FUNDAMENTALS OF NURSING

GOOD MORNING!!!

- SIR RITCHEL . . .`

NURSING
> the diagnosis of human responses to actual and potential problems. -- American Nurses Association > the act of utilizing the environment of the patient to assist him in his recovery. -- Florence Nightingale > to assist the individual sick or well. -- Virginia Henderson

Common Themes:
Nursing

is Caring. Nursing is an Art. Nursing is Science. Nursing is Client-Centered. Nursing is Holistic. Nursing is Adaptive. Nursing is concerned with health Promotion, Health Maintenance and Health Restoration. Nursing is a Helping Profession.

Nursing as a Profession.
Profession - calling that requires special knowledge, skill and preparation. Primary Characterisitics: 1. Education 2. Theory 3. Service 4. Autonomy 5. Code of Ethics

INTRODUCTION TO NURSING

BRIEF HISTORY

I. INTRODUCTION TO NURSING

1. Intuitive Nursing
(primitive times to 6th century) a. Nursing in ancient civilizations; instinctive nursing dates back even during the primitive tribes; Nursing was a function that belonged to women because of their place in society. b. Beliefs about the cause of disease were embedded in superstition and magic c. Earliest recording of healing was a 4,000 year-old clay tablet attributed to the Sumerian civilization

d. As societies evolved, nursing became a function of female slaves who cared for infant children of wealthy families through wet nursing and the practice of midwifery or the provision of care to the mother and infant during birthing; the slave-nurse was dependent on the master, healer or priest for instruction or direction in the care of her charge e. Lasted through the Christian era out of feeling of compassion for others, out of desire to help and out of wish to do good to others as embodied in the Christian value of love thy neighbor as thyself.

2. APPRENTICE NURSING (6TH - 18TH CENTURY)

a. Also called the period of on the job training b. Men engaged in Nursing during the Crusades through: - Knights Hospitalers or Knights of Saint John of Jerusalem - Teutonic Knights - Knights of Saint Lazarus c. This historical period extends from the founding of religious nursing orders in the 6th century, through the Crusades which began in the 11th century, to 1836 when Theodore Fliedner reinstituted the Order of Deaconnesses and opened a small hospital and training school in Kaisserwerth, Germany d. Florence Nightingale was the most famous Kaisserweth pupil; she changed the status of

3. EDUCATION NURSING

a. Began in June 1860 when the Florence Nightingale School of Nursing opened at St. Thomas Hospital in London; this school had the first program of formal education for the nurse b. The Philosophy of the Nightingales System was based on the following: - training of nurses should be considered as important as any other form of education and be supported by public funds. - training schools for nurses should have close affiliation with hospitals but retain financial and administrative independence from them. - professional nurses should be responsible for the education of nursing students rather than persons not involved in nursing - nursing students should be provided with

c. US and Canada copied the Nightingale Schools of England very closely but the US training schools failed to remain separate from the hospitals resulting in a form of educational abuse of nursing students by the hospitals d. Written physicians orders originated with Nightingale who insisted that nurses accompany the physicians on patient visits e. Believed that health teaching was a critical responsibility of the nurse if national health was to improve f. The last two decades of the 19th century is also

g. In the early decades of the 20th century, hospitals started to segregate patients according to their disease process thus the concept of clinical nurse specialist arose h. Between 1913 and 1937, a standardized curriculum for Schools of Nursing was prepared by the National League for Nursing Education

4. CONTEMPORARY NURSING

a. Began at the end of World War II; associated with scientific and technological developments and social changes since 1945 b. Changing patterns in Nursing education by adding more clinical content c. Professionalization of Nursing d. Globalization: borderless nursing

The Earliest Hospitals:

A. Hospital Real de Manila (1577) - it was established mainly to care for the Spanish Kings soldiers but also admitted Spanish civilians. - founded by Gov. Francisco de Sande. B. San Lazaro Hospital (1578) - built exclusively for patients with leprosy. - founded by Briother Juan Clemente. C. Hospital de Indio (1586) - service was in general supported by alms and contributions from charitable persons.

D. Hospital de Aguas Santas (1590) - founded by Brother J. Bautista of the Franciscan Order. E. San Juan De Dios Hospital (1596) - founded byBrotherhood of Misericordia and administered by the Hospitalliers of San Juan de Dios.

The Prominent persons:

1. Josephine Bracken - wife of Jose Rizal. Installed a field hospital in an estate house of Tejeros. Provided nursing care to the wounded night and day. 2. Rosa Sevilla De Alvero - converted their house into quarters for the Filipino soldier during the Philippine-American war that broke out in 1899. 3. Doa Hilaria de Aguinaldo -wife of Amelio Aguinaldo; organized the Filipino Red Cross under the inspiration of Apolinario Mabini.

4. Doa Maria de Aguinaldo - second wife of Emilio Aguinaldo. Provided nursing care for the Filipino soldiers during the Revolution. President of the Filipino Red Cross branch in Batangas. 5. Melchora Aquino (Tandang Sora) - nurse the wounded Filipino soldiers and gave them shelter and food. 6. Trinidad Tecson - Ina ng Biac na Bato, stayed in the hospital at Biac na Bato to care for the wounded soldiers.

Hospitals and Nursing Schools:

1. Iloilo Mission Hospital School of Nursing (Iloilo City, 1906) > It was run by the Baptist Foreign Mission Society of America. > Miss Rose Nicolet first superintendent > Miss Flora Ernst an American nurse, took charge of the school in 1942 2. St. Pauls Hospital School of Nursing (Manila, 1907) >The hospital was established by the Archbishop of Manila, The Most Reverend Jeremiah Harty, under the supervision of the Sisters of St. Paul de Chartres.

3. Philippine General Hospital School of Nursing (Manila, 1907) > In 1907, with the support of the Gov. Gen. Forbes and the Director of Health and among others, opened classes in nursing under the auspices of the Bureau of Education. > Anastacia Giron-Tupas, was the first Filipino to occupy the position of Chief Nurse and Superintendent in the Philippines.

4. St. Lukes Hospital School of Nursing (Quezon City, 1907) > The Hospital is an Episcopalian Institution. It began as a small dispensary in 1903. In 1907, the school opened with 3 Filipino girls admitted. > Mrs. Vitiliana Beltran was the first Filipino Director of the school. 5. Mary Johnston Hospital and School of Nursing (Manila, 1907) > It started as a small dispensary on Calle Cervantes. > It was called Bethany Dispensary and was founded by the Methodist Mission. > Miss Librada Javelera was the first Filipino Director of the school.

The First Colleges of Nursing in the Philippines:

University of Santo Tomas, College of Nursing > 1946 > Sor Taciana Trinanes First Directress Manila Central University, College of Nursing > 1948 > Consuelo Gimeno First Principal University of the Philippines, College of Nursing > 1948 > Ms. Julita Sotejo First Dean

Socialization for Professional Nursing Practice

1. Socialization
- process by which a person learns the ways of a group or society in order to become a functioning participant Benners (1984) five levels of proficiency as the nurse acquires SKA and values of nursing 5 STAGES: Stage 1: Novice - may be student or nurse entering a clinical setting where that person has no experience Stage 2: Advanced beginner - demonstrates marginally accepted performance

Stage 3: Competent - nurse has been on the job in the same situation for 2 to 3 years; demonstrates organizational ability but lacks the speed and flexibility of the proficient nurse Stage 4: Proficient - perceives a situation as a whole rather than just its individual aspects; nurse focuses on long-term goals and is oriented toward managing the nursing care of the client rather than performing specific tasks Stage 5: Expert - no longer relies on rule, guidelines or maxims to connect an understanding of the situation to an appropriate action; have highly developed perceptual acuity or recognitional ability, and their performance is fluid, flexible and highly proficient

Roles of the Professional Nurse

1. Care provider/Parent Surrogate - primarily concerned with the clients needs. *** Recognize the patients most immediate needs. 2. Communicator/Helper - communicates with the client, support persons and colleagues. ***Establish trust. 3. Teacher - provides health teaching to effect behavior change which focuses on acquiring new knowledge or technical skills. *** Assess clients learning needs/ Assess clients readiness to learn.

4. Counselor - process of helping a client to recognize and cope with stressful psychological or social problems, to develop improved interpersonal relationships and to promote personal growth. *** Render active listening/ Do not give advice. 5. Client advocate - advocates for client rights. 6. Change agent - initiates changes and assists the client makes modifications in the lifestyle to promote health. - helps the client to speak up for themselves. *** Patient must develop self awareness.

7. Leader - mutual process of interpersonal influence through which the nurse helps a client make decisions in establishing and achieving goals to improve clients well-being. 8. Manager - plans, gives direction, develops staff, monitors operations, gives reward fairly and represents both staff members and administration as needed. 9. Researcher - participates in scientific investigation and uses research findings in practice. 10. Collaborator - initiates nursing actions within the health team.

EXPANDED CAREER ROLES FOR NURSES: 1. 2. 3. 4. 5. 6. 7. 8. Nurse Practitioner Clinical Nurse Specialist Nurse Anesthetist Nurse Midwife Nurse Researcher Nurse Administrator Nurse Educator Nurse Enterpreneur

Focus of Nursing
1. Health and Wellness Promotion - helping people develop resources to maintain or enhance their well-being. 2. Illness Prevention - maintain optimal health by preventing disease. 3. Health Restoration - helping people to improve health following health problems or illness. 4. Care of the Dying - comforting and caring for people of all ages while they are dying.

The 4 Major Concepts:

1. Person - recipient of the nursing care. 2. Health - the degree of wellness and well being that a person experiences. 3. Environment - pertains to the internal and external surroundings that affects a person. 4. Nursing - pertains to attributes, characteristics and actions of the nurse providing care in behalf of the client or in conjunction with the client.

NURSING THEORIES

GENERAL THEORIES
1. Nightingales Environmental Theory
> focuses on the patient and his environment. > her work in Crimea (1854-1856) earned her the title The Lady with the Lamp. > also known as the First Nurse Scientist Theorist for her work, Notes on Nursing: What it is and What it is Not (1860). > she focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.

2. Virginia Hendersons Nature of Nursing Model

> conceptualizes the nurses role as assisting sick or healthy individuals to gain independence in meeting 14 FUNDAMENTAL NEEDS. > she postulated that the unique function of a nurse is assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. > she further believed that nursing involves assisting the client in gaining independence as rapid as possible, of assisting him achieves peaceful death if recovery is no longer possible.

14 BASIC COMPONENTS OF NURSING CARE ACCORDING TO VIRGINIA HENDERSON 1. Breath normally 2. Eat and drink adequately 3. Eliminate body wastes 4. Move and maintain desirable posture 5. Sleep and rest 6. Select suitable clothes 7. Maintain body temperature within normal range by adjusting clothing or modifying the environment 8. Keep the body clean and well-groomed and protect the integument 9. Avoid dangers in the environment and avoid injuring others

10. Communicate with others in expressing emotions, needs, fears or opinions 11. Worship according to ones faith 12. Work in such a way that there is a sense of accomplishment 13. Play or participate in various forms of recreation 14. Learn, discover or satisfy the curiosity that leads to the normal development and health and use the available health facility 1-9 10 & 14 11 12 & 13 Physiologic Component Psychological Spiritual Sociological

3. Martha Rogers Science of Unitary Human Beings

> Considers man as a unitary human being co-existing with in the universe, views nursing primarily as a science and is committed to nursing research. > Five assumptions about human beings: 1. Is an irreducible, four-dimensional energy field identified by pattern. 2. Manifests characteristics different from the sum of the parts. 3. Interacts continuously and creatively with the environment. 4. Behaves as a totality. 5. As a sentient being, participates creatively in change.

4. Dorothea Orems Self-Care Deficit Theory

> emphasizes the clients self-care needs, nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs. > she defined self-care as the practice of activities that individuals initiate to perform on their own behalf in maintaining life, health well-being. > conceptualized 3 Nursing Systems: 1. Wholly compensatory 2. Partially compensatory 3. Supportive-Educative

3 NURSING SYSTEMS: WHOLLY COMPENSATORY - nurse acts for the patient; patient has no active role. PARTIALLY COMPENSATORY - both nurse and patient perform care measures. SUPPORTIVE -EDUCATIVE - patient is able to perform.

5. Sister Callista Roys Adaption Model

> views client as an adaptive system. > She viewed each person as a unified biopsychosocial system in constant interaction with a changing environment. > goal of nursing is to enhance life processes through adaptation in four (4) adaptive modes. 1. Physiologic mode 2. Self-concept mode a. physical self b. personal self 3. Role function mode 4. Interdependence mode

6. Imogene M. Kings Goal Attainment Theory

> Nursing process is defined as a dynamic interpersonal process between nurse, client and health care system. > She described nursing as a helping profession that assists individuals and groups in society to attain, maintain and restore health, If is this not possible, nurses help individuals die with dignity.

7. Betty Neumans Health Care Systems Model

> based on two components - STRESS and REACTION TO STRESS FOUR CONCEPTS: A.CLIENT 1. FLEXIBLE LINE OF DEFENSE - keeps system free from stressor reactions or symptomatology; expands in the presence of stressors to protect the core. 2. LINES OF RESISTANCE - consist of internal defensive processes. 3. NORMAL LINE OF DEFENSE - usual level of wellness; standard used to measure deviation from health.

B. ENVIRONMENT - has potential to alter system stability due to internal and external stressors; also provides resources for managing stressors - ex. Immune system, good coping skills, family support, community health center. STRESSORS CAN BE: 1. EXTRAPERSONAL ex. unemployment, microorganisms, peer pressure 2. INTERPERSONAL - between 2 or more individuals; ex. parent-child expectations, conflict among colleagues 3. INTRAPERSONAL

C. HEALTH - condition in which all parts and subparts are in harmony with the whole client. RECONSTITUTION - process by which a person progresses from his normal line of defense to a higher or lower state of wellness. WELLNESS - occurs after adaptation to stressors.

D. NURSING NURSING INTERVENTION MODALITIES OF PREVENTION: 1. Primary Prevention - promotion of client wellness and protection of normal line of defense by strengthening flexible line of defense through the reduction of risk factors and stress prevention. 2. Secondary Prevention - protection of basic structure by strengthening internal line of resistance. 3. Tertiary prevention - promotion of existing reconstitution by supporting existing strengths and resource.

8. Dorothy Johnsons Behavioral System Model

> focuses on how the client adapts to illness; the goal of nursing is to reduce stress so that the client can move more easily through recovery. > Viewed the patients behavior as a system, which is a whole with interacting parts. 7 Subsystems of Behavior: 1. Ingestive - taking in nourishment in socially and culturally acceptable ways. 2. Eliminative - ridding the body of waste in socially and culturally acceptable ways.

3. Affiliative - security seeking behavior. 4. Aggressive - self-protective behavior. 5. Dependence - nurturance-seeking behavior. 6. Achievement - master of oneself and ones environment according to internalized standards of excellence. 7. Sexual and Role Identity behavior

9. Hildegard Peplaus Interpersonal Relations in Nursing

> defined nursing as a therapeutic, interpersonal process which strives to develop a nursepatient relationship in which the nurse serves as a resource person, counselor and surrogate. Peplaus Phases of Nurse-Patient Relationship: 1. Orientation Phase - leveling off between nurse and client in terms of expectations 2. Identification Phase - selective response of the client to those who can meet his/her needs; affected by clients beliefs 3. Exploitation Phase - client takes control of

10. Madeleine L einingers Transcultural Care and Universality Theory

Transcultural Nursing
- is culturally competent nursing care focused on differences and similarities among cultures, with respect to caring, health and illness, based on the clients cultural values, beliefs, and practices. > she advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition.

11. Ida Jean Orlandos Dynamic-Nurse Relationship > NURSING is a disciplined professional response > Types of Nursing response: a. deliberate - (based on correct identification of patient needs) b. automatic action > Nursing function is concerned with providing direct assistance to individuals in whatever setting to avoid, diminish,

12. Jean Watsons Philosophy and Science of Caring > Nursing is the science of caring > Caring is more healthogenic than curing > Main focus of nursing is on carative factors that are derived from humanistic perspectives combined with a scientific base TEN CARATIVE FACTORS: 1. Formation of a humanistic-altruistic value system. 2. Faith-hope. 3. Cultivation of sensitivity to self and others.

4. Establishing a helping-trust relationship. 5. Expression of feelings, both positive and negative. 6. Research and systematic problem-solving. 7. Promotion of interpersonal teaching-learning. 8. Provisions for a supportive, protective and corrective mental, physical, socio-cultural and spiritual environment 9. Assistance with the gratification of human needs. 10. Allowance for existential-phenomenological factors.

13. Faye Glenn Abdellahs 21 Nursing Problems

> defined nursing as having a problem-solving approach, with key nursing problems related to health needs of people. > She also defined nursing as a service to individual and families; therefore the society. ***Crucial in nursing practice is the correct identification of nursing problems: a. OVERT: apparent conditions b. COVERT: hidden conditions

Abdellahs 21 NURSING PROBLEMS:

1. To maintain good hygiene and physical comfort. 2. To promote optimal activity; exercise, rest and sleep 3. To promote safety through the prevention of accidents, injury or other trauma and through the prevention and spread of infection. 4. To maintain good body mechanics and prevent and correct deformities. 5. To facilitate the maintenance of a supply of oxygen to all body cells. 6. To facilitate the maintenance of nutrition of all body cells 7. To facilitate the maintenance of elimination.

8. To facilitate the maintenance of fluid and electrolyte balance. 9. To recognize the physiological responses of the body to disease conditions- pathological, psychological and compensatory. 10. To facilitate the maintenance of regulatory mechanisms and functions.. 11. To facilitate the maintenance of sensory function 12. To identify and accept positive and negative expressions, feelings and reactions. 13. To identify and accept the interrelatedness of emotions and organic illness. 14. To facilitate the maintenance of effective verbal and nonverbal communication.

15. To promote the development of productive interpersonal relationships. 16. To facilitate progress toward achievement of personal spiritual goals. 17. To create and/or maintain therapeutic environment. 18. To facilitate awareness of self as an individual with varying physical, emotional and developmental needs. 19. To accept the optimum possible goals in the light of limitations, physical and emotional. 20. To use community resources as an aid in resolving problems arising from illness. 21. To understand the social problems as influencing factors in the case of illness.

14. Nola J. Penders Health Promotion Model

Health Promotion: - directed towards increasing the level of well-being and self-actualization of a given individual or group. ex. maintaining 6 to 8 hours of daily sleep Disease prevention or Health Protection: - activities directed towards decreasing the probability of experiencing illness by active protection of the body against pathological stressors. ex. BCG vaccination

15. Lydia E. Hall Theory of Care, Core and Cure

> patient is composed of three elements: the Body (care), Pathology (cure), and the Person (core). > nursing operates in ALL three elements. **Care - represents nurturance and is exclusive to nursing. **Core - involves the therapeutic use of self and emphasizes the use of reflection. **Cure - focuses on nursing related to the physicians orders.

16. Myra Estrin Levines Four Conservation Principles of Nursing

> She advocated that nursing is a human interaction and proposed four conservation principles of nursing which are concerned with the unity and integrity of the individual.
> The Four Conservation Principles are as follows: 1. Conservation of Energy 2. Conservation of Structural Integrity 3. Conservation of Personal Integrity 4. Conservation of Social Integrity

MAN and His Basic Human Needs

CONCEPT OF MAN
A. ATOMISTIC APPROACH The atomistic study of man views man as an organism composed of different organ systems where each system is composed of organs and ear organ is composed of tissues and cells. B. HOLISTIC APPROACH This view traces mans relationship with other human beings in the suprasystem of society. This approach views man as a whole organism with interrelated and interdependent parts functioning to produce behavior. Man as a whole therefore is different from and more than the sum of his component parts. The dimensions of man include the physical, social, spiritual, cognitive and psychological aspects.

- Man as a social being is capable of relating with others. His first agent of socialization is the family where he is nurtured, where he learns his first language and where he first learns to socialize. - Man as a spiritual being is capable of such virtues as faith, hope and charity. Faith is the unquestioning belief in someone or something. It is the foundation where hope rests. Charity means the love of man for his fellowmen. Man as a spiritual being believes in a power beyond himself and of transcending ones limitations.

- Man as a thinking being is capable of perception, cognition, and communication. He is also capable of logical thinking and reasoning. - Man as a psychological being is capable of rationality. His rational side makes him merciful, kind and compassionate. - Man as a physical being has such characteristics as genetic endowment, sex, other physical attributes, physical structure and functions.

Abraham Maslows Hierarchy of Basic Human Needs

NEED - is something that is essential to the survival of humans. A basic need is something whose: 1. Absence may lead to illness 2. Presence may signal health or prevent illness 3. If unmet needs are met or fulfilled, health may be restored

FIRST LEVEL: Physiological Needs a. Oxygen e. Elimination b. Fluids f. Shelter c. Nutrition g. Rest d. Temperature H. Sex SECOND LEVEL: Safety and Security Needs 1. Physical Safety: - involves reducing or eliminating threats to the body such as illness, accident and environmental exposure. 2. Psychological Safety: - understanding and the appropriateness of what to expect from others, from new experiences and from encounters with the environment.

THIRD LEVEL: Love and Belonging Needs - need to establish social relationships and to experience emotional nurturance and care to and from others. FOURTH LEVEL: Esteem and Self-Esteem Needs - linked with the desire for strength, achievement, adequacy, competence, confidence, and independence. FIFTH LEVEL: Need for Self-Actualization - highest level of all needs.

Characteristics of a self-actualized individual: 1. Solves own problems. 2. Assists others in problem-solving. 3. Accepts suggestions of others. 4. Has broad interest in work and social topics. 5. Possesses good communication skills as a listener and communicator. 6. Manages stress and assists others in managing stress. 7. Enjoys privacy. 8. Seeks new experiences and knowledge. 9. Shows confidence in abilities and decisions. 10. Anticipates problems and successes. 11. Likes self.

Characteristics of Basic Human Needs: 1. Needs are universal 2. Needs may be met in different ways. 3. Needs may be stimulated by external and internal factors. 4. Priorities may be altered. 5. Needs may be deferred. 6. Needs are interrelated.

HEALTH and ILLNESS

CONCEPT OF HEALTH, WELLNESS, WELL-BEING AND ILLNESS

HEALTH > is the fundamental right of every human being. It is the state of integration of the body and mind. - is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. (WHO) - is the ability to maintain the internal milieu. Illness is the result of failure to maintain the internal environment. (Claude Bernard)

> is being well and using ones power to the fullest extent. Health is maintained through the prevention of diseases via environmental health factors. (Florence Nightingale) > is the ability to maintain homeostasis or dynamic equilibrium. (Walter Cannon) > is a dynamic state in the life cycle. Illness is an interference in the life cycle. (Imogene King) > is a state of a process of being becoming an integrated and a whole as a person. (Sister Calista Roy)

WELLNESS AND WELL-BEING

> Wellness is a state of well-being. > Well-Being is a subjective perception of balance, harmony and vitality. > Wellness has different dimensions: 1. Physical - the ability to carry-out daily tasks (grooming, mobility, etc.) and to achieve fitness of the different organ systems of the body.
2. Emotional - the ability to manage stress and to express emotions appropriately.

3. Social - ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others and to develop respect and tolerance for those with different beliefs. 4. Intellectual - the ability to learn and use information effectively for personal, family, and career development. 5. Spiritual - the belief in some force (nature, science, religion, or a higher power) that serves to unite human beings and provide meaning and purpose of life. 6. Occupational - ability to achieve balance between work and leisure time.

MODELS OF HEALTH AND WELLNESS 1. LEAVELL & CLARKS AGENT-HOSTENVIRONMENT MODEL or ECOLOGICAL MODEL This model has three dynamic interactive elements: 1. Agent: any environmental factor or stressor (biologic, chemical, mechanical, physical, and psychological) whose presence or absence can lead to illness or death 2. Host: person(s) who may or may not be at risk of acquiring a disease based on family history of disease, lifestyle habits and age 3. Environment: all factors external to the

HEALTH-ILLNESS CONTINUA DUNNS HIGH-LEVEL WELLNESS GRID - A health grid in which the health axis and the environment axis intersect to demonstrate interaction. The health axis extends from peak wellness to death and the environmental axis extends from very favorable to very unfavorable. The intersection forms four health/wellness quadrants:

1. High-level wellness in a favorable environment: - example is a person who implements healthy lifestyle behaviors and has economic resources to support this lifestyle and a family or social environment who also practices or encourages the practice of healthy lifestyle. 2. Emergent high-level wellness in an unfavorable environmental - example is a person who knows the importance of implementing a healthy

3. Protected poor health in a favorable environment - example is an ill person confined in a hospital and whose needs are met by the hospital personnel, who can afford appropriate medication, proper diet and other treatments needed. 4. Poor health in an unfavorable environment - example is a starving young child in a refugee camp in Mindanao.

HEALTH BELIEF MODEL (HBM) Becker, 1975 > describes the relationship between a persons belief and behavior. > individual perceptions and modifying factors may influence health beliefs and preventive health behavior.

Individual perceptions includes the ff: 1. Perceived susceptibility to an illness. 2. Perceived seriousness of an illness. 3. Perceived threat of an illness. Modifying factors include the ff: 1. Demographic variables 2. Sociopsychologic variables 3. Structural variables 4. Cues to action

TRAVIS ILLNESS-WELLNESS CONTINUUM - The model illustrates that movement to the right of the neutral point indicates increasing levels of health and well-being for an individual. This is achieved through awareness, education and growth. In contrast, movement to the left of the neutral point indicates a progressively decreasing state of health.

SMITHS MODEL OF HEALTH 1. Clinical Model - absence of signs and symptoms of disease. 2. Role Performance Model - ability to fulfill societal roles. 3. Adaptive Model - views health as a creative process and disease as a failure in adaptation or mal-adaptation. 4. Eudaemonistic Model - health is a condition of actualization or realization of a persons potential.

Disease and Illness

Disease alteration in the body functioning which results in the reduction of capacities and shortening of life span. Illness a personal state in which the person feels unhealthy. In other words: Disease is an illness with objective facts while Illness is a subjective perception of not being well.

Stages of Illness:
Stage 1. Symptoms Experience - experience some symptoms, persons believes something is wrong. 3 aspects physical, cognitive and emotional. Stage 2. Assumption of the Sick Role - acceptance of illness, seeks advice. Stage 3. Medical Care Contact - seeks advice to professionals for validation of real illness, explanation of symptoms, reassurance or predict of outcome.

Stage 4. Dependent Patient Role - the person becomes a client dependent on the health professional for help; accepts or rejects health professionals suggestions; becomes more passive and accepting. Stage 5. Recovery/Rehabilitation - gives up the sick role and returns to former roles and functions.

Classification of Diseases:
1. According to Etiologic Factors: A. Hereditary due to defect in the genes of one or other parent which is transmitted to the offspring. B. Congenital due to defect in the development, hereditary factors or prenatal infection C. Metabolic due to disturbance or abnormality in the intricate processes of metabolism D. Deficiency results from inadequate intake or absorption of essential dietary factor E. Traumatic due to injury

F. Allergic due to abnormal response of the body to chemical and protein substances or to physical stimuli G. Neoplastic due to abnormal or uncontrolled growth of cell H. Idiopathic cause is unknown; self-originated; of spontaneous origin I. Degenerative results from the degenerative changes that occur in the tissues and organs J. Iatrogenic result from the treatment of the disease

2. According to Duration or Onset: A. Acute Illness has short duration and is severe. Signs and symptoms appear abruptly, intense, and often subside after a relatively short period. B. Chronic Illness usually longer than 6 months, and can also affects functioning in any dimension. Is characterized by: > Remission periods during which the disease is controlled and symptoms are not obvious. > Exacerbations disease becomes more active given at a future time, with recurrence of pronounced symptoms. C. Sub-Acute symptoms are pronounced but more prolonged than the acute disease.

3. Disease may also be described as: A. Organic B. Functional C. Occupational D. Venereal E. Familial F. Epidemic attacks a large number of individuals in a community at the same time. (SARS) G. Endemic present more or less continuously or recurs in a community. H. Pandemic extremely widespread involving an etire country or continent. I. Sporadic a disease in which only occasional cases occur.

Risk Factors of a Disease:

1. Genetic or Physiologic - genetic predisposition. 2. Age - increase or decrease clients susceptibility to acquire disease. 3. Environment - surroundings that can affect the person. 4. Lifestyle - habits that increases the chance of acquiring a disease. 5. Sex - gender.

Levels of Prevention:
1. Primary Prevention - applied on healthy individual. focus: health promotion, disease prevention 2. Secondary Prevention - applied on patients with signs and symptoms. focus: screening, diagnosing, case-finding, early detection, prompt treatment 3. Tertiary Prevention - applied on patients with chronic and debilitative disease. focus: rehabilitation

COMMUNICATION in NURSING

Communication
- exchange of ideas, feelings, and information from one person to another. 1. Is the means to establish a helping-healing relationships. All behavior communication influences behavior. 2. Communication is essential to the nurse-patient relationship. 3. Is the vehicle for establishing a therapeutic relationship. 4. Is the means by which an individual influences the behavior of another, which leads to the successful outcome of nursing intervention.

Components of Communication Process:

1. Sender is the person who encodes and delivers the message. 2. Message is the content of the communication. 3. Channel is the medium used to convey the message. 4. Receiver is the person who receives the message. 5. Response/Feedback is the message returned by the receiver. It indicates whether the meaning of the senders message was understood.

Modes/Types of Communication:
1. Verbal - use of spoken or written words. 2. Nonverbal - use of gestures, facial expressions, posture/gait, body movements, physical appearance and body language.

Characteristics of Communication: 1. Simplicity - the use of commonly understood words. 2. Clarity - saying what is actually meant. - speak slowly and enunciate words. 3. Timing and Relevance - appropriate time. - consider clients concerns and interests. 4. Adaptability - ability to adjust. - consider circumstances and behavior 5. Credibility - pertains to worthiness of words and reliability

COMMUNICATION SYSTEM
1.

Downward communication it is the traditional line of the communication from the manager down through the levels of management. what should be communicated downward Dissemination of corporate goals/plans Organization changes in structure and personnel Administration policies, rules and regulations Work systems, method, procedures Current corporate issues, new date on operations Staff meeting should be scheduled An open data policy should be adopted by the management

DOWNWARD COMMUNICATION

METHODS OF DOWNWARD COMMUNICATION

Letters Employee handbooks Mass magazines Operating manuals Job description sheets Magazines or newsletters Bulletin boards Public address system Face to face communication Information racks Annual reports Grapevine and unions

2.

Upward Communication - It provides a means for motivating and satisfying personnel by allowing employee input. The manager summarizes the information and pauses it upward to the next management level for decision. what should be communicated upward Job performance of the subordinates, highlights of their work. achievements and future job plans. Outlines of unsolved work problems by which subordinates may need guidance and help the future Suggestions for improvement of the department and their company What subordinates think and feel about their jobs, their associates and their company

UPWARD COMMUNICATION

METHODS OF UPWARD COMMUNICATION

Face to face communication Grievance procedures Suggestion systems Attitude surveys Employee committees

3.

Lateral Communication also called as the horizontal communication. The communication is between departments on the same level of hierarchy and is the most frequently used to coordinate activities.

4.

Diagonal communication it occurs between individuals or departments that are now on the same level of hierarchy.

5.

Grapevine Communication an informed method of communication coexist with formal channels and is referred to as the grapevine. The communication passes at an increasing rate as individuals from clusters inform other small groups of people who work near each other or have contact with each other.

RECORDING AND REPORTING

Record
- a formal and legal document that provides evidence of the clients care. Purposes: 1. Communication 2. Planning client care 3. Audit and quality assurance 4. Research 5. Education 6. Reimbursement 7. Legal documentation 8. Statistics

Responsible for the disposal of medical records in government hospital: - DOH Criteria for disposal: - DOH accredited DOH Records Mgt & Archive Office Where to get the chart of a pt who has been discharged: - Medical Records Section Where to obtain the clients chart during period of hospitalization : - Nurse Station

2 Types of Records
1. Problem Oriented Medical Record
- data are arranged based on the clients problem rather than the source of information. Basic Components: A. Database - primary information about the client. B. Problem List - involves all aspects of the persons life that requires health care. C. Initial Orders and Health Care Plans D. Progress Notes - SOAPIE, Graphic Flow Sheet, Discharge Notes

2. Source Oriented Medical Record

- chart is divided & organized according to the different sources of data. Basic Components: A. Admission Sheet B. Physicians Order C. Medical History D. Nurses Notes E. Special Records and Reports

REPORTING: - either oral, taped or written exchanges of information between nurses or other members of the health care team. Purpose: To promote continuity of care. KINDS: I. Change of Shift Reports - exchange of information from the nurse of the previous shift to the next shift. A. Oral B. Audiotape recording C. Nursing Rounds

II. Telephone Orders & Reports - reports and orders via telephone. Physician: capable of ordering the medication RN: receives the medication order from the doctor Important: 1. It must be countersigned by the physician within 24 hrs. 2. If it was not signed within 24 hours, notify the Head Nurse. 3. Ideally, 2 nurses must receive the telephone order.

III. Incidence Reports - record of accidents or unusual events that occurs in the agency. Purpose: To prevent future harm/accidents. Data Included: 1. Clients name and ID number 2. Date, time and place of the incidence 3. Facts of the incidence 4. Clients account of the incident 5. Witnesses of the incident 6. Equipments and medications involved Facts to Remember: 1. It must be filed within 24 hours. 2. It should be submitted to the Risk Manager. 3. It should not be included in the patients chart.

DOCUMENTATION

DOCUMENTATION
- is anything written or printed that is relied on as record or proof for authorized person. Nursing documentation must be: Accurate. Comprehensive. Flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflects current standards of nursing practice. As members of the health care team, nurses need to communicate information about clients accurately and in timely manner. Effective documentation ensures continuity of care, saves time and minimizes the risk of error.

Different Sheets:
1. Nursing Health History and Assessment Worksheet - completed upon admission. > Biographic data > Age, sex and address > Method of admission 2. Graphic Flowsheet - it allows the nurse to record specific measurements on a repeated basis. > Vital signs > Intake and Output 3. Medicine & Treatment record - allows for the repeated recording of medication and treatment of the patient on a repeated basis.

4. Nursing Kardex R Readily accessible. E Ensure continuity of care. S Series of flips cards kept at a portable index file at the nurses station. T Tool for communication. 2 Parts: 1. Activity and Treatment Section 2. Nursing Care Plan

5. Discharge Summary - helps ensure that the clients condition during discharge is in desirable outcome. F Final physical assessment. I Instructions about medications and treatment regimen. R Record pertinent data. A Assess the client support system. H Health teaching.

Guidelines of Quality Documentation and Reporting: 1. Factual > A record must contain descriptive, objective information about what a nurses sees, hears, feels and smells. > The use of vague terms such as appears, seems and apparently, is not acceptable because these words suggest that the nurse is stating an opinion. 2. Accurate > The use of exact measurements establish accuracy . > Documentation of concise data is clear and easy to understand. > It is essential to avoid the use of unnecessary words and irrelevant details.

3. Complete > The information within a recorded entry or a report needs to be complete, containing appropriate and essential information. 4. Current > Timely entries are essential in the clients ongoing care. To increase accuracy and decrease unnecessary duplication, many healthcare agencies use records kept near the clients bedside which facilitate immediate documentation of information as it is collected from a client. 5. Organized > The nurse communicates information in a logical order.

Legal Guidelines for Recording:

Draw single line through error, write word error above it and sign your name or initials. Then record note correctly. Do not write retaliatory or critical comments about the client care by other health care professionals. Enter only objective descriptions of clients behavior; clients comments should be quoted. Correct all errors promptly. Errors in recording can lead to errors in treatment. Avoid rushing to complete charting, be sure information is accurate. Do not leave blank spaces in nurses notes. Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at end.

Record all entries legibly and in black ink. Never use pencil, felt pen. Black ink is more legible when records are photocopied or transferred to microfilm. If order is questioned, record that clarification was sought. If you perform orders known to be incorrect, you are just as liable for prosecution as the physician is. Chart only for yourself. Never chart for someone else. You are accountable for information you enter into chart.

Avoid using generalized, empty phrases such as status unchanged or had good day. Begin each entry with time, and end with your signature and title. Do not wait until end of shift to record important changes that occurred several hours earlier. Be sure to sign each entry. For computer documentation keep your password to yourself. Maintain security and confidentiality. Once logged into the computer do not leave the computer screen unattended.

THE NURSING PROCESS

Nursing Process
- provides the framework in which nurses use their knowledge and skills to express human caring and to help clients meet their health needs. - a systematic, rational method of planning and providing care using the process of ADPIE. Steps: 1. ASSESSMENT 2. DIANOSIS 3. PLANNING 4. IMPLEMENTATION 5. EVALUATION

Characteristics of the Nursing Process:

1. Systematic 2. Skills and Knowledge-based 3. Cyclical 4. Dynamic 5. Client-centered 6. Interpersonal and Collaborative 7. Universal 8. Goal-oriented 9. Priority-based

PHASE I: ASSESSMENT
- is Collecting, Organizing, Validating, and Recording data about a clients health status. Purpose: - To establish a data base.

4 Types of Assessment:
1. Initial Assessment - completed upon admission. - Ex. Nursing History, Assessment Worksheet 2. Problem-Focused/Ongoing Assessment - on-going assessment performed during nursing care. - Hourly Assessment of Intake and Output

3. Emergency Assessment - rapid assessment of the patients ABC during any physiologic and psychologic crisis. - Cardiac Arrest, Suicidal Ideation 4. Time-Lapse Reassessment - assessment performed in two periods of time. - Operation Timbang, Assessment for Hypertension

Different Methods of Assessment:

1. Observation - gathering data using the 5 senses. 2. Interview - a planned and purposive conversation between the nurse and the client. A. Directive interview: - highly structured - elicits specific information. B. Nondirective interview: - less structured - allows the client to verbalize his thoughts and feelings.

3 Types of Interview Questions: 1. Closed-ended 2. Open-ended 3. Leading questions 3. Physical Examination - systematic data collection method using the techniques of IPPA. - objective data are collected. 2 Types of Data: 1. Subjective - data that are apparent only to the person affected. 2. Objective - data that can be seen, heard, felt, smelled, or even tasted.

PHASE II: NURSING DIAGNOSIS

- is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. C clustering A analysis N nursing diagnosis formulation

TYPES OF NURSING DIAGNOSIS:

1. ACTUAL DIAGNOSIS - judgment about a clients response to a health problem at the time of assessment and signified by the presence of associated signs of symptoms. Examples: Fluid volume deficit Ineffective airway clearance 2. RISK NURSING DIAGNOSIS - a clinical judgment that a client is more vulnerable to develop the problem than others in the same situation. Examples: Risk for injury Risk for infection

3. POSSIBLE NURSING DIAGNOSIS - evidence about a certain health problem is unclear or the causative factors are unknown; needs collection of more data either to support or refute it; not a real type or nursing diagnosis. Examples: Possible social isolation Possible ineffective coping 4. WELLNESS DIAGNOSIS - is a clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness. Example: Readiness for enhanced spiritual well-being

COMPONENTS OF A NURSING DIAGNOSIS: 1. Problem - clients response to his/her illness. - ex. Elimination, Breathing pattern, airway clearance * Qualifiers words added to give meaning to the diagnostic statement. - ex. Decreased, Ineffective, Impaired 2. Etiology - related factor/probable cause. 3. Signs and symptoms - defining characteristics. - evidences or manifestations.

Guidelines for Writing Nursing Diagnosis

1. Word the statement so that is legally advisable. Example: Impaired skin integrity related to improper positioning 2. Make sure that both elements of the statement do not say the same thing. Example: Impaired skin integrity related to skin ulceration. 3. Make sure to use universally accepted abbreviations. Example: Ineffective airway clearance related to accu. of secrens

4. Use nursing terminology rather than medical term to describe the clients response. Example: Ineffective airway clearance related to pneumonia. 5. Use non-judgmental statements. Example: Ineffective sexuality pattern related to sexual role confusion. 6. Word the diagnosis specifically and precisely to provide direction for planning nursing intervention. Example: Impaired oral mucous membrane related to noxious agent.

NURSING DIAGNOSIS VERSUS MEDICAL DIAGNOSIS

Nursing Diagnosis

Medical Diagnosis

Identifies diseases Focus on identifying human responses to health and illness Describe problems for which Describe problems treated by nurses within the physician directs the the scope of independent primary treatment nursing practice

Changes from day to day Remains the same for as as the client responses long as the disease is

PHASE III: PLANNING

- a deliberative, systematic phase of the nursing process that involves decision making and problem solving. - the nurse refers to the assessment data and the diagnostic statement. - the end product is the creation of NCP. - begins upon the admission and ends when nurse-patient relationships ends.

PLANNING involves the following activities: Establishing priorities. Writing goals/outcomes and developing an evaluate strategy. Selecting nursing strategies/interventions. Developing nursing care plans Communicate the plan of nursing care.

Types of Planning:
1. INITIAL PLANNING - the nurse who performs the initial admission assessment develops the initial comprehensive plan of care; needs refinements when missing data becomes available. 2. ONGOING PLANNING - using ingoing assessment data, the nurse carries out daily planning for the following purposes: a. to determine whether the clients health status has changed b. to set the priorities for the clients care during the shift c. to decide which problems to focus on during the shift d. to coordinate the nurses activities so that more than one problem can be addressed at each client contact

3. DISCHARGE PLANNING - the process of anticipating and planning for needs after discharge; is becoming a crucial part of comprehensive healthcare. Effective discharge planning begins at the time of admission where each client is assessed for: a. potential health needs b. availability and ability of the clients support network to assist with these needs c. how the home environment supports the client, and d. client, family, and community resources

Types of Discharge Planning: A. Simple/Basic - patient has been discharged from the agency and proceeded directly into his/her home. B. Complex - patient is discharged from the agency and returned to another health care institution. Setting Priorities - the process of establishing the preferential sequence or rank of interventions in accordance to the clients most immediate needs.

Nursing Goal/Expected Outcome - declaration of purposal intention which directs interventions. Types of Goals: 1. Short Term - can be achieved in a short period of time. 2. Long Term - requires longer period of time to be accomplished.

PURPOSE of GOALS/EXPECTED OUTCOMES: 1. Provide direction for planning nursing interventions. 2. Provide a time span for planned activities. 3. Serve as a criteria for evaluation of client progress 4. Enable client and nurse to determine when the problem has been resolved. 5. Help motivate client and nurse by providing a sense of achievement.

Guidelines in Writing Goals and Outcomes:

1. The goals must pertain to the client. 2. It should be realistic. 3. It should be compatible with the therapies of other health professionals. 4. It must be specific. 5. It must be written in behavioral terms. 6. It should be measurable. 7. It should be time-bounded.

Intervention Selection 1. Independent - nurse-initiated. Example: Health Teaching, Taking Vital Signs, Making NCP 2. Dependent - physician-initiated. - performed under the doctors order and supervision. Example: Medications, Blood Transfusion, Catheterization 3. Collaborative/Interdependent - overlapping functions among health care team. Example: Diet, Laboratory Exams Nursing Care Plan blueprint of the nursing process

PHASE IV: IMPLEMENTATION

- is putting the nursing care plan in action. Activities: 1. Reassessing 2. Set priorities 3. Perform nursing intervention 4. Record actions Composed of 3 Ds: 1. Doing 2. Delegating 3. Documenting

Doing * Cognitive Skills intellectual skills * Technical Skills psychomotor skills * Interpersonal Skills communication skills Activities: 1. Reassessing the client. 2. Prepare the client physically and psychologically. 3. Prepare the equipment and supplies. 4. Implement the interventions. 5. Communicate the nursing actions.

Delegation - the transfer of responsibility or task to a subordinate with commensurate authority while retaining accountability for the outcome. 5 Rights to Delegation 1. Right Task 2. Right Circumstance 3. Right Person 4. Right Direction/Communication 5. Right Supervision

Activities that cannot be delegated: 1. Initial and ongoing assessment. 2. Planning, nursing diagnosis formulation and evaluation. 3. Education and supervision of the nursing personnel. 4. Special activities like Sterile procedures. 5. Speech and signing of names. Activities that can be delegated: 1. Routine activities. - Vital signs taking - Bed bath 2. Clean procedure. - Enema - Ear irrigation

PHASE V: EVALUATION
- is assessing the clients response to nursing interventions and then comparing the response to predetermined standards or outcome criteria. Purpose: To appraise the extent to which goals and outcome criteria of nursing care have been achieved.

3 Types of Evaluation: 1. Ongoing 2. Intermittent 3. Terminal 3 Possible Judgments during Evaluation: 1. Goal met 2. Goal partially met 3. Goal not met 4 Types of Outcome Evaluated: 1. Cognitive 2. Psychomotor 3. Affective 4. Physiologic

Quality Assurance
1. Structure Evaluation - physical settings, condition through which care is given. 2. Process Evaluation - pertains to the manner on how the care was given. 3. Outcome Evaluation - pertains to any changes in the clients health status as a result of the nursing intervention.

OXYGENATION

Chest X-ray
- provides information regarding the anatomical location and appearance of the lungs. Before X-ray: > Assess presence of pregnancy. > Remove jewelries and metals on the clients chest. > Instruct the client to inhale and hold breath. After X-ray: > Assist the client to dress up.

Ultrasound
NPO Consent NO : for KUB an Abdomen YES : for Tansvaginal and Transrectal NPO YES : Abdomen > VOID NO : for KUB > DONT VOID POSITIONS: Lithotomy for Transvaginal Sims for Transrectal

CT SCAN DYE and RADIATION FOR DYE : Iodine based Ask for Allergy to Seafoods If Yes : give Antihistamine then proceed If No : Proceed

For Radiation : External Teletheraphy No Metal based No Pregnant

MRI ( electromagnetism ) No Metals Superficial Accessories Dentures Braces Dental Feelings a. Nail Polish - metallic color - w/ glitters - jaguar / pure black b. Contact Lenses c. Tattoo - < 6 mos. ( no ) > 6 mos. ( yes ) d. Hair Extension

DEEP Nuts / Bolts Pacemaker PlatesMicrochips IUD

Implants Tracers Stents

1. Keep still / restrain w/ order Either Physical / Chemicals Sedate Diazepam ( Valium ) Antidote : Flumazenil ( Romazicon ) 2. No Metals

3. Asses for Claustrophobia For Yes Sedate For No Proceed 4. Inform that is NOISY procedure Earmuff No Metal Agitated

PULSE OXIMETER: - device that measures O2 saturation level before signs and symptoms of hypoxemia develops. N > level: 95-100% > hypoxemia: O2 in the blood > brain: most sensitive organ in hypoxia/hypoxemia (1st sign: restlessness)

2 Types of Pulse Oximeter: 1. Adhesive 2. Clip > if allergic to adhesive use clip pulse oximeter > acetone: used to remove nail polish >alcohol: used if theres no nail polish

Sites for pulse oximeter: fingers, ear lobe, nose, and forehead > how frequent is the changing of site: clip: q 2 adhesive: q 4-6 > it is necessary to IMMOBILIZE THE SITE because movements are detected as pulsation > if the sun is shining over the pulse oximeter site cover the site.

THORACENTESIS
> remove fluid > aspiration of fluid from the pleural cavity > posn: orthopneic posn, sitting posn, side lying posn at unaffected site > securing the consent R.N. not getting doctor > local anesthesia

> instruction to the client during needle insertion & withdrawal exhale & stay still (take shallow breath) > after thoracentesis: position: side-lying (prevent leakage of N pleural fluid) > client coughing red sputum red tinged saliva Ab notify the physician lung perforation

CHEST PHYSIOTHERAPY
- dependent nursing action of using positioning, vibrating, and percussing to remove tenacious respiratory secretions. 1. Dependent nursing action - needs doctors order to know if the client can tolerate the procedure. 2. Correct sequence of CPT Positioning Percussion Vibrating
--- POPE VI

3. Gravitational force: force that drains the secretion 4. Positioning > Orthopneic: to drain secretions from APEX POSTERIOR SEGMENT > Trendelenburg, leaning/lying on abd: to drain secretions from lower lobe posterior segment 5. Position is around 10 mins. 6. Max. time of CPT: 30 mins. 7. Best time in performing postural drainage: early in the morning upon waking up before meals *risk for aspiration (same in general anesthesia)

Percussing:
-- striking of the skin using a cupped hand like scooping H2O to dislodge clients tenacious secretions. > prevention for reddening: put a layer of cloth > force come from the wrist > percuss for 10 mins. (1-2 mins./segment) > to check if correct: popping/booming sound

Vibration:
-- vigorous quivering of the heel of the hand > When to start vibrating using the hand? - take deep breath then exhale > Post procedure: cough #1 Consideration: Toleration of patient to the procedure Contraindication: Inability to tolerate the R procedure
L

* If the affected:

upper lobe of the lungs is

SUCTIONING:
-- removal of secretion using a catheter

connected to a suctioning machine. **suctioning is done as needed (PRN) because it is hassle & can cause hypoxemia & stimulation of the vagus nerve > positioning: conscious: semi-fowlers unconscious: side-lying >lubrication: nose: sterile, water-based mouth: PNSS

Measurement for Suctioning: > oropharyngeal: - mouth to earlobe > orotracheal: - mouth to midsternum > nasopharyngeal: - nose to earlobe > nasotracheal: - nose to earlobe to neck * hyperventilate the pt. with 100% O2 before suctioning * apply suction only during the withdrawal - to prevent trauma in the mucous

Pressure of the Suction Gauge:

1. Infant mmHg 2. Child 10 mmHg 3. Adult above 10 mmHg Wall Portable below 95 mmHg below 5 95-100 mmHg above 110 mmHg 5-

* duration: - 10-15 seconds * if repeated, interval is: - 20 to 30 seconds

patient suction

CTT (3 Way Bottle System) > Drainage Bottle > Water-seal Bottle > Suction Control bottle -- draw fluid & air from the

*Bottle 1: Drainage: no bubbling N *Bottle 2: Water seal: visible bubbling, intermittent >if continuous bubbling: theres leakage, dump/ clamp the tube >if theres no bubbling: 1. (+) obstruction to correct: PRESS RELEASE METHOD if no choice: MILK THE TUBE 2. Lung reexpansion N *Bottle 3: Suction: gentle continuous bubbling > continuous bubbling

DISCONNECTION OF TUBE: A. Chest: > use vaso-occlusive dressing > if vaso-occlusive dressing is not available - use VASELINIZED DRESSING B. Bottle: > if still intact: -- re-insert the tube into the bottle > if broken: -- immerse tube in PNSS

Nursing Considerations:
1. Maintain aseptic technique. 2. Palpate for crepitus. Rationale: To determine presence of subcutaneous emphysema. 3. Minimize clamping and opening of the tube. Rationale: To prevent pneumothorax. 4. Removal of the chest tube is done by the physician. Position: Upright position Instruction: Inhale and hold the breath and then do the Valsalva maneuver.

ELIMINATIO N

Elimination: URINARY
* Assessing N the urine: 1. Amount per hour N 30-60 cc/hr >60 cc/hr: polyuria <30 cc/hr: oliguria anuria: state of suspension 0-10 cc/hr 2. Color > straw, amber, yellow, clear > hematuria: with blood > tea colored: hepatitis/dehydration

3. clarity: clear > if turbid (cloudy): UTI 4. Odor: aromatic 5. Sterility: sterile N 6. pH: acidic (6.0) 7. Specific gravity >N 1.01-1.025 or 1.030 > specific gravity: greater than 1.030 in particles/solute: dark in color dehydrated > specific gravity: less than 1.01 fluid with light: overdehydration, diabetes insipidus

Collecting Urine Specimen for C/S: 1. Clean catch: midstream clean catch > cleaning the urinary meatus a. Female: use povidone iodine > wipe front to back b. Male: use povidone iodine > circular motion; inner to outer; hold the penis firmly 2. Collect: 30cc 3. Contaminated after 30 mins. 4. Sterile technique

Urinary Catheter 1. self-sealing rubber catheter: type of catheter wherein collection can be done 2. wipe the collection part with alcohol 3. 30-45: angle of needle insertion 4. 30cc of urine for urinalysis: 3cc of urine for C/S 5. if theres no urine: clamp below the insertion point; 30 mins. put the syringe above the clamp part

CATHETERIZATION
> contraindicated with pelvic fx, perineal herniation, urethral stricture N > French 16-18: 22-24: gross hematuria 1. Coude catheter: > 24 hour Foley catheter > contraindicated: 14 French Foley catheter > #1 complication: UTI > #1 cause: Nosocomial infection > #1 causative agent: E.coli

Position: Female: dorsal recumbent > knees are flexed & avoid extending knees Male: supine Lubricant: sterile water-based > Female: until urine begins to flow; insert 1-2 inches further/3-4 inches > Male: 6-8 inches During insertion & withdrawal: > act as if voiding > exhale Male: hold the penis 90 against the body

Position in taping: Female: inner thigh Male: inner thigh > abdomen (prevent pressure at scrotum & erection) *secure the bag at bed frame *use 5-10cc distilled H2O: -- pure PNSS can cause precipitate formation & crystallization.

Elimination: FECAL
N *Assessing the stool: color (yellow, brown, greenish) *For breastfeeding infants, expect a golden yellow stool > Odor: aromatic > Amount: 300g to 500g/day > Frequency: 1-3x/day 1x/2 days Hirchsprung: at birth, no defecation > Shape: cylindrical > Consistency: semi/formed

ENEMA
>introduction of a solution to the clients rectum for 3 purposes: 3 Types According to Purpose: 1. Cleansing enema (cleanse the bowel) 2. Retention (soften & lubricate) 3. Carminative (expel flatus) 2 Types of Cleansing Enema 1. High cleansing enema > 18 inches (height) > 1 liter of fluid > indicated to clean the entire colon 2. Low cleansing enema > 12 inches (height) > 500ml of fluid > from sigmoid to descending colon

> Position: left side lying > Use: Medical / Cleaning > Length: should pass the internal sphincter; 34 inches *if theres any resistance, never force the obstruction > to relax: inhale > If client experience cramping & pain:

MEDICATION COMPUTATI ON

TEMPERATURE COMPUTATION: 1. C F = C x 18 + 32 F C = F 32 / 1.8

DRUGS
IV = mL/hr Drugs: > D x Q S > D = SxQ > S = D/Q IV= vol(mL) x drop factor hrs hours = mL gtts/min * U 40 = 40 units/mL

Drop Factor: > Adult: 15 > Pedia: 60

ordered amount of drug = unknown quantity needed (X) amount of drug on hand known quantity of drug

Sample Computation: Dosage calculation for units (some medications such as heparin and penicillin are ordered in units) 1. The order is penicillin 750,000 units. The vial reads 300,000 units/2mL. How many mL will be given? 2. Ordered amount of drug is 750,000 units; amount of drug on hand is 300,000 units. 3. Unknown quantity is X; known quantity is 2 mL

4. Calculations: a. 750,000 units = X 300,000 units 2mL b. (300,000 units) (X) = (750,000 units) (2mL) c. 300,000 X = 1,500,000 3,000,000 units 300,000

d. X = 150 30 e. X = 5 mL

Administration of Medication:
Medication - a substance administered for diagnosis, cure, treatment, relief or prevention of disease. - also called drug. Effects of the Drug. 1. Therapeutic effect primary effect/positive effect. 2. Side effect secondary effect/negative effect/unintended effect. 3. Drug tolerance usually low physiologic response to a drug which requires additional dosage to achieve the desired effect. 4. Drug abuse inapropriate use of the drug either continually or

Principles in Administering Medications

1. Observe the 10 rights of drug administration. 1. Right Medication 2. Right Dosage 3. Right Client 4. Right Time 5. Right Route 6. Right Documentation 7. Right Education 8. Right Assessment 9. Right to Refuse 10. Right Evaluation

2. Practice asepsis; wash hands before and after preparing medications. 3. Be knowledgeable and accountable about the medications that you administer. 4. Before administering the medication, identify the client correctly. 5. Do not leave the medication at bedside. 6. The nurse who prepares the drug administers it. 7. If the client vomits, report this to the nurse incharge or physicians. 8. When a medication error is made, assess the client and report it immediately to the nurse in charge or physician.

Routes of Drug
ORAL
Advantages: 1. Most accessible 2. Safe 3. Cost effective Disadvantages: 1. Inappropriate for client with nausea and vomiting. 2. Inappropriate for clients with difficulty of swallowing. 3. Inappropriate for patients with decrease gastric motility. 4. May have unpleasant taste or discolor the teeth. 5. May cause aspiration.

Different Forms of Oral Medications:

1. Solid tablet, capsule, pills, caplet, powdered 2. Liquid > Syrup sugar-based > Emulsion oilbased > Suspension water-based > Elixir alcoholbased * Allow 30 minutes to elapse before giving a glass of water. 3. Sublingual 4. Buccal 5. Rectal 6. Vaginal 7. Topical

Parenteral Routes
1. Intradermal Advantage: slow absorption rate, used for drug testing. Disadvantage: requires sterile technique, causes anxiety, can only administer small amount of drug. Sites: inner forearm, anterior chest, underneath of the scapula Angle of needle: 10-15 angle, almost parallel to the skin Gauge: 25, 26, 27 Length: 3/8, 5/8, inch Maximum cc: 0.1cc to 0.2cc

2. Subcutaneous Advantage: faster than oral routes. Disadvantage: expensive, requires sterile technique, slower than IM and IV, can cause anxiety, some drugs can cause pain and irritation, breaks the client skin integrity. Sites: upper arm, outer thigh, abdomen, ventrogluteal, dorsogluteal Angle of needle: 45 angle; obese and insulin administration - 90 angle Gauge: 25, 26, 27 Length: 3/8, 5/8, inch

3. Intramuscular Advantage: faster absorption, can reduce pain and irritation from irritating drugs. Disadvantage: requires sterile technique, can cause anxiety, it breaks the clients skin integrity Sites: ventrogluteal, dorsogluteal, vastus lateralis, rectus femoris, deltoid Angle of needle: 90 angle Gauge: 21,22, 22 Length: 1, 1 , 2 inches Maximum cc: 3-5 ml

Z-track > retract the skin laterally away from the site > pierce the skin quickly and smoothly at 90 > aspirate (5-10cc) > inject the drug slowly and steadily (10 sec/ml) > wait for 10 secs and allow the medication to disperse > do not massage

3. Intravenous Advantage: rapid effect Disadvantage: limited for highly soluble solutions only, poor circulation can interfere absorption

** Intravascular Gauge: 24, 23, 22, 21, 20 Length: 1, 1 , 2 inches Maximum cc: IV push 10 ml IV infusion 4L per day

BLOOD

TRANSFUSIO

> Unit of blood = depends on agency - 450 cc, 500 cc, 250 cc, 240 cc > PNSS: - only fluid compatible during BT > gauge: 19, 18, 17, 16 > bacteria; administered within 30 mins. > max. time: 4 hours > RN to check: 2 RN > if blood is too cold: - cover the blood with a dry cloth

> best way to check clients identity before transfusion - through ID Band/bracelet > mix the bag of blood by tilting the blood from side to side > Adverse reaction: during the first 20 mins (15 mins) at 20 gtts/min > S/Sx of adverse rxn: - itchiness, hives, temp., chills, fever, & pain. 1st adverse rxn: dizziness/headache IV: STOP, RUN PNSS, NOTIFY THE DOCTOR

THATS ALL FOLKS!