Fundamentals of Nursing

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Slide 1:

FUNDAMENTALS OF NURSING

GOOD MORNING!!! - Sir Ritchel . . .` :

GOOD MORNING!!! - Sir Ritchel . . .`

Slide 3:

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

Slide 4:

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.

Slide 5:

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 :

INTRODUCTION TO NURSING BRIEF HISTORY

I. INTRODUCTION TO NURSING :

I. INTRODUCTION TO NURSING 1. Intuitive Nursing (primitive times to 6 th 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

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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):

2. Apprentice Nursing (6 th - 18 th 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 6 th century, through the Crusades which began in the 11 th 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 nursing to a respectable occupation for women

3. “Education” Nursing :

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 Nightingale’s 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 residence during their training which offer them pleasant, comfortable surroundings close to the hospital.

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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 physician’s 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 19 th century is also called the “awakening of nursing”

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g. In the early decades of the 20 th 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 :

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

Slide 14:

The Earliest Hospitals: A. Hospital Real de Manila (1577) - it was established mainly to care for the Spanish King’s 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.

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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.

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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. Do ña Hilaria de Aguinaldo -wife of Amelio Aguinaldo; organized the Filipino Red Cross under the inspiration of Apolinario Mabini.

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4. Doña 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.

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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. Paul’s 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 .

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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.

Slide 20:

4. St. Luke’s 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.

Slide 21:

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

Slide 22:

Socialization for Professional Nursing Practice

Slide 23:

1. Socialization - process by which a person learns the ways of a group or society in order to become a functioning participant Benner’s (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

Slide 24:

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

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Roles of the Professional Nurse

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1. Care provider/Parent Surrogate - primarily concerned with the clients needs. *** Recognize the patient’s 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 client’s learning needs/ Assess client’s readiness to learn.

Slide 27:

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.

Slide 28:

7. Leader - mutual process of interpersonal influence through which the nurse helps a client make decisions in establishing and achieving goals to improve client’s 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::

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

Slide 31:

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 :

NURSING THEORIES

GENERAL THEORIES:

GENERAL THEORIES 1. Nightingale’s 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.

Slide 34:

2. Virginia Henderson’s Nature of Nursing Model > conceptualizes the nurse’s 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 :

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

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10. Communicate with others in expressing emotions, needs, fears or opinions 11. Worship according to one’s 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 Physiologic Component 10 & 14 Psychological 11 Spiritual 12 & 13 Sociological

Slide 37:

3. Martha Roger’s 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.

Slide 38:

4. Dorothea Orem’s Self-Care Deficit Theory > emphasizes the client’s 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

Slide 39:

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. - patient only needs health teaching.

Slide 40:

5. Sister Callista Roy’s 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

Slide 41:

6. Imogene M. King’s 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.

Slide 42:

7. Betty Neuman’s Health Care System’s 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.

Slide 43:

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 – ex. anger, physical abilities, financial condition

Slide 44:

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.

Slide 45:

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.

Slide 46:

8. Dorothy Johnson’s 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 patient’s 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.

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

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9. Hildegard Peplau’s Interpersonal Relations in Nursing > defined nursing as a therapeutic, interpersonal process which strives to develop a nurse-patient relationship in which the nurse serves as a resource person, counselor and surrogate. Peplau’s 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 client’s beliefs 3. Exploitation Phase - client takes control of the situation by extracting help from the nurse 4. Resolution Phase - evaluation of care and discharge of client

Slide 49:

10. Madeleine Leininger’s 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 client’s 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.

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11. Ida Jean Orlando’s 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, relieve, or sure individual’s sense of helplessness

Slide 51:

12. Jean Watson’s 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.

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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.

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13. Faye Glenn Abdellah’s 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

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Abdellah’s 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.

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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.

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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.

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14. Nola J. Pender’s 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

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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 physician’s orders.

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16. Myra Estrin Levine’s 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

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MAN and His Basic Human Needs

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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 man’s 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.

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- 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 one’s limitations.

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- 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.

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Abraham Maslow’s 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

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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.

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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.

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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.

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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.

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HEALTH and ILLNESS

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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)

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> is being well and using one’s 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)

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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.

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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.

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MODELS OF HEALTH AND WELLNESS 1. LEAVELL & CLARK’S AGENT-HOST-ENVIRONMENT 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 host that may or may not predispose the person to the development of disease

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HEALTH-ILLNESS CONTINUA DUNN’S 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:

Slide 76:

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 lifestyle but could not do so because of family responsibilities, job demands or lacks the resources to do so.

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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.

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

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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

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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.

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SMITH’S 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 person’s potential.

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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.

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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.

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

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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

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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

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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.

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3. Disease may also be described as: A. Organic B. Functional C. Occupational D. Venereal E. Familial F. Epidemic G. Endemic H. Pandemic I. Sporadic

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Risk Factors of a Disease: 1. Genetic or Physiologic - genetic predisposition. 2. Age - increase or decrease client’s 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.

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Levels of Prevention: 1. Primary Prevention - applied on healthy individual. focus: health promotion, disease prevention 2. Secondary Prevention - applied on patient’s 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

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STRESS MANAGEMENT 1. Massage – manipulation of the client’s skin to promote blood circulation. 2. Guided Imagery – suggestion of images which helps reduce anxiety. 3. Mediation – relaxation of the mind, body and soul. 4. Relaxation Technique – quite environment, passive attitude, comfortable position, comfortable clothing. 5. Autogenic Training – teaching the mind and body to follow verbal commands. 6. Therapeutic Touch – used to manage anxiety, relief from pain.

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7. Yoga – combination of exercise and meditation. 8. Progressive Muscle Relaxation – series of tensing and relaxing group of muscles systematically. 9. Thought Stopping – stopping the negative thoughts. 10. Abdominal Breathing – breathing with the use of the diaphragm. 11. Distraction – diverting one’s attention from one thought to another. 12. Pharmacotherapy – the use of medication.

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COMMUNICATION in NURSING

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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.

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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 sender’s message was understood.

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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.

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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 client’s concerns and interests. 4. Adaptability - ability to adjust. - consider circumstances and behavior 5. Credibility - pertains to worthiness of words and reliability

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RECORDING AND REPORTING

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

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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 client’s chart during period of hospitalization : - Nurse’ Station

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

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2. Source Oriented Medical Record - chart is divided & organized according to the different sources of data. Basic Components: A. Admission Sheet B. Physician’s Order C. Medical History D. Nurse’s Notes E. Special Records and Reports

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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

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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.

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III. Incidence Reports - record of accidents or unusual events that occurs in the agency. Purpose: To prevent future harm/accidents. Data Included: 1. Client’s name and ID number 2. Date, time and place of the incidence 3. Facts of the incidence 4. Client’s 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 patient’s chart.

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DOCUMENTATION

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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.  Data recorded, reported, or communicated to other health care professionals are CONFIDENTIAL and must be practiced.

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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.

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4. Nursing Kardex R – Readily accessible. E – Ensure continuity of care. S – Series of flips cards kept at a portable index file at the nurse’s station. T – Tool for communication. 2 Parts: 1. Activity and Treatment Section 2. Nursing Care Plan

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5. Discharge Summary - helps ensure that the client’s 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.

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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.

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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 client’s bedside which facilitate immediate documentation of information as it is collected from a client. 5. Organized > The nurse communicates information in a logical orde r.

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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 client’s behavior; client’s 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 nurse’s notes.  Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at end.

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Record all entries legibly and in blank 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.

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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.

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THE NURSING PROCESS

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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. A SSESSMENT 2. D IANOSIS 3. P LANNING 4. I MPLEMENTATION 5. E VALUATION

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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

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PHASE I: ASSESSMENT - is C ollecting, O rganizing, V alidating, and R ecording data about a client’s health status. Purpose: - To establish a data base .

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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

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3. Emergency Assessment - rapid assessment of the patient’s 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

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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.

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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.

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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

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TYPES OF NURSING DIAGNOSIS: 1. ACTUAL DIAGNOSIS - judgment about a client’s 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

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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

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COMPONENTS OF A NURSING DIAGNOSIS: 1. Problem - client’s 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.

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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 secre’ns …

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4. Use nursing terminology rather than medical term to describe the client’s 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 VERSUS MEDICAL DIAGNOSIS Nursing Diagnosis Medical Diagnosis Focus on identifying human responses to health and illness Identifies diseases Describe problems treated by nurses within the scope of independent nursing practice Describe problems for which the physician directs the primary treatment Changes from day to day as the client responses change Remains the same for as long as the disease is present

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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.

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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.

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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 client’s health status has changed b. to set the priorities for the client’s 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

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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 client’s support network to assist with these needs c. how the home environment supports the client, and d. client, family, and community resources

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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 client’s most immediate needs.

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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.

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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.

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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.

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Intervention Selection 1. Independent - nurse-initiated. Example: Health Teaching, Taking Vital Signs, Making NCP 2. Dependent - physician-initiated. - performed under the doctor’s 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”

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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 D’s: 1. Doing 2. Delegating 3. Documenting

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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.

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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

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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

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PHASE V: EVALUATION - is assessing the client’s 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.

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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

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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 client’s health status as a result of the nursing intervention.

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OXYGENATION

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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 client’s chest. > Instruct the client to inhale and hold breath. After X-ray: > Assist the client to dress up.

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PULSE OXIMETER: - device that measures O 2 saturation level before signs and symptoms of hypoxemia develops. > level: 95-100% > hypoxemia: ↓ O 2 in the blood > brain: most sensitive organ in hypoxia/hypoxemia (1 st sign: restlessness) N

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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 there’s no nail polish

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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.

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

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> instruction to the client during needle insertion & withdrawal exhale & stay still (take shallow breath) > after thoracentesis: position: side-lying (prevent leakage of pleural fluid) > client coughing red sputum – red tinged saliva Ab notify the physician ← lung perforation > after thoracentesis, the doctor will order CXR to rule out PNEUMOTHORAX (deadliest complication) N

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CHEST PHYSIOTHERAPY - dependent nursing action of using positioning, vibrating, and percussing to remove tenacious respiratory secretions. 1. Dependent nursing action - needs doctor’s order to know if the client can tolerate the procedure. 2. Correct sequence of CPT Po sitioning Pe rcussion Vi brating --- POPE VI

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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)

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Percussing: -- striking of the skin using a cupped hand like scooping H 2 O to dislodge client’s 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

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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 procedure * If the upper lobe of the lungs is affected: side lying with head ↑ to 30° R L

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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-fowler’s unconscious: side-lying >lubrication: nose: sterile, water-based mouth: PNSS

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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% O 2 before suctioning * apply suction only during the withdrawal - to prevent trauma in the mucous membrane.

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Pressure of the Suction Gauge: Wall Portable 1. Infant below 95 mmHg below 5 mmHg 2. Child 95-100 mmHg 5-10 mmHg 3. Adult above 110 mmHg above 10 mmHg * duration: - 10-15 seconds * if repeated, interval is: - 20 to 30 seconds

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patient suction CTT (3 Way Bottle System) > Drainage Bottle > Water-seal Bottle > Suction Control bottle -- draw fluid & air from the pleura. 1 2 3

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

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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 ** If the tube disconnects : re-insert

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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.

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N U T R I T I O N

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N U T R I T I O N Definition of Terms: 1. Digestion - the process in which foods are broken down for the body to use. 2. Absorption - the process in which digested CHO, CHON, Fats, Water and Minerals are transported into the blood circulation. 3. Metabolism - complex chemical process that occurs in a cell in which nutrients are utilized for energy source, cell growth and cell repair.

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Measures to stimulate appetite: 1. Serve food in a pleasant and attractive manner. 2. Provide comfort. 3. Enhance food with colors. 4. Engage in pleasant conversation.

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COMMON THERAPEUTIC DIETS Clear Liquid Diet Purpose: Relieve thirst and help maintain fluid balance. Use: Post-surgically and following acute vomiting of diarrhea. Foods allowed: Carbonated beverages; coffee (caffeinated and decaf), tea; fruit-flavored drinks, strained fruit juices, clear, flavored gelatins; broth, popsicles, commercially prepared clear liquids and hard candy. Foods avoided: Milk and milk products , fruit juices with pulp, and fruit.

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Full Liquid Diet Purpose: Provide an adequately nutritious diet for patients who cannot chew or who are too ill to do so. Use: Acute infection with fever , GI upsets, after surgery as a progression from clear liquids Foods allowed: clear liquids, milk drinks, cooked cereals, custard, ice cream, sherbets, eggnog, all strained fruit juices, creamed vegetables soups, puddings, mashed potatoes, instant breakfast drinks, yogurt, mild cheese sauce or pureed meat, and seasoning. Foods avoided: nuts, seeds, coconuts, fruit jam and marmalade.

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Soft diet Purpose: Provide adequate nutrition for those who have troubled chewing. Use: Patient with no teeth or ill-fitting dentures; transition from full liquid to general diet and for those who cannot tolerate highly seasoned, fried or raw foods following acute infections or gastrointestinal disturbances such as gastric ulcer or cholelithiasis. Foods allowed: Very tender minced, ground, baked broiled, roasted, stewed or creamed beef, lamb, veal, liver, poultry or fish, crisp bacon or sweat bread; cooked vegetables; pasta; all fruit juices; soft raw fruits; soft bread and cereals, all desserts that are soft and cheeses.

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Foods avoided: coarse whole grain cereals and bread, nuts; raisins; coconuts; fruits with small seeds; fried foods; high fat gravies or sauces; spicy salad dressings; pickled meat, fish or poultry; strong cheeses; brown or wild rice; raw vegetables, as well as lima beans and corns; spices such as horseradish, mustard, and catsup; and popcorn.

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Sodium Restricted Diet Purpose: Reduce sodium content in the tissue and promote excretion of water. Use: Heart failure, hypertension, renal disease, cirrhosis, toxemia of pregnancy and cortisone therapy. Modifications: Mildly restrictive 2g sodium diet to extremely restricted 200mg sodium diet

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Foods avoided: Table salt; all commercial soups, including bouillon, gravy, catsup, mustard, meat sauces, and soy sauce; buttermilk, ice cream, and sherbet; sodas; beet greens, carrots, celery, and spinach; all canned vegetables; frozen peas : All baked products containing salt; baking powder, or baking soda; potato chips and popcorn; fresh or canned shellfish; all cheeses; smoked or commercially prepared meats; salted butter or margarine; bacon, olives and salad dressings.

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Renal Diet Purpose: Control protein, potassium, sodium and fluid levels in the body. Use: Acute and chronic renal failure, hemodialysis Foods allowed: - High-biological proteins such as meat, fowl, fish, cheese and dairy products- range between 20 and 60 mg/day - Potassium is usually limited to 1500mg/day - Vegetables such as cabbage, cucumber and peas are lowest in potassium - Sodium is restricted to 500 mg/day - Fluid intake is restricted to the daily volume plus 500 ml, which represents insensible water loss - Fluid intake measures water in fruit, vegetables, milk and meat

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Foods avoided: Cereals, bread, macaroni, noodles, spaghetti, avocados, kidney beans, potato chips, raw fruits, yams, soy beans, nuts, gingerbread, apricots, bananas, figs, grapefruit, oranges, percolated coffee, coca-cola, orange crush, sport drinks and breakfast drinks such as tang or awake.

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High Protein, High Carbohydrate Diet Purpose: To correct large protein losses and raises the level of blood albumin. May be modified to include low fat, low sodium and low cholesterol diets. Use: Burns, hepatitis, cirrhosis, pregnancy, hyperthyroidism, mononucleosis, protein deficiency due to poor eating habits, geriatric patient with poor intake, nephritis, nephrosis, and liver and gall bladder disorder. Foods allowed: General diet with added protein. Foods avoided: Restrictions depend on modifications added to the diet. The modifications are determined by the patient’s condition.

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Purine - Restricted Diet Purpose: Designed to reduce intake of uric acid- producing foods. Use: High uric acid retention, uric acid renal stones and gout. Foods allowed: General diet plus 2-3 quarts of liquid daily. Foods avoided: Cheese containing spices or nuts, fried eggs, meat, liver, seafood, lentils, dried peas and beans, broth, bouillon, gravies, oatmeal and whole wheat, pasta, noodles and alcoholic beverages. Limited quantities of meat, fish, and seafood allowed.

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Bland Diet Purpose: Provision of a diet in low fiber, roughage, mechanical irritants, and chemical stimulants. Use: Gastritis, hyperchlorhydria (excess hydrochloric acid), functional GI disorders, gastric atony, diarrhea, spastic constipation, biliary indigestion and hiatus hernia. Foods allowed: Varied to meet individual needs and food tolerance

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Foods avoided: Fresh foods including eggs, meat, fish, and seafood, cheese with added nuts, or spices, commercially prepared luncheon meats, cured meats such as ham; gravies; and sauces and raw vegetables : Potato skins; fruit juices with pulp; figs; raisins; fresh fruits; whole wheat; rye bread; bran cereals; rich pastries; pies; chocolate; jams with seeds, nuts, seasoned dressings, coffee, strong tea, cocoa, alcoholic and carbonated beverages and pepper.

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Low-Fat, Cholesterol Restricted Diet Purpose: Reduce hyperlipedimia, provide dietary treatment for malabsorption syndromes and patients having acute intolerance for fats. Use: Hyperlipedimia, atherosclerosis, pancreatitis, cystic fibrosis, sprue (disease of intestinal tract characterized by malabsorption), gastrectomy, massive resection of small intestine, and cholecystitis. Foods allowed: Non-fat milk; low-carbohydrate, low-fat vegetables; most fruits; breads; pastas; cornmeal; lean meats. Foods avoided: Remember to avoid the five C’s of cholesterol – cookies, cream, cake, coconut, chocolate; whole milk or cream products, avocados, olives, commercially prepared baked goods such as donuts and muffins, poultry skin, highly marbled meals.

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Diabetic Diet Purpose: Maintain blood glucose as near as normal as possible; prevent or delay onset of diabetic complications. Use: Diabetes mellitus Foods allowed: Choose foods with low glycemic index compose of: - 45-55% carbohydrates - 30-35% fats - 10-25% protein

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:Coffee, tea, broth, spices and flavoring can be used as desired. : Exchange groups include milk, vegetables, fruits, starch/bread, meat (divided in lean, medium fat, and high fat), and fat exchanges. :The number of exchanges allowed from each group is dependent on the total number of calories allowed. : Non-nutritive sweeteners (sorbitol) in moderation with controlled, normal weight diabetics. Foods avoided: concentrated sweets or regular soft drinks

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High- fiber Diet Purpose: Soften the stool : Exercise digestive tract muscles : Speed passage of food through digestive tract to prevent exposure to cancer-causing agents in food : Lower blood lipids : Prevent sharp rise in glucose after eating Use: Diabetes, hyperlipedimia, constipation, diverticulitis, anticarcinogenics (colon) Foods allowed: Recommended intake about 6 gms crude fiber dail : All bran cereal : Watermelon, prunes, dried peaches, apple with skin, parsnip, peas, brussels sprout, sunflower seeds.

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Low- Residue Diet Purpose: Reduce stool bulk and slow transit time. Use: Bowel inflammation during acute diverculitis or ulcerative colitis, preparation for bowel surgery, esophageal and intestinal stenosis. Foods allowed: Eggs; ground or well cooked tender meat, fish, poultry; milk; cheeses; strained fruit juices ( except prune); cooked or canned apples, apricots, peaches, pears, ripe bananas; strained vegetable juice: canned or cooked or strained asparagus, beets, green beans, pumpkin, squash, spinach, white bread, refine cereals (cream of wheat).

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Elimination: URINARY * Assessing the urine: 1. Amount per hour 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 N N

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3. clarity: clear > if turbid (cloudy): UTI 4. Odor: aromatic 5. Sterility: sterile 6. pH: acidic (6.0) 7. Specific gravity > 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 N N

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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

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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 there’s no urine: clamp below the insertion point; 30 mins. put the syringe above the clamp part

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CATHETERIZATION > contraindicated with pelvic fx, perineal herniation, urethral stricture > 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 N

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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

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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 H 2 O: -- pure PNSS can cause precipitate formation & crystallization.

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Elimination: FECAL *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 N

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ENEMA >introduction of a solution to the client’s 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

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> Position: left side lying > Use: Medical / Cleaning > Length: should pass the internal sphincter; 3-4 inches *if there’s any resistance, never force the obstruction > to relax: inhale > If client experience cramping & pain: clamp for 30 mins. ** rectal suppository: 3-4 inches

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MEDICATION COMPUTATION

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

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DRUGS IV = mL /hr hours = mL gtts /min Drugs: > D x Q S * “U 40” = 40 units/ mL > D = SxQ > S = D/Q Drop Factor: IV= vol ( mL ) x drop factor > Adult: 15 hrs > Pedia : 60 ordered amount of drug = unknown quantity needed (X) amount of drug on hand known quantity of drug

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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

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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

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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 habitually. 5. Drug dependence – client’s reliance on the drug.

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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. 8. 9. 10.

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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 in-charge or physicians. 8. When a medication error is made, assess the client and report it immediately to the nurse in charge or physician.

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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 client’s with difficulty of swallowing. 3. Inappropriate for patient’s with decrease gastric motility. 4. May have unpleasant taste or discolor the teeth. 5. May cause aspiration.

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Different Forms of Oral Medications: 1. Solid – tablet, capsule, pills, caplet, powdered 2. Liquid > Syrup – sugar-based > Emulsion – oil-based > Suspension – water-based > Elixir – alcohol-based * Allow 30 minutes to elapse before giving a glass of water. 3. Sublingual 4. Buccal 5. Rectal 6. Vaginal 7. Topical 8. Transdermal

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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, ½ inch Maximum cc: 0.1cc to 0.2cc

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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, ½ inch Maximum cc: 1-3 ml

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3. Intramuscular Advantage: faster absorption, can reduce pain and irritation from irritating drugs. Disadvantage: requires sterile technique, can cause anxiety, it breaks the client’s skin integrity Sites: ventrogluteal, dorsogluteal, vastus lateralis, rectus femoris, deltoid Angle of needle: 90 angle

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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

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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 ½, 2 inches Maximum cc: IV push – 10 ml IV infusion – 4L per day

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BLOOD TRANSFUSION

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> 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

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> best way to check client’s 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. 1 st adverse rxn: dizziness/headache IV: STOP, RUN PNSS, NOTIFY THE DOCTOR - bring blood to the laboratory - get a urine specimen

That’s All Folks!:

That’s All Folks!