Fundamentals of Nursing

1. THEORETICAL FRAMEWORK of NURSING PRACTICE

1. Nursing

As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia

Henderson: The unique function of the nurse is to assist the individual, sick or well,
in the performance of those activities contributing to health. It’s recovery, or to a
peaceful death that the client would perform unaided if he had the necessary
strength, will or knowledge. Help the client gain independence as rapidly as
possible.

1. CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE

Theorist Description
· Developed the first theory of nursing. · Focused on changing and
FLORENCE
manipulating the environment in order to put the patient in the
NIGHTINGALE
best possible conditions for nature to act.
· Introduced the Interpersonal Model. · She defined nursing as a
therapeutic, interpersonal process which strives to develop a
HILDEGARD PEPLAU
nurse-patient relationship in which the nurse serves as a
resource person, counselor and surrogate.
· Defined nursing as having a problem-solving approach, with
FAYE ABDELLAH key nursing problems related to health needs of people;
developed list 21 nursing problem areas
· Developed the three elements – client behavior, nurse reaction
and nurse action – compose the nursing situation. She observed
IDA JEAN ORLANDO that the nurse provide direct assistance to meet an immediate
need for help in order to avoid or to alleviate distress or
helplessness.
· Described the Four Conservation Principles.

1. conservation of energy
MYRA LEVINE 2. conservation of structured integrity
3. conservation of personal integrity

4. conservation of social integrity

· Developed the Behavioral System Model.

1. Patient’s behavior as a system that is a whole with

interacting parts
DOROTHY JOHNSON
2. how the client adapts to illness

3. goal of nursing is to reduce so that the client can move

more easily through recovery.
Conceptualized the Science of Unitary Human Beings. She
asserted that human beings are more than different from the sum
MARTHA ROGERS
of their parts; the distinctive properties of the whole are
significantly different from those of its parts.
DOROTHEA OREM Emphasizes the client’s self care needs; nursing care becomes
 necessary when client is unable to fulfill biological, psychological,
developmental or social needs.
Nursing process is defined as dynamic interpersonal process
IMOGENE KING
between nurse, client and health care system.
Stress reduction is a goal of system model of nursing practice.
BETTY NEUMAN Nursing actions are in primary, secondary or tertiary level of
prevention
Presented the Adaptation Model. She viewed each person as a
unified bio-psychosocial system in constant interaction with a
SISTER CALLISTA ROY changing environment. The goal of nursing is to help the person
adapt to changes in physiological needs, self-concept, role
function and interdependent relations during health and illness.
Introduced the notion that nursing centers around three
LYDIA HALL components: person(core), pathologic state and
treatment(cure) and body(care).
Conceptualized the Human Caring Model. She emphasized that
nursing is the application of the art and human science through
JEAN WATSON transpersonal caring transactions to help persons achieve mind-
body-soul harmony, which generates self-knowledge, self-control,
self-care and self-healing.
Introduced the Theory of Human Becoming. She emphasized
ROSEMARIE RIZZO free choice of personal meaning in relating to value priorities, co-
PARSE creating of rhythmical patterns, in exchange with the environment
and contranscending in many dimensions as possibilities unfold.
Developed the Transcultural Nursing Model. She advocated
that nursing is a humanistic and scientific mode of helping a client
MADELEINE LENINGER
through specific cultural caring processes (cultural values, beliefs
and practices) to improve or maintain a health condition

2. ROLES AND FUNCTION OF A NURSE

a. Caregiver – the caregiver role has traditionally included those activities that
assist the client physically and psychologically while preserving the client’s dignity.
Caregiving encompasses the physical, psychosocial, developmental, cultural and
spiritual levels.
b. Communicator – communication is an integral to all nursing roles. Nurses
communicate with the client, support persons, other health professionals, and
people in the community. In the role of communicator, nurses identify client
problems and then communicate these verbally or in writing to other members of
the health team. The quality of a nurse’s communication is an important factor in
nursing care.
c. Teacher – as a teacher, the nurse helps clients learn about their health and the
health care procedures they need to perform to restore or maintain their health.
The nurse assesses the client’s learning needs and readiness to learn, sets specific
learning goals in conjunction with the client, enacts teaching strategies and
measures learning.
d. Client advocate – a client advocate acts to protect the client. In this role the
nurse may represent the client’s needs and wishes to other health professionals,
such as relaying the client’s wishes for information to the physician. They also assist
clients in exercising their rights and help them speak up for themselves.
e. Counselor – counseling is a process of helping a client to recognize and cope
with stressful psychologic or social problems, to developed improved interpersonal
relationships, and to promote personal growth. It involves providing emotional,
intellectual, and psychologic support.
f. Change agent – the nurse acts as a change agent when assisting others, that is,
clients, to make modifications in their own behavior. Nurses also often act to make
changes in a system such as clinical care, if it is not helping a client return to
health.
g. Leader – a leader influences others to work together to accomplish a specific
goal. The leader role can be employed at different levels; individual client, family,
groups of clients, colleagues, or the community. Effective leadership is a learned
process requiring an understanding of the needs and goals that motivate people,
the knowledge to apply the leadership skills, and the interpersonal skills to
influence others.
h. Manager – the nurse manages the nursing care of individuals, families, and
communities. The nurse-manager also delegates nursing activities to ancillary
workers and other nurses, and supervises and evaluates their performance.
i. Case manager – nurse case managers work with the multidisciplinary health
care team to measure the effectiveness of the case management plan and to
monitor outcomes.
j. Research consumer – nurses often use research to improve client care. In a
clinical area nurses need to: · Have some awareness of the process and language of
research · Be sensitive to issues related to protecting the rights of human subjects ·
Participate in identification of significant researchable problems · Be a
discriminating consumer of research findings

2. Concepts of Health and Illness

I. Health – As defined by the World Health Organization (WHO): state of complete

physical, mental and social well-being, not merely the absence of disease or
infirmity.

a. Characteristics
i. A concern for the individual as a total system
ii. A view of health that identifies internal and external environment
iii. An acknowledgment of the importance of an individual’s role in life A dynamic
state in which the individual adapts to changes in internal and external environment
to maintain a state of well being

b. Models of Health and Illness

i. Health-Illness Continuum (Neuman) – Degree of client wellness that exist at any
point in time, ranging from an optimal wellness condition, with available energy at
its maximum, to death which represents total energy depletion.

ii. High – Level Wellness Model (Halbert Dunn) – It is oriented toward maximizing the
health potential of an individual. This model requires the individual to maintain a
continuum of balance and purposeful direction within the environment.

iii. Agent – Host – environment Model (Leavell) – The level of health of an individual
or group depends on the dynamic relationship of the agent, host and environment
Ø Agent – any internal or external factor that disease or illness.
Ø Host – the person or persons who may be susceptible to a particular illness or
disease
Ø Environment – consists of all factors outside of the host

iv. Health – Belief Model – Addresses the relationship between a person’s belief and
behaviors. It provides a way of understanding and predicting how clients will
behave in relation to their health and how they will comply with health care
therapies.

Four Components
Ø The individual is perception of susceptibility to an illness
Ø The individual’s perception of the seriousness of the illness
Ø The perceived threat of a disease
Ø The perceived benefits of taking the necessary preventive measures

v. Evolutionary – Based Model – Illness and death serves as a evolutionary function.

Evolutionary viability reflects the extent to which individual’s function to promote
survival and well-being.
The model interrelates the following elements:
Ø Life events
Ø Life style determinants
Ø Evolutionary viability within the social context
Ø Control perceptions
Ø Viability emotions
Ø Health outcomes

vi. Health Promotion Model – A “complimentary counterpart models of health

protection”. Directed at increasing a client’s level of well being. Explain the reason
for client’s participation health-promotion behaviors.

The model focuses on three functions:

Ø It identifies factors (demographic and socially) enhance or decrease the
participation in health promotion
Ø It organizes cues into pattern to explain likelihood of a client’s participation
health-promotion behaviors
Ø It explains the reasons that individuals engage in health activities I

II. Illness – State in which a person’s physical, emotional, intellectual, social

developmental or spiritual functioning is diminished or impaired. It is a condition
characterized by a deviation from a normal, healthy state.

a. 3 Stages of Illness
i. Stage of Denial – Refusal to acknowledge illness; anxiety, fear, irritability and
aggressiveness.
ii. Stage of Acceptance – Turns to professional help for assistance
iii. Stage of Recovery (Rehabilitation or Convalescence) – The patient goes through
of resolving loss or impairment of function

b. Rehabilitation
i. A dynamic, health oriented process that assists individual who is ill or disabled to
achieve his greatest possible level of physical, mental, spiritual, social and
economical functioning.
ii. Abilities not disabilities, are emphasized.
iii. Begins during initial contact with the patient iv. Emphasis is on restoring the
patient to independence or regain his pre-illness/predisability level of function as
short a time as possible v. Patient must be an active participant in the rehabilitation
goal setting an din rehabilitation process.

c. Focuses of Rehabilitation
i. Coping pattern
ii. Functional ability – focuses on self-care: activities of daily living (ADL); feeding,
bathing/hygiene, dressing/grooming, toileting and mobility
iii. Mobility
iv. Integrity of skin
v. Control of bowel and bladder function

3. Concepts of Stress

I. Stress (Theory by Hans Selye)

a. Non specific response of the body to nay demand made upon it
b. Any situation in which a non specific demand requires an individual to respond or
take action

II. Characteristics of Stress

a. Stress is not nervous energy. Emotional reactions are common stressors
b. Stress is not always the result of damage to the body
c. Stress does not always result in feelings of distress (harmful or unpleasant stress)

d. Stress is a necessary part of life and is essential for normal growth and
development
e. Stress involves the entire body acting as a whole and is an integrated manner
f. Stress response is natural, productive and adaptive

III. Stressors – Factor or agent producing stress, maybe: physiological,

psychological, social, environmental, developmental, spiritual or cultural and
represent an unmet needs

a. Classification of Stressors
i. Internal Stressors – originate from within the body. E.g. fever, pregnancy,
menopause, emotion such as guilt
ii. External Stressors – originate outside a person. E.g. change in family or social
role, peer pressure, marked change in environmental temperature

b. Factors influencing response to stressors

i. Physiological functioning
ii. Personality
iii. Behavioral characteristics
iv. Nature of the stressor: integrity, scope, duration, number, and nature of other
stressors

4. Homeostasis – Process of maintaining uniformity, stability and

constancy with in the living organisms. (from Greek word homotos –
like, and stasis – position)

5. Adaptation – Body’s adjustment to different circumstances and

conditions. Process by the physiological or psychological dimensions
change in response to stress; attempt to maintain optimal functioning

6. Adaptation to Stress-Physiological Response (Hans Selye)

I. Local Adaptation Syndrome (LAS) – Response of a body tissue, organ or part to
the stress of trauma, illness or other physiological change

a. Characteristics
i. The response is localized, it does not involve entire body systems
ii. The response is adaptive, meaning that a stressor is necessary to stimulate it
iii. The response is short term. It does not persist indefinitely
iv. The response is restorative, meaning that the LAS assists in restoring
homeostasis to the body region or part

b. Two Localized Responses

i. Reflex Pain Response – is a localized response of the central nervous system to
pain. It is an adaptive response and protects tissue from further damage. The
response involves a sensory receptor, a sensory nerve from the spinal cord, and an
effector muscle. An example would be the unconscious, reflex removal of the hand
from a hot surface.
ii. Inflammatory Response – is stimulated by trauma or infection. This response
localizes the inflammation, thus revenging its spread and promotes healing. The
inflammatory response may produce localized pain, swelling, heat, redness and
changes in functioning.

c. Three Phases of Inflammatory Response

i. First Phase – Narrowing of blood vessels occurs at the injury to control bleeding.
Then histamine is released at the injury, increasing the number of white blood cells
to combat infection.
ii. Second Phase – It is characterized by release of exudates from the wound
iii. Third Phase – The last phase is repair of tissue by regeneration or scar formation.
Regeneration replaces damaged cells with identical or similar cells.

II. General Adaptation Syndrome (GAS) or Stress Syndrome – characterized

by a chain or pattern of physiologic events.
a. 3 Stages
i. Alarm Reaction – initial reaction of the body which alerts the body’s defenses.

SELYE divided this stage into 2 parts:

Ø The SHOCK PHASE
Ø The COUNTERSHOCK PHASE

ii. Stage of Resistance – occurs when the body’s adaptation takes place; the body
attempts to adjust with the stressor and to limit the stressor to the smallest area of
the body that can deal with it. iii.
Stressor
Epinephrine Tachycardia ↑ Myocardial contractility ↑ Blood clotting ↑ Metabolism
Norepinephrine ↓ Blood to kidney ↑ Renin
Cotisone Protein catablism Gluconeogenesis
Stage of Resistance
Adaptation
Shock Phase
Stage of Exhaustion ↓ ↓ Rest Death
Stage of Exhaustion – the adaptation that the body made during the second stage
cannot be maintained; the ways used to cope with the stressors have been
exhausted

b. STRESSORS stimulate the sympathetic nervous system, which in turn stimulates

the hypothalamus. The HYPOTHALAMUS releases corticotrophin releasing hormone
(CRH). During times of stress, the ADRENAL MEDULLA secretes EPINEPHRINE &
NOREPINEPHRINE in response to sympathetic stimulation.

Significant body responses to epinephrine include the following:

i. Increased myocardial contractility, which increases cardiac output & blood flow to
active muscles
ii. Bronchial dilation, which allows increased oxygen intake
iii. Increased blood clotting
iv. Increased cellular metabolism
v. Increased fat mobilization to make energy available & to synthesize other
compounds needed by the body.

7. Physiologic Indicators of Stress

a. Pupils dilate to increase visual perception when serious threats to the body arise.
b. Sweat production (diaphoresis) increases to control elevated body heat due to
increased metabolism.
c. The heart rate & cardiac output increase to transport nutrients and by-products of
metabolism more efficiently.
d. Skin is pallid because of constriction of peripheral vessels, an effect of
norepinephrine.
e. Sodium & water retention increase due to release of mineralocorticoids, which
results in increased blood volume.
f. The rate & depth of respirations increase because of dilation of the bronchioles,
promoting hyperventilation.
g. Urinary output may increase or decreases.
h. The mouth may be dry.
i. Peristalsis of the intestines decreases, resulting in possible constipation and
flatus.
j. For serious threats, mental alertness improves.
k. Muscle tension increases to prepare for rapid motor activity or defense.
l. Blood sugar increases because of release of glucocorticoids & gluconeogenesis.

8. Psychologic Indicators – psychologic manifestations of stress

include anxiety, fear, anger, depression & unconscious ego defense
mechanisms.

a. Anxiety – a common reaction to stress. It is a state of mental uneasiness,

apprehension, dread, or foreboding or a feeling of helplessness related to an
impending or anticipated unidentified threat to self or significant relationships. It
can be experienced, subcutaneous or unconscious level. Can be manifested on 4
LEVELS:
b. Fear – an emotion or feeling of apprehension aroused by impending or seeming
danger, or other perceived threat. The object of fear may or may not be based in
reality.
c. Anger – an emotional state consisting of a subjective feeling of animosity or
strong displeasure. People may feel guilty when they feel anger because they have
been taught that to feel angry is wrong.
d. Depression – common reaction to events that seem overwhelming or negative. It
is an extreme feeling of sadness, despair, dejection, lack of worth or emptiness.
Emotional symptoms can include: Feelings of tiredness, sadness, emptiness, or
numbness Behavioral signs include: Irritability, inability to concentrate, difficulty
making decisions, loss of sexual desire, crying, sleep disturbance and social
withdrawal.

Physical signs include: Loss of appetite, weight loss, constipation, headache and
dizziness

I. Cognitive Indicators – are thinking responses that include problem-solving,

structuring, self-control or self-discipline, suppression and fantasy
a. Problem solving – involves thinking through the threatening situation, using a
specific steps to arrive at a solution
b. Structuring – arrangement or manipulation of a situation so that threatening
events do not occur.
c. Self-Control (discipline) – assuming a manner of facial expression that convey a
sense of being in control or in change.
d. Suppression – consciously and willfully putting a thought or feeling out of mind
e. Fantasy – (daydreaming) – likened to make believe. Unfulfilled wishes & desires
are imagined as fulfilled, or a threatening experience is reworked or replayed so
that it ends differently from reality.

2. COPING STRATEGIES (COPING MECHANISMS)

3.

Coping – dealing with problems & situations or contending with them successfully.
Coping Strategy – innate or acquired way of responding to a changing environment
or specific problem or situation. According to Folkman and Lazarus, coping is “the
cognitive & behavioral effort to manage specific external and/ or internal demands
that are appraised as taxing or exceeding the resources of the person”.

1. Coping Strategies: 2 Types

I. Problem-focused coping – efforts to improve a situation by making changes or

taking some action
II. Emotion-focused coping – does not improve the situation, but the person often
feels better.

Coping strategies are also viewed as:

a. Long-term coping strategies – can be constructive & realistic
b. Short-term coping strategies – can reduce stress to a tolerable limit temporarily
but are in the end od ineffective ways to deal with reality.

Coping can be adaptive or maladaptive:

B. Adaptive Coping – helps the person to deal effectively with stressful events &
minimizes distress associated with them.
C. Maladaptive Coping – can result in unnecessary distress for the person & others
associated with the person or stressful event.

*Effective coping results in adaptation; ineffective coping results in maladaptation.

The effectiveness of an individual’s coping is influenced by a number of factors: ·
The number, duration & intensity of the stressors · Past experiences of the
individual · Support systems available to the individual · Personal qualities of the
person

*If the duration of the stressors is extended beyond the coping powers of the
individual, that person becomes exhausted and may develop increased
susceptibility to health problems. *Reaction to long term stress is seen in family
members who undertake the care of a person in the home for a long period. This
stress is called caregiver burden & produces responses such as chronic fatigue,
sleeping difficulties & high BP. *Prolonged stress can also result in mental illness.

4. Relaxation Techniques – used to quiet the mind, release tension &

counteract the fight or flight responses of General Adaptation
Syndrome (GAS).

I. Breathing Exercises
II. Massage
III. Progressive Relaxation
IV. Imagery
V. Biofeedback
VI. Yoga
VII. Meditation
VIII. Therapeutic Touch
IX. Music Therapy
X. Humor & Laughter

3. PSYCHOLOGICAL RESPONSE

Exposure to a stressor results in psychological and physiological and physiological

adaptive responses. As people are exposed a stressors, their ability to meet their
basic needs is threatened. This threat whether actual or perceived, produces
frustration, anxiety and tension. Psychological adaptive behaviors assist the
person’s ability to cope with stressors. These behaviors are directed at stress
management and are acquired through learning and experience as a person
identifies acceptable and successful behaviors. Psychological adaptive behaviors
are also related to as COPING MECHANISMS.
It involves:

1. Task – Oriented Behaviors – Involve using cognitive abilities to

reduce stress, solve problems, resolve conflicts and gratify needs. It
enables a person to cope realistically with the demands of a stressor.

Three General Types

I. Attack Behavior – Is acting to remove or overcome a stressor or to satisfy a need
II. Withdrawal Behavior – Is removing the self physically or emotionally from the
stressor
III. Compromise Behavior – Is changing the usual method of operating, substituting
goals or omitting the satisfaction of needs to meet other needs or to avoid stress.

2. Defense Mechanisms – Unconscious behaviors that offer

psychological protection from a stressful event. They are used by
everyone and help protect against feelings of worthlessness and
 anxiety. Frequently activated by short-term stressors and usually do
not result in psychiatric disorders.

4. TYPES OF NURSING DIAGNOSES

1. Formulating the Nursing Diagnosis

I. Actual
a. Clients demonstrates defining characteristics of a problem
b. Nurse intervenes to resolve or help client cope with the problem

II. High-risk
a. A problem is likely to develop based on assessment of risk factors
b. Nurse intervenes to reduce risk factors or increase protective factors
c. Example: encourage smoking cessation

III. Wellness
a. Client is presently healthy but wishes to achieve a higher level of function
b. Nurse intervenes to promote growth or maintenance of the healthy response

2. Collaborative Problems

I. Definition: a potential problem the nurse manages using both independent and
interdependent interventions
II. Example: potential complication of head injury: loss of consciousness, epidural or
subdural hematoma, seizures
III. Usually occurs when a disease is present or a treatment is prescribed
IV. Clients with similar disease or treatment will have the same potential for
complications, which must be managed collaboratively; however, their responses to
the condition will vary, so a broad range of nursing diagnoses will apply.
a. Example: a client with asthma will always be at risk for lowered oxygen
saturation; however, the client’s response to this condition will be unique based on
his/her developmental level, past experiences and family configuration
b. Refer to Table for examples of collaborative problems
Example:

Disease/Situation Complication Related to Etiology

Potential 1.Uterine atony 2.
complication of Retained placental
Hemorrhage Related to Related
childbirth Potential fragment 3. Bladder
Dysrhythmia to
complication of distention Low
diuretic therapy serum potassium

5. METHODS USED for ASSESSMENT

 1. Collaboration of Data: Objective & Subjective

I. Review of clinical record

a. Client records contain information collected by many members of the healthcare
team, such as demographics, past medical history, diagnostic test results and
consultations
b. Reviewing the client’s record before beginning an assessment prevents the nurse
from repeating questions that the client has already been asked and identifies
information that needs clarification.

II. Interview
a. The purpose of an interview is to gather and provide information, identify
problems of concerns, and provide teaching and support.
b. The goals of an interview are to develop a rapport with the client and to collect
data
c. An interview has 3 major stages

i. Opening: purpose is to establish rapport by creating goodwill and trust; this is

often achieved through a self – introduction, nonverbal gestures (a handshake), and
small talk about the weather, local sports team, or recent current event; the
purpose of the interview is also explained to the client at this time.
ii. Body: during this phase, the client responds to open and closed-ended questions
asked by the nurse.
iii. Closing: either the client or the nurse may terminate the interview, it is
important fro the nurse to try to maintain the rapport and trust that was developed
thus far during the interview process.
d. Types of questions

i. Closed questions used in directive interview

Ø Re____ short factual answers; e.g. “Do you have pain?”
Ø Answers usually reveal limited amounts of information
Ø Useful with clients who are highly stressed and/or have difficulty communicating

ii. Open-ended questions used in nondirective interview

Ø Encourage clients to express and clarify their thoughts and feelings; e.g. “How
have you been sleeping lately?’
Ø Specify the broad area to be discussed and invite longer answers
Ø Useful at the start of an interview or to change the subject

iii. Leading questions

Ø Direct the client’s answer; e.g. “You don’t have any questions about your
medications, do you?”
Ø Suggests what answer is expected
Ø Can result in client giving inaccurate data to please the nurse
Ø Can limit client choice of topic for discussion

III. Nursing History

a. Collection of information about the effect of the client’s illness on daily
functioning and ability to cope with the stressor (the human response)
b. Subjective data
i. May be called “covert data”
ii. Not measurable or observable
iii. Obtained from client (primary source), significant others, or health professionals
(secondary sources).
iv. For example, the client states, “I have a headache”
c. Objective data
i. May be called “overt data”
ii. Can be detected by someone other than the client
iii. Includes measurable and observable client behavior
iv. For example, a blood pressure reading of 190/110 mmHg.

IV. Physical assessment

a. Systematic collection of information about the body systems through the use of
observation, inspection, auscultation, palpation and percussion
b. A body system format for physical assessment is found below:
· General assessement
· Integumentary system
· Head, ears, eyes, nose, throat · Breast and axillae
· Thorax and lungs
· Cardiovascular system
· Nervous system
· Abdomen and gastrointestinal system
· Anus and rectum
· Genitourinary system
· Reproductive system
· Musculoskeletal system
V. Psychosocial assessment
a. Helpful framework for organizing data

b. A suggested format for psychosocial assessment is found below:

· Vocation/education/financial
· Home and Family
· Social, leisure, spiritual and cultural
· Sexual
· Activities of daily living
· Health Habits
· Psychological

c. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also
be helpful for guiding data collection

VI. Consultation
a. The nurse collects data from multiple sources: primary (client) and secondary
(family members, support persons, healthcare professionals and records)
b. Consultation with individuals who can contribute to the client’s database is
helpful in achieving the most complete and accurate information about a client
c. Supplemental information from secondary sources (any source other then the
client) can help verify information, provide information for a client who cannot do
so, and convey information about the client’s status prior to admission

VII. Review of literature

a. A professional nurse engages in continued education to maintain knowledge of
current information related to health care
b. Reviewing professional journals and textbooks can help provide additional data to
support or help analyze the client database

6. DOCUMENTING and REPORTING

 1. Guidelines for Good Documentation and Reporting

I. Fact – information about clients and their care must be factual. A record should
contain descriptive, objective information about what a nurse sees, hears, feels and
smells

II. Accuracy – information must be accurate so that health team members have
confidence in it

III. Completeness – the information within a record or a report should be complete,

containing concise and thorough information about a client’s care. Concise data are
easy to understand

IV. Currentness – ongoing decisions about care must be based on currently reported
information. At the time of occurrence include the following:
a. Vital signs
b. Administration of medications and treatments
c. Preparation of diagnostic tests or surgery
d. Change in status
e. Admission, transfer, discharge or death of a client
f. Treatment fro a sudden change in status

V. Organization – the nurse communicate in a logical format or order

VI. Confidentiality – a confidential communication is information given by one

person to another with trust and confidence that such information will not be
disclosed

2. Documentation – anything written or printed that is relied on as a

record of proof fro authorized persons.

Purposes of Records:
I. Communication
II. Planning Client Care
III. Auditing Health Agencies
IV. Research
V. Education
VI. Reimbursement
VII. Legal Documentation
VIII. Health Care Analysis

3. Documentation Systems

I. Source – Oriented Record

a. The traditional client record
b. Each person or department makes notations in a separate section or sections of
the client’s chart
c. It is convenient because care providers from each discipline can easily locate the
forms on which to record data and it is easy to trace the information
d. Example: the admissions department has an admission sheet; the physician has
a physician’s order sheet, a physician’s history sheet & progress notes
e. NARRATIVE CHARTING is a traditional part of the source-oriented record
II. Problem – Oriented Medical Record (POMR)
a. Established by Lawrence Weed
b. The data are arranged according to the problems the client has rather than the
source of the information.

The four (4) basic components:

i. Database – consists of all information known about the client when the client first
enters the health care agency. It includes the nursing assessment, the physician’s
history, social & family data
ii. Problem List – derived from the database. Usually kept at the front of the chart &
serves as an index to the numbered entries in the progress notes. Problems are
listed in the order in which they are identified & the list is continually updated as
new problems are identified & others resolved
iii. Plan of Care – care plans are generated by the person who lists the problems.
Physician’s write physician’s orders or medical care plans; nurses write nursing
orders or nursing care plans
iv. Progress Notes – chart entry made by all health professionals involved in a
client’s care; they all use the same type of sheet fro notes. Numbered to correspond
to the problems on the problem list and may be lettered for the type of data

Example: SOAP Format Or SOAPIE and SOAPIER

S – Subjective data O – Objective data A – Assessment P – Plan I – Intervention E –
Evaluation R- Revision Advantages of POMR: § It encourages collaboration § Problem
list in the front of the chart alerts caregivers to the client’s needs & makes it easier
to track the status of each problem. Disadvantages of POMR: § Caregivers differ in
their ability to use the required charting format

§ Takes constant vigilance to maintain an up-to-date problem list

§ Somewhat inefficient because assessments & interventions that apply to more
than one problem must be repeated.

III. PIE (Problems, Interventions, and Evaluation)

a. Groups information in to three (3) categories
b. This system consists of a client care assessment floe sheet & progress notes
c. FLOW SHEET – uses specific assessment criteria in a particular format, such as
human needs or functional health patterns
d. Eliminate the traditional care plan & incorporate an ongoing care plan into the
progress notes

IV. Focus Charting

a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns fro recording are usually used: date & time, focus & progress
notes

V. Charting by Exception
a. Documentation system in which only abnormal or significant findings or
exceptions to norms are recorded
b. Incorporates three (3) key elements:
i. Flow sheets
ii. Standards of nursing care
iii. Bedside access to chart forms

VI. Computerized Documentation

a. Developed as a way to manage the huge volume of information required in
contemporary health care
b. Nurses use computers to store the client’s database, add new data, create &
revise care plans & document client progress.

VII. Case Management

a. Emphasizes quality, cost-effective care delivered within an established length of
stay
b. Uses a multidisciplinary approach to planning & documenting client care, using
critical pathways.

4. Nursing Care Plan (NCP)

Two Types:
I. Traditional Care Plan – written fro each client; it has 3 columns: nursing
diagnoses, expected outcomes & nursing interventions.
II. Standardized Care Plan – based on an institution’s standards of practice; thereby
helping to provide a high quality of nursing care

5. KARDEX widely used, concise method of organizing & recording data

about a client, making information quickly accessible to all health
professionals. Consists of a series of cards kept in a portable index
file or on computer generated forms. Information may be organized
into sections:

I. Pertinent information about the client

II. List of medications
III. List of IVF
IV. List of daily treatments & procedures
V. List of Diagnostic procedures
VI. Allergies
VII. Specific data on how the client’s physical needs are to be met
VIII. A problem list, stated goals & list of nursing approaches to meet the goals

6. Nursing Discharge / Referral Summaries – completed when the

client is being discharged & transferred to another institution or to a
home setting where a visit by a community health nurse is required.
Regardless of format, it include some or all of the following:

I. Description of client’s physical, mental & emotional state

II. Resolved health problems
III. Unresolved continuing health problems
IV. Treatments that can be continued (e.g. wound care, oxygen therapy)
V. Current medications
VI. Restrictions that relate to activity, diet & bathing
VII. Functional/self-care abilities
VIII. Comfort level
IX. Support networks
X. Client education provided in relation to disease process
XI. Discharge destination
XII. Referral Services (e.g. social worker, home health nurse)

7. PHYSICAL EXAMINATION
8.
1. Purposes

The nurse uses physical assessment for the following reasons:

I. To gather baseline data about the client’s health
II. To supplement, confirm or refute data obtained in the nursing history
III. To confirm and identify nursing diagnoses
IV. To make clinical judgments about a client’s changing health status and
management

2. Preparation of Examination

I. Environment – A physical examination requires privacy. An examination room that

is well equipped for all necessary procedures is preferable
II. Equipment – Hand washing is done before equipment preparation and the
examination. Hand washing reduces the transmission of microorganisms
III. Client
a. Psychological Preparation – clients are easily embarrassed when forced to answer
sensitive questions about bodily functions or when body parts are exposed and
examined. The possibility that the examination will find something abnormal also
creates anxiety so reduction of this anxiety may be the nurse’s highest priority
before the examination
b. Physical Preparation – the client’s physical comfort is vital to the success of the
examination. Before starting, the nurse asks if the client needs to use the toilet.
c. Positioning – during the examination, the nurse asks the clients to assume proper
positions so that body parts are accessible and clients stay comfortable. Client’s
abilities to assume positions will depend on their physical strength and degree of
wellness.

3. Order of Examination

I. General Survey – includes observation of general appearance and behavior, vital

signs, height and weight measurement
II. Review of systems III. Head to toe examination

4. Skills in Physical Examination

I. Inspection – to detect normal characteristics or significant physical signs. To

inspect body parts accurately the nurse observes the following principles:
a. Make sure good lighting is available
b. Position and expose body parts so that all surface can be viewed
c. Inspect each areas fro size, shape, color, symmetry, position and abnormalities
d. If possible, compare each area inspected with the same area of the opposite side
of the body
e. Use additional light (for example, a penlight) to inspect body cavities
II. Palpation – the hands can make delicate and sensitive measurements of specific
physical signs, so palpation is used to examine all accessible parts of the body. The
nurse uses different parts of the hand to detect characteristics such as texture,
temperature and the perception of movement.

III. Percussion – examination by striking the body’s surface with a finger, vibration
and sound are produced. This vibration is transmitted through the body tissues and
the character of the sound depends on the density of the underlying tissue

IV. Auscultation – is listening to sound created in body organs to detect variations

from normal. Some sounds can be heard with the unassisted ear, although most
sounds can be heard only through a stethoscope.
a. Bowel sounds
b. Breath sounds
i. Vesicular
ii. Bronchovesicular
iii. Bronchial

5. Examples of Adventitious Breath Sounds

I. Crackles (previously called rales)

II. Rhonchi
III. Wheeze
IV. Friction rub

Therapeutic Communication Techniques

1. Using silence
2. Providing general leads
3. Being specific & tentative
4. Using open-ended questions
5. Using touch
6. Restating to paraphrasing
7. Seeking clarification
8. Perception checking or seeking consensual validation
9. Offering self
10. Giving information
11. Acknowledging
12. Clarifying time or sequence
13. Presenting reality
14. Focusing
15. Reflecting
16. Summarizing & planning

B. Barriers to Communication
1. Stereotyping
2. Agreeing & disagreeing
3. Being defensive
4. Challenging
5. Probing
6. Testing
7. Rejecting
8. Changing topics & subjects
9. Unwarranted reassurance
10. Passing judgment
11. Giving common advice

Phases of the Helping Relationship

1. Pre-interaction Phase

2. Introductory Phase
a. Opening the relationship
b. Clarifying the problem
c. Structuring & formulating the contract

3. Working Phase
a. Exploring & understanding thoughts or feelings
b. Facilitating & taking action

4. Termination Phase

8. PRINCIPLES of ASEPSIS and INFECTION CONTROL

1. Chain of Infection

I. The chain of infection refers to those elements that must be present to cause
an infection from a microorganism
II. Basic to the principle of infection is to interrupt this chain so that an infection
from a microorganism does not occur in clients
III. Infectious agent; microorganisms capable of causing infections are referred to as
an infectious agent or pathogen.
IV. Modes of transmission: the microorganism must have a means of
transmission to get from one location to another, called direct and indirect
V. Susceptible host describes a host (human or animal) not possessing enough
resistance against a particular pathogen to prevent disease or infection from
occurring when exposed to the pathogen; in humans this may occur if the person’s
resistance is low because of poor nutrition, lack of exercise of a coexisting illness
that weakens the host.
VI. Portal of entry: the means of a pathogen entering a host: the means of entry
can be the same as one that is the portal of exit (gastrointestinal, respiratory,
genitourinary tract).
VII. Reservoir: the environment in which the microorganism lives to ensure
survival; it can be a person, animal, arthropod, plant, oil or a combination of these
things; reservoirs that support organism that are pathogenic to humans are
inanimate objects food and water, and other humans.
VIII. Portal of exit: the means in which the pathogen escapes from the reservoir
and can cause disease; there is usually a common escape route for each type of
microorganism; on humans, common escape routes are the gastrointestinal,
respiratory and the genitourinary tract.

Modes of Transmission
1. Direct contact: describes the way in which microorganisms are transferred from
person to person through biting, touching, kissing, or sexual intercourse; droplet
spread is also a form of direct contact but can occur only if the source and the host
are within 3 feet from each other; transmission by droplet can occur when a person
coughs, sneezes, spits, or talks.
2. Indirect contact: can occur through fomites (inanimate objects or materials) or
through vectors (animal or insect, flying or crawling); the fomites or vectors act as
vehicle for transmission 3. Air: airborne transmission involves droplets or dust;
droplet nuclei can remain in the air for long periods and dust particles containing
infectious agents can become airborne infecting a susceptible host generally
through the respiratory tract

2. Course of Infection

I. Incubation: the time between initial contact with an infectious agent until the
first signs of symptoms - - > the incubation period varies from different
pathogens; microorganisms are growing and multiplying during this stage
II. Prodromal Stage: the time period from the onset of nonspecific symptoms
to the appearance of specific symptoms related to the causative pathogen - -
> symptoms range from being fatigued to having a low-grade fever with malaise;
during this phase it is still possible to transmit the pathogen to another host
III. Full Stage: manifestations of specific signs & symptoms of infectious agent;
referred to as the acute stage; during this stage, it may be possible to transmit
the infectious agent to another, depending on the virulence of the infectious
agent
IV. Convalescence: time period that the host takes to return to the pre-illness
stage; also called the recovery period; - - >the host defense mechanisms have
responded to the infectious agent and the signs and symptoms of the disease
disappear; the host, however, is more vulnerable to other pathogens at this time;
an appropriate nursing diagnostic label related to this process would be Risk for
Infection

3. Inflammation – The protective response of the tissues of the body to

injury or infection; the physiological reaction to injury or infection is
the inflammatory response; it may be acute or chronic

Body’s response
I. The “inflammatory response” begins with vasoconstriction that is followed by a
brief increase in vascular permeability; the blood vessels dilate allowing plasma to
escape into the injured tissue
II. WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury
and attack and ingest the invaders (phagocytosis); this process is responsible for
the signs of inflammation
III. Redness occurs when blood accumulates in the dilated capillaries; warmth
occurs as a result of the heat from the increased blood in the area, swelling occurs
from fluid accumulation; the pain occurs from pressure or injury to the local nerves.

4. Immune Response

I. The immune response involves specific reactions in the body to antigens or

foreign material

II. This specific response is the body’s attempt to protect itself, the body protects
itself by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes
III. Cell mediated immunity: T-lymphocytes are responsible for cellular immunity
a. When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they
enter the circulation from lymph tissue and seek out the antigen
b. Once theantigen is found they produce proteins (lymphokines) that increase the
migration of phagocytes to the area and keep them there to kill the antigen
c. After the antigen is gone, the lymphokines disappear
d. Some T-lymphocytes remain and keep a memory of the antigen and are
reactivated if the antigen appears again.

IV. Humoral response: the ability of the body to develop a specific antibody to a
specific antigen (antigen-antibody response)
a. B-lymphocytes provide humoral immunity by producing antibodies that convey
specific resistance to many bacterial and viral infections
b. Active immunity is produced when the immune system is activated either
naturally or artificially.
i. Natural immunity involves acquisition of immunity through developing the disease

ii. Active immunity can also be produced through vaccination by introducing into
the body a weakened or killed antigen (artificially acquired immunity) iii. Passive
immunity does not require a host to develop antibodies, rather it is transferred to
the individual, passive immunity occurs when a mother passes antibodies to a
newborn or when a person is given antibodies from an animal or person who has
had the disease in the form of immune globulins; this type of immunity only offers
temporary protection from the antigen.

5. Nosocomial Infection

I. Nosocomial Infections: are those that are acquired as a result of a healthcare

delivery system
II. Iatrogenic infection: these nosocomial infections are directly related to the
client’s treatment or diagnostic procedures; an example of an iatrogenic infection
would be a bacterial infection that results from an intravascular line or
Pseudomonas aeruginosa pneumonia as a result of respiratory suctioning
III. Exogenous Infection: are a result of the healthcare facility environment or
personnel; an example would be an upper respiratory infection resulting from
contact with a caregiver who has an upper respiratory infection
IV. Endogenous Infection: can occur from clients themselves or as a reactivation of
a previous dormant organism such as tuberculosis; an example of endogenous
infection would be a yeast infection arising in a woman receiving antibiotic therapy;
the yeast organisms are always present in the vagina, but with the elimination of
the normal bacterial flora, the yeast flourish.

6. Factors Increasing Susceptibility to Infection

I. Age: young infants & older adults are at greater risk of infection because of
reduced defense mechanisms
a. Young infants have reduced defenses related to immature immune systems
b. In elderly people, physiological changes occur in the body that make them more
susceptible to infectious disease; some of these changes are:
i. Altered immune function (specifically, decreased phagocytosis by the neutrophils
and by the macrophages)
ii. Decreased bladder muscle tone resulting in urinary retention
iii. Diminished cough reflex, loss of elastic recoil by the lungs leading to inability to
evacuate normal secretions
iv. Gastrointestinal changes resulting in decreased swallowing ability and delayed
gastric emptying.

II. Heredity: some people have a genetic predisposition or susceptibility to some

infectious diseases

III. Cultural practices: healthcare beliefs and practices, as well as nutritional and
hygiene practices, can influence a person’s susceptibility to infectious diseases

IV. Nutrition: inadequate nutrition can make a person more susceptible to infectious
diseases; nutritional practices that do not supply the body with the basic
components necessary to synthesized proteins affect the way the body’s immune
system can respond to pathogens

V. Stress: stressors, both physical and emotional, affect the body’s ability to protect
against invading pathogens; stressors affect the body by elevating blood cortisone
levels; if elevation of serum cortisone is prolonged, it decreases the anti-
inflammatory response and depletes energy stores, thus increasing the risk of
infection

VI. Rest, exercise and personal health habits: altered rest and exercise patterns
decrease the body’s protective, mechanisms and may cause physical stress to the
body resulting in an increased risk of infection; personal health habits such as poor
nutrition and unhealthy lifestyle habits increase the risk of infectious over time by
altering the body’s response to pathogens

VII. Inadequate defenses: any physiological abnormality or lifestyle habit can

influence normal defense mechanisms in the body, making the client more
susceptible to infection; the immune system functions throughout the body and
depends on the following:
a. Intact skin and mucous membranes
b. Adequate blood cell production and differentiation
c. A functional lymphatic system and spleen
d. An ability to differentiate foreign tissue and pathogens from normal body tissue
and flora; in autoimmune disease, the body has a problem with recognizing it’s own
tissue and cells; people with autoimmune disease are at increased risk of infection
related to their immune system deficiencies.

VIII. Environmental: an environment that exposes individuals to an increased

number of toxins or pathogens also increases the risk of infection; pathogens grow
well in warm moist areas with oxygen (aerobic) or without oxygen (anaerobic)
depending on the microorganism, an environment that increases exposure to toxic
substances also increases risk

IX. Immunization history: inadequately immunized people have an increased risk of

infection specifically for those diseases for which vaccines have been developed.

X. Medications and medical therapies: examples of therapies and medications that

increase clients risk for infection includes radiation treatment, anti-neo-plastic
drugs, anti inflammatory drugs and surgery
 7. Diagnostic Tests Used to Screen for Infection

I. Signs and symptoms related to infections are associated with the area infected;
for instance, symptoms of a local infection on the skin or mucous membranes are
localized swelling, redness, pain and warmth
II. Symptoms related to systemic infections include fever, increased pulse &
respirations, lethargy, anorexia, and enlarged lymph nodes
III. Certain diagnostic tests are ordered to confirm the presence of an infection.

9. THEORIES OF PAIN
1. Specific Theory

I. Proposes that body’s neurons & pathways for pain transmission are specific,
similar to other senses like taste
II. Free nerve endings in the skin act as pain receptors, accept input & transmit
impulses along highly specific nerve fibers
III. Does not account for differences in pain perception or psychologic variables
among individuals.

2. Pattern Theory

I. Identifies 2 major types of pain fibers; rapidly & slowly conducting

II. Stimulation of these fibers forms a pattern; impulses ascend to the brain to be
interpreted as painful
III. Does not account for differences in pain perception or psychologic variables
among individuals.

3. Gate Control Theory

I. Pain impulses can be modulated by a transmission blocking action within the CNS.

II. Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or

scratching an area) and may inhibit smaller diameter fibers to prevent transmission
of the impulse (“close the gate”).

4. Current Developments in Pain Theory – Indicate that pain

mechanisms & responses are far more complex than believed to be in
the past.

I. Pain may modulated at different points in the nervous system.

a. First-order neurons at the tissue level
b. Second-order neurons in the spinal cord that process nociceptor information
c. Third-order tracts & pathways in the spinal cord & brain that relay/process this
information

II. The role of the pain experience in the development of new nociceptors and/or
reducing the threshold of current nociceptor is also being investigate
 10. TYPES OF PAIN
1. Acute Pain

I. Usually temporary, sudden in onset, localized, lasts for 6 months; results from
tissue injury associated with trauma, surgery, or inflammation.
Types of Acute Pain
a. Somatic: arises from nerve receptors in the skin or close to body’s surface; may
be sharp & well-localized or dull & diffuse; often accompanied by nausea & vomiting

b. Visceral: arises from body’s organs; dull & poorly localized because of minimal
noriceptors; accompanied by nausea & vomiting, hypotension & restlessness
c. Referred pain: pain that is perceived in an area distant from the site of stimuli
(e.g. pain in a shoulder following abdominal laparoscopic procedure).

II. Acute pain initiates the “fight-or-flight” response of the Autonomic Nervous
System and is characterized by the following symptoms:
a. Tachycardia
b. Rapid, shallow respirations
c. Increased BP
d. Sweating
e. Pallor
f. Dilated pupils
g. Fear & Anxiety

2. Chronic Pain

I. Prolonged, lasting longer than 6 months, often not attributed to a definite cause,
often unresponsive to medical treatment.
Types of Chronic Pain
a. Neuropathic: painfuil condition that results from damage to peripheral nerves
caused by infection or disease; post-therapeutic neuralgia (shingles) is an example

b. Phantom: pain syndrome that occurs following surgical or traumatic amputation

of a limb.
i. The client is aware that the body part is missing
ii. Pain may result of stimulation of severed nerves at the site of amputation
iii. Sensation may be experienced as an itching, pressure, or as stabbing or burning
in nature
iv. It can be triggered by stressors (fatigue, illness, emotions, weather)
v. This experience is limited for most clients because the brain adapts to amputated
limb; however, some clients experience abnormal sensation or pain over longer
periods
vi. This type of pain requires treatment just as any other type of pain does.

c. Psychogenic: pain that is experienced in the absence of a diagnosed physiologic

cause or event; the client’s emotional needs may prompt pain sensation.

II. Depression is a common associated symptom for the client experiencing chronic
pain; feelings of despair & hopelessness along with fatigue are expected findings.

11.PAIN ASSESSMENT
 1. TOOLS/INTRUMENTS USED

I. A VERBAL REPORT using an intensity scale is a fast, easy & reliable method
allowing the client to state pain intensity & in turn, promotes consisted
communication among the nurse, client & other healthcare professionals about the
client’s pain status; the 2 most common scales used are “0 to 5” or “0 to 10”. With
0 specifying no pain & the highest number specifying the worst pain

II. A VISUAL ANALOG SCALE is a horizontal pain-intensity scale with word modifiers
at both ends of the scale, such as “no pain” at one end and “worst pain” at the
other, clients are asked to point or mark along the line to convey the degree of pain
being experienced

III. A GRAPHIC RATING SCALE is similar to the visual analog scale but adds a
numerical scale with the word modifiers, usually the numbers “0 to 10” are added
to the scale.

IV. FACES PAIN SCALE children, clients who do not speak English & clients with
communication impairments may have difficulty using a numerical pain intensity
scale; the FACES pain scale may be used for children as young as 3 years old; this
scale provides facial expressions (happy face reflects no pain, crying face
represents worst pain)

V. PHYSIOLOGIC INDICATORS OF PAIN may be the only means a nurse can use to
assess pain for a non-communicating client, facial & vocal expression may be the
initial manifestations of pain; expressions may include rapid eye blinking, biting of
the lip, moaning, crying, screaming, either closed or clenched eyes, or stiff
unmoving body position

2. A B C D E method of pain assessment

I. This acronym was developed for cancer pain; however, it is very appropriate for
clients with any type of pain, regardless of the underlying disease. II. A = Ask about
pain
III. B = Believe the client & family reports pain
IV. C = Choose pain control options appropriate for the client
V. D = Deliver interventions in a timely, logical &coordinated fashion
VI. E = Empower clients & families

3. P Q R S T assessment for pain reception

I. This method is especially helpful when approaching a new pain problem

II. P = What precipitated the pain?
III. Q = What are the quality & quantity of the pain?
IV. R = What is the region of the pain?
V. S = What is the severity of the pain?
VI. T = What is the timing of the pain?

4. Pain History
I. Location – when clients report “pain all over”, this generally refers to total pain or
existential distress (unless there is an underlying physiologic reason for pain all
over the body, such as myalgias); assess the client’s emotional state for depression,
fear, anxiety or hopelessness.

II. Intensity – It is important to quantify pain using a standard pain intensity scale.
When clients cannot conceptualize pain using a number, simple word categorizes
can be useful (e.g. no pain, mild, moderate, severe).

III. Quality
a. Nociceptive pain are usually related to damage to bones, soft tissues, or internal
organs; nociceptive pain includes somatic & visceral pains.
i. Somatic pain is aching, throbbing pain; example arthritis
ii. Visceral pain is squeezing, cramping pain; example: pain associated with
ulcerative colitis

IV. Pattern – pain may be always present for a client; this is often termed baseline
pain. Additional pain may occur intermittently that is of rapid onset & greater
intensity than the baseline pain; known as breakthrough pain. People at end-of-life
often have both types of pain. Cultural beliefs regarding the meaning of pain should
be examined ADMINISTRATION OF MEDICATIONS

12. DRUG NOMENCLATURE and FORMS

1. Names

I. Chemical Name – provides an exact description of the drug’s composition. An

example of chemical name acetylsalicylic known common as Aspirin
II. Generic Name – is given by the manufacturer who first develops the drug before
it receives official approval. Protected by law, the generic name is given before a
drug receives official publications.
III. Official Name – is the name under which drug is listed in official publication
IV. Trade, Brand or Propriety Name – is the name under which a manufacturer
markets.

2. Classification – Nurses categorized medications with similar

characteristics by their class. Drug classification indicates the effects
on a body system, the symptoms relieved or the desired effect. Each
class contains drugs prescribed for similar types of health problems.
The physical and chemical composition of drugs within a class is not
necessarily the same. A drug may also belong to more than one class.
For example, aspirin is an analgesic and antipyretic and an anti-
inflammatory drug.

3. Forms – Drugs are available in a variety of forms preparations. The

form of the drug determines its route o administration. For example,
a capsule is taken orally and a solution may be given intravenously.
The composition drug is designed to enhance its absorption and
metabolism within the body. Many drugs are available in several
forms such as tablets, capsules, elixirs and suppositories. When
 administering a medication, the nurse must be certain to give the
metabolism in the proper form.

4. Principles in Administering Medications

I. Observe the 7 RIGHTS of Drug Administration:

a. Right Drug
b. Right Dose
c. Right Time
d. Right Route
e. Right Patient
f. Right Recording
g. Right Approach

II. Practice asepsis

III. Nurses who administer medications are responsible for their own actions.
Question any order that you can consider incorrect.

IV. Be knowledgeable about medications that you administer

V. Keep narcotics & barbiturates in locked place

VI. Use only medications that are in clearly labeled containers

VII. Return liquid that are cloudy or have changed in color to the pharmacy

VIII. Before administering a medication, identify the client correctly

IX. Do not leave the medication at the bedside

X. If the client vomits after taking an oral medication, report this to the nurse in
charge and/or physician

XI. Preoperative medications are usually discontinued during the post operative
period unless ordered to be continued

XII. When a medication is omitted for any reason, record the fact together with the
reason

XIII. When a medication error is made, report immediately to the nurse in charge
and/or physician

13. BASIC HUMAN NEEDS

1. Abraham Maslow – developed the five (5) levels of human needs:

I. Physiologic Needs – needs such as air, food, water, shelter, rest, sleep, activity
and temperature maintenance are crucial for survival
II. Safety and Security Needs – the need for safety has both physical and physiologic
aspects
III. Love and Belonging Needs – the third level of needs includes giving and
receiving affection, attaining a place in a group and maintaining the feeling of
belonging
IV. Self-Esteem Needs – the individual needs both self-esteem and esteem from
others
V. Self-Actualization – when the need for self-esteem is satisfied, the individual
strives for self-actualization, the innate need to develop one’s maximum potential
and realize one’s abilities and qualities

2. Maslow’s Characteristics of a Self-Actualized Person

I. Is realistic, sees life clearly and is objective about his or her observations
II. Judges people correctly
III. Has superior perception, is more decisive
IV. Has a clear notion of right or wrong
V. Is usually accurate in predicting future events
VI. Understands art, music, politics and philosophy
VII. Possesses humility, listens to others carefully
VIII. Is dedicated to some work, task, duty or vocation
IX. Is highly creative, flexible, spontaneous, courageous, and willing to make
mistakes
X. Is open to new ideas XI. Is self-confident and has self-respect
XII. Has low degree of self-conflict; personality is integrated
XIII. Respect self, does not need fame, possesses a feeling of self-control
XIV. Is highly independent, desires privacy
XV. Can appear remote or detached
XVI. is friendly, loving and governed more by inner directives than by society
XVII. Can make decisions contrary to popular opinion
XVIII. Is problem centered rather than self-centered
XIX. Accepts the world for what it is

14. MEETING OXYGENATION NEEDS

1. Oxygenation – a basic human need & is required to sustain life.

2. Cardiovascular Physiology – the function of the cardiac system is

to

deliver oxygen, nutrients, & other substances to the tissues and to remove the
waste products of cellular metabolism

3. Structure and Function – the heart pumps blood through the

pulmonary circulation by way of the right ventricle and to the
systemic circulation by way of the left ventricle

I. Myocardial Pump – the “pumping action” of the heart is essential to maintain

oxygen delivery
II. Myocardial Blood Flow – to maintain adequate blood flow to the pulmonary and
systemic circulations, myocardial blood flow must sufficiently supply oxygen and
nutrients to the myocardium itself
III. Coronary Artery Circulation – blood flow to the atria and ventricles does not
supply oxygen and nutrients to the myocardium itself. It is the branch of the
systemic circulation that supplies oxygen and nutrients and removal of waste from
the myocardium
IV. Systemic Circulation – the arteries and veins of the systemic circulation deliver
nutrients and oxygen and remove wastes from the tissues. Oxygenated blood flows
from the left ventricle by way of of the aorta and into the large systemic arteries
V. Regulation of Blood Flow – the amount of blood ejected from the left ventricle
each minute is the cardiac output. The circulating volume of blood changes
according to the oxygen and metabolic needs of the body. For example, during
exercise, pregnancy and fever, the cardiac output increases but during sleep, the
cardiac output decreases.

4. Steps in the Process of Oxygenation

I. Ventilation – process by which gases are moved into and out of the lungs.
Adequate ventilation requires coordination of the muscular and elastic properties of
the lung and thorax and intact innervation. The major inspiratory muscle is the
“diaphragm” which is innervated by the “phrenic nerve”.
II. Perfusion – the primary function of pulmonary circulation is to move blood to and
from the alveolar-capillary membrane so that gas exchange can occur
III. Exchange of Respiratory Gases – respiratory gases are exchanged in the alveoli
of the lungs and the capillaries of the body tissues
a. Diffusion – movement of molecules from an area of higher concentration to an
area of lower concentration
b. Oxygen Transport – delivery depends on the amount of oxygen entering the
lungs (ventilation), blood flow to the lungs & tissues (perfusion), adequacy of
diffusion & capacity of the blood to carry oxygen.
c. Carbon Dioxide Transport – carbon dioxide diffuses into RBCs and I rapidly
hydrated into carbonic acid because of the presence of carbonic hydrase

15. MEETING NUTRITIONAL NEEDS

1. Principles of Nutrition

I. Digestion – process by which food substances are changed into forms that can be
absorbed through cell membranes
II. Absorption – the taking in of substance by cells or membranes
III. Metabolism – sum of all physical and chemical processes by which a living
organism is formed and maintained and by which energy is made available
IV. Storage – some nutrients are stored when not used to provide energy; e.g.
carbohydrates are stored either as glycogen or as fat
V. Elimination – process of discarding unnecessary substances through evaporation,
excretion

2. Nutrients

I. Carbohydrates – the primary sources are plant foods

Types of Carbohydrates
a. Simple (sugars) such as glucose, galactose, and fructose
b. Complex such as starches (which are polysaccharides) and fibers (supplies bulk
or roughage to the diet)
II. Proteins – organic substances made up of amino acids

III. Lipids – organic substances that are insoluble in water but soluble in alcohol and
ether.
a. Fatty acids – the basic structural units of all lipids and are either saturated (all the
carbon atoms are filled with hydrogen) or unsaturated (could accommodate more
hydrogen than it presently contains)
b. Food sources of lipids are animal products (milk, egg yolks and meat) and plants
and plant products (seeds, nuts, oils)

IV. Vitamins – organic compounds not manufactured in the body and needed in
small quantities to catalyze metabolic processes
a. Water-soluble vitamins include C and B-complex vitamins
b. Fat-soluble vitamins include A, D, E, and K and these can be stored in limited
amounts in the body

V. Minerals – compounds that work with other nutrients in maintaining structure and
function of the body
a. Macronutrients – calcium, phosphate, sodium, potassium, chloride, magnesium
and sulfur
b. Micronutrients (trace elements) – iron, iodine, copper, zinc, manganese and
fluoride The best sources are vegetables, legumes, milk and some meats

VI. Water – the body’s most basic nutrient need; it serves as a medium for
metabolic reactions within cells and a transporter fro nutrients, waste products and
other substances

16. MEETING URINARY ELIMINATION NEEDS

1. Normal Urinary Function

I. Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr to

ensure continued normal kidney function II. Urine normally consists of 96%
water III. Solutes found in urine include: a. Organic solutes: urea, ammonia,
uric acid and creatinine b. Inorganic solutes: sodium, potassium, chloride,
sulfate, magnesium & phosphorus

2. Common Assessment Findings

I. Urgency – strong desire to void my be caused by inflammations or infections in

the bladder or urethra
II. Dysuria – painful or difficult voiding
III. Frequency – voiding that occurs more than usual when compared with the
person’s regular pattern or the generally accepted norm of voiding once every 3 to
6 hours
IV. Hesitancy – undue delay and difficulty in initiating voiding
V. Polyuria – a large volume of urine or output voided at any given time
VI. Oliguria – a small volume of urine or output between 100 to 500 mL/24 hr
VII. Nocturia – excessive urination at night interrupting sleep
VIII. Hematuria – RBCs in the urine

17.URINARY CATHETERIZATION
Ø Is the introduction of a catheter through the urethra into the bladder for the
purpose of withdrawing urine.

1. Purposes

I. To relieve urinary retention

II. To obtain a sterile urine specimen from a woman
III. To measure the amount of residual urine in the bladder
IV. To obtain a urine specimen when a specimen cannot secure satisfactory by other
means
V. To empty bladder before and during surgery and before certain diagnostic
examinations
***Several BASIC FACTS about the lower urinary tract system should be borne in
mind when considering catheterization.

2. Necessary Equipment for Catheterization

Ø Catheters are graded on the French scale according to the size of the lumen.
For the female adult, No. 14 and No. 16 French catheters are usually used. Small
catheters are generally not necessary and the size of the lumen is also so small that
it increases the length of time necessary for emptying the bladder.
Larger catheter distends the urethra and tends to increase the discomfort of the
procedure.
For male adult, No.18 and No. 20 French catheters usually used, but if this appears
to be too large, smaller catheter should be used.
No. 8 and No. 10 French catheters are commonly used for children.

3. Preparation of the Patient

I. Adequate exploration II. Position – dorsal recumbent for the female and supine for
the male using a firm mattress or treatment table, Sim’s or lateral position can be
an alternate for the female patient III. Provision for privacy

4. Retention or Indwelling Catheter (Foley) – A catheter to remain

in place for the following purposes:

I. The gradual decompression of an over distended bladder II. For intermittent

bladder drainage III. For continuous bladder drainage An indwelling catheter has a
balloon which is inflated after the catheter is inserted into the bladder. Because the
inflated balloon is larger than the opening to the urethra, the catheter is retained in
the bladder.

5. Procedure for Insertion

I. Inflate the balloon with the prefilled syringe before inserting the catheter to check
for balloon patency. Aspirate the fluid back into the syringe when it is determined
that the balloon is patent. II. Hold the catheter with one hand and inflate the balloon
according to the manufacturer’s instructions, as soon as the catheter is in the
bladder and urine has begun to drain from the bladder. Usually 5 ml to 10 ml of
sterile water is used III. If the patient complains of pain after the balloon is inflated,
allow it to empty and replace the catheter with another one. The balloon is probably
located in the urethra and is causing discomfort owing to distention of the urethra
IV. Exert slight tension on the catheter after the balloon is inflated to assure its
proper placement in the bladder V. Connect the catheter to the drainage tubing and
drainage bag if not already connected VI. Tape the catheter along the interior
aspect of the thigh fro a female patient. Be sure there is no tension on the catheter
when it is taped to the patient VII. Hang the drainage bag on the frame of the bed
below the level of the bladder

6. Caring for the Patient with an Indwelling Catheter

I. Be sure to wash hands before and after caring for a patient with an indwelling
catheter II. Clean the perineal area thoroughly, especially around the meatus, twice
a day and after each bowel movement. This helps prevent organisms for entering
the bladder III. Use soap or detergent and water to clean the perineal area and rinse
the area well IV. Make sure that the patient maintains a generous fluid intake. This
helps prevent infection and irrigates the catheter naturally by increasing urinary
output V. Encourage the patient to be up and about as ordered VI. Record the
patient’s intake and output VII. Note the volume and character of urine and record
observations carefully VIII. Teach the patient the importance of personal hygiene,
especially the importance of careful cleaning after having bowel movement and
thorough washing of hands frequently IX. Report any signs of infection promptly.
These include a burning sensation and irritation at the meatus, cloudy urine, a
strong odor to the urine, an elevated temperature and chills X. Plan to change
indwelling catheters only as necessary. The usual length of time between catheter
changes varies and can be anywhere from 5 days to 2 weeks. The less often a
catheter is changed, the less the likelihood than an infection will develop

7. Removing the Indwelling Catheter and Aftercare of the

Patient

I. Be sure the balloon is deflated before attempting to remove the catheter. This
may be done by inserting a syringe into the balloon valve or by cutting the balloon
valve II. Have the patient take several deep breaths to help him relax while gently
removing the catheter. Wrap the catheter in a towel or disposable, waterproof
drape III. Clean the area at the meatus thoroughly with antiseptic swabs after the
catheter is removed IV. See to it that the patient’s fluid intake is generous and
record the patient’s intake and output. Instruct the patient to void into the bedpan
or urinal V. Observe the urine carefully for any signs of abnormality VI. Record and
report any usual signs such as discomfort, a burning sensation when voiding,
bleeding and changes in vital signs, especially the patient’s temperature. Be alert to
any signs of infection and report them promptly

18. MEETING BOWEL ELIMINATION NEEDS

1. Factors that influence Bowel Elimination

I. Age II. Diet III. Position IV. Pregnancy V. Fluid Intake VI. Activity VII. Psychological
VIII. Personal Habits IX. Pain X. Medications XI. Surgery/Anesthesia

2. Characteristics of Normal Stool

I. Color – varies from light to dark brown foods & medications may affect color II.
Odor – aromatic, affected by ingested food and person’s bacterial flora III.
Consistency – formed, soft, semi-solid; moist IV. Frequency – varies with diet (about
100 to 400 g/day) V. Constituents – small amount of undigested roughage, sloughed
dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices
(bile pigments); inorganic matter (calcium, phosphates)

3. Common Bowel Elimination Problems

I. Constipation – abnormal frequency of defecation and abnormal hardening of

stools II. Impaction – accumulated mass of dry feces that cannot be expelled III.
Diarrhea – increased frequency of bowel movements (more than 3 times a day) as
well as liquid consistency and increased amount; accompanied by urgency,
discomfort and possibly incontinence IV. Incontinence – involuntary elimination of
feces V. Flatulence – expulsion of gas from the rectum VI. Hemorrhoids – dilated
portions of veins in the anal canal causing itching and pain and bright red bleeding
upon defecation.

19. TYPES OF ENEMAS

1. Cleansing Enemas: Stimulate peristalsis through irrigation of colon
and rectum and by distention

I. Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5
ml of castile soap in 1000 ml of water
II. Tap water: Give caution o infants or to adults with altered cardiac and renal
reserve
III. Saline: For normal saline enemas, use smaller volume of solution
IV. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-
lubricate and does not require further preparation

2. Oil-Retention Enemas: Lubricates the rectum and colon; the feces

absorb the oil and become softer and easier to pass

3. Carminative Enema: Provides relief from gaseous distention

4. Astringent Enema: Contracts tissue to control bleeding

Key Points: Administering Enema

I. Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for
children, 250 cc or less fro an infant), 99 degrees F to 102 degrees F. Solutions that
are too hot or too cold, or solutions that are instilled too quickly, can cause
cramping and damage to rectal tissues
II. Allow solution to run through the tubing so that air is removed
III. Place client on left side in Sim’s position
IV. Lubricate the tip of the tubing with water-soluble lubricant
V. Gently insert tubing into client’s rectum (3 to 4 inches for adult, 1 inch for
infants, 2 to 3 inches for children), past the external and internal sphincters
VI. Raise the water container no more than 12 to 18 inches above the client
VII. Allow solution to flow slowly. If the flow is slow, the client will experience fewer
cramps. The client will also be able to tolerate and retain a greater volume of
solution
VIII. After you have instilled the solution, instruct client to hold solution for about 10
to 15 minutes
IX. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are
retained 10 to 15 minutes.

20.NASOGASTRIC and INTESTINAL TUBES

1. Nasogastric Tubes

I. Levin Tube – single lumen a. Suctioning gastric contents b. Administering tube

feedings
II. Salem Sump Tube – double lumen (smaller blue lumen vents the tube & prevents
suction on the gastric mucosa, maintains intermittent suction regardless of suction
source)
a. Suctioning gastric contents
b. Maintaining gastric decompression
Key Points:
a. Prior to insertion, position the client in High-Fowler’s position if possible.
b. Use a water-soluble lubricant to facilitate insertion
c. Measure the tube from the tip of the client’s nose to the earlobe and from the
nose to the xiphoid process to determine the approximate amount of tube to insert
to reach the stomach
d. Flex the client’s head slightly forward; this will decrease the chance of entry into
the trachea
e. Insert the tube through the nose into the nasopharyngel area; ask the client to
swallow, and as the swallow occurs, progress the tube past the area of the trachea
and into the esophagus and stomach. Withdraw tube immediately if client
experiences respiratory distress
f. Secure the tube to the nose; do not allow the tube to exert pressure on the upper
inner portion of the nares
g. Validating placement of tube. · Aspirate gastric contents via a syringe to the end
of the tube · Measure ph of aspirate fluid · Place the stethoscope over the gastric
area and inject a small amount of air through the NGT. A characteristic sound of air
entering the stomach from the tube should be heard
h. Characteristics of nasogastric drainage: · Normally is greenish-yellowish, with
strands of mucous · Coffee-ground drainage – old blood that has been broken down
in the stomach · Bright red blood – bleeding from the esophagus, the stomach or
swallowed from the lungs · Foul-smelling (fecal odor) – occurs with reverse
peristalsis in bowel obstruction; increase in amount of drainage with obstruction

2. Intestinal Tubes – provide intestinal decompression proximal to a

bowel obstruction. Prevent/decrease intestinal distention. Placement
of a tube containing a mercury weight and allowing normal peristalsis
to propel tube through the stomach into the intestine to the point of
obstruction where decompression will occur

I. Types of Intestinal Tubes

a. Cantor and Harris Tubes
i. Approximately 6-10 feet long
ii. Single lumen
iii. Mercury placed in rubber bag prior to tube insertion
b. Miller-Abbot Tubes
i. Approximately 10 feet long
ii. Double lumen
iii. One lumen utilized for aspiration of intestinal contents
iv. Second lumen utilized to instill mercury into the rubber bag after the tube has
been inserted into the stomach

II. Nursing Implications

a. Maintain client on strict NPO
b. Initial insertion usually done by physician and progression of the tube may be
monitored via an X-ray
c. After the tube has been placed in the stomach, position client on the right side to
facilitae passage through the pyloric valve
d. Advance the tube 2 to 4 inches at regular intervals as indicated by the physician
e. Encourage activity, to facilitate movement of the tube through the intestine
f. Evaluate the type of gastric secretions being aspirated
g. Do not tape or secure the tube until it has reached the desired position
h. Tubes may attached to suction and left in place for several days
i. Offer the client frequent oral hygiene, if possible offer hard candy or gum to
reduce thirst j. Removal of the tube depends on the relief of the intestinal
obstruction
i. May be removed by gradual pulling back (4-6 inches per hour) and eventual
removal via the nose or mouth
ii. May be allowed to progress through the intestines and expelled via the rectum.

21.LOSS AND GRIEF

Loss – absence of an object, person, body part, emotion, idea or function that was
valued I. Actual loss is identified and verified by others II. Perceived Loss cannot be
verified by others III. Maturational Loss occurs in normal development IV. Situational
Loss occurs without expectations V. Ultimate Loss (Death) results in a lost for a
dying person as well as for those left behind, can be viewed as a time of growth for
all who experienced it

2. Grieving Process (Theories of Grief, Dying and Mourning)

I. 3 Phases of Grief
a. Protest: lack of acceptance, concerning the loss, characterized by anger,
ambivalence and crying
b. Despair: denial and acceptance occurs simultaneously causing disorganized
behavior, characterized by crying and sadness
c. Detachment: loss is realized; characterized by hopelessness, accurately defining
the relationship with the lost individual and energy to move forward in life.

II. Kubler-5 Stages of Grieving

a. Denial – characterized by shock and disbelief, serves as a buffer to mobilize
defense mechanism
b. Anger: resistance of the loss occurs, anger is typically directed toward others
c. Bargaining = deals are sought with God or other higher power in an effort to
postpone the loss
d. Depression: loss is realized; may talk openly or withdraw.
e. Acceptance: recognition of the loss occurs, disinterest may occur; future thinking
may occur.

III. Worden’s 4 Tasks of Mourning

a. Accept the reality of the loss, the loss is accepted
b. Experience the pain of grief, healthy behaviors are accomplished to assist in the
grieving process.
c. Adjust to the environment without the deceased, task are accomplished to
reorient the environment,
i.e. removing the clothes of the deceased from the closet.
d. Emotionally relocate the deceased and move forward with life, correctly align the
past, the present & look towards the future

3. Anticipatory Grief – expression of the symptoms of grief prior to the

actual loss, grief period following the lost may be shortened and the
intensity lessened because of the previous of grief; for example, a
child told that a family move is expected may grieve about losing
friends prior to actually living

4. Complications of Bereavement

I. Chronic Grief – symptoms of grief occur beyond the expected time frame and the
severity of symptoms is greater; depression may result.
II. Delayed Grief – when symptoms of grief are not expressed and are suppressed, a
delayed reaction of grief occurs, the nurse should discuss the normal process of
grieving with the client and give permission to express these symptoms

5. Symptoms of Normal Grief

I. Feelings include sadness, exhaustion, numbness, helplessness, loneliness, and

disorganization, preoccupation with the lost object or person, anxiety, depression.
II. Thought patterns include fear, guilt, denial, ambivalence, anger
III. Physical sensations include nausea, vomiting, anorexia, weight loss or gain,
constipation or diarrhea, Diminished hearing or sight, chest pain, shortness of
breath, tachycardia
IV. Behaviors include crying, difficulty carrying out activities of daily living and
insomia

6. Nursing Health Promotion (to facilitate mourning)

1. Help client accept that the loss is real by providing sensitive, factual information
concerning the loss
2. Encourage the expression of feelings to support people; this build relationships
and enhances the grief process
3. Support efforts to live without the diseased person or in the face of disability; this
promotes a client’s sense of control as well as a healthy vision of the future
4. Encourage establishment with new relationships to facilitate healing.
5. Allow time to grief, the work of grief may take longer for some; observe for a
healthy progression of symptoms.
6. Interpret “normal” behavior by teaching thoughts, feelings, and behaviors that
can be expected in the grief process
7. Provide continuing support in the form of the presence for therapeutic
communication and resource information.
8. Be alert for signs of ineffective coping such as inability to carry out activities of
daily living, signs of depression, or lack of expression of grief.