (️️) HR; Before

- 🌟Introduce/orient to Px to a new
administration asses HR
room > Left R: right sided is not
blind so he is aware of what is at
the right. Introduce to the Nine known Pulses
neglected side to increase 1. Superficial Temporal
awareness.  Most east to palpate pulse
next to brachial in INFANT.

2. Carotid
Amplitude/Volume of the pulse
 CPR in adults, NOT for infant
 4 + = strong bound.
due to short neck.
 3 + = full pulse.
 2 + = Normal and easy to read
3. Apical
pulse.
 Point of maximal impulse.
 1 + = weak and thready
 0 = absent

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 FUNDAMENTALS OF NURSING

4. Brachial - ALL (common in children).

 CPR in infants. - Stem cell for WBC.
 BP monitoring. - Complication due to infection.

5. Femoral - 🌟WBC crowds the RBC > Anemia.

 Pulse checked for bleeding
after a cardiac catheterization. - (️️) platelet.

6. Popliteal Cranial Nerves

 Pulse checked for circulation to
the leg (behind knee).

7. Dorsalis Pedis
 Pulse checked for circulation to
the foot.

8. Posterior Tibial
 If dorsalis pedis is not present
anymore.

9. Ulnar
 Collateral circulation.
 ABGs is taken in Radial.
 Allen’s test (check patency of
collateral circulation).

 🌟NEVER INSERT NEEDLE FOR

ABG IN RADIAL IF ULNAR IS
OBSTRUCTED > Hand will have
Necrosis.

🌟What is the most accessible pulse?

A: Radial Pulse

🌟What is the most routinely checked

pulse in neonates? Factors Affecting Blood Pressure
A: Apical
 (️️) Age = (️️) BP due to decreased
elasticity of blood vessels.
Leukemia - (️⬇️) Thrombocytes  Medications such as steroids,
1. Myeloid (AML & CML) anticholinergic, and adrenergic
- CML (common in adult). increases BP.
- Stem cell for RBC, Platelet, and WBC.
 Males will have an (️️) BP after
- 🌟 Most complicated. puberty and before 65 years due

to (️️) testosterone.
2. Lymphoid (ALL & CLL)

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 FUNDAMENTALS OF NURSING

 Females will have an (️️) BP after 60 - 🌟Done 1 hour before meals/before

bedtime.
years due to menopause, (️️) - Percussion > copped hands.
estrogen (vasodilator) production. - Vibration > shaking.

Assessment of Blood Pressure Suctioning

- Done 10-15 seconds (adult).
 🌟Retake of BP, wait for 1-2
- No more than 10 seconds (pedia).
minutes. - Suction upon withdrawal using
circular motion with intermittent
 🌟Deflate, 2-3 mmHg/sec suction.
(at a time); if too fast, result will
have false low systolic, and false Hyperventilate
high diastolic. - Use of ambu bag.
 Width of BP cuff should 40% of - Adult = 3 hyper inflations.
the arm circumference. - Pedia = 3 inflations.
o 🌟Cover 80% of the area from
Hyperoxygenate
the shoulder to the elbow. - O2 tank = 10 Lpm
o Narrow – false high - Ventilator = find for FiO2
o Wide – false low (Fraction of inspired O2) > 100%.
o Loose – false high - Before and after suctioning.
o Arm above the heart – false
low Ear Examination
- Pedia (3 below) = Down and Back
Catheterization - Adult (3 above) = Up and Back
- Aseptic technique
Occult Blood test
- 🌟Encourage liberal amount of fluid - Hemoglobin Free diet for 3 days R:
intake. no red meat, no dark colored
foods.

🌟How will you maintain safety in Results:

catheterization? False (+)
A: Maintain closed sterile drainage - Iron
system > to prevent UTI - Red meat
- Fish
- Raisins
🌟How will you collect residual urine? - Chocolate
A: Catheterize Px immediately - NSAIDs
after voiding – Straight catheter. - Anti-coagulant
- Thrombolytics

Lung Catheterization False (-)

- Vit C.
- Elderly (️️) residual air volume; (️️) - Vit K.
vital capacity - Green leafy vegies

Chest Physiotherapy

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