Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

BS NURSING

NCM 103: FUNDAMENTALS OF NURSING PRACTICE

RELATED LEARNING EXPERIENCE

I.Nursing Skills no. 5 PROMOTING COMFORT

REMOVING PAINFUL STIMULI
1. Neurophysiologic Pain
*Reception: exposure to painful stimuli releases substances such as histamine, bradykinin and
potassium, which combine with receptor sites on nociceptors (receptors that respond to
harmful stimuli) to initiate the neural transmission associated with pain. Important neuro-
regulators include:
a. Neurotransmitters (Excitatory)
i. Substance P
-Found in the pain neurons of the dorsal horn (excitatory peptide)
-Needed to transmit pain impulses from the periphery to higher brain centers.
-Causes vasodilation and edema
ii. Serotonin
-Released from the brain stem and dorsal horn to inhibit pain transmission.
iii. Prostaglandins
-Increase sensitivity to pain
b. Neuromodulators (Inhibitory)
i. Endorphins and Dynorphins
-Body’s natural supply of morphine-like substances
-Activated by stress and pain
-Located within the brain, spinal cord, and gastrointestinal tract
-Cause analgesia when they attach to opiate receptor in the brain
ii. Bradykinin
-Released from Plasma that leaks from the surrounding blood vessels at the site
of tissue injury.
-Binds to receptors on peripheral nerves, increasing pain stimuli.

*GATE CONTROL THEORY OF PAIN. The gate control theory suggests that the pain
impulses can be regulated or even blocked by gating mechanisms along the central
nervous system. The gating mechanism occurs within the spinal cord, thalamus,
 reticular formation, and limbic system. The theory suggests that the pain impulses pass
through when the gate is open and not while it is closed. Closing of the gate is the basis
for pain relief therapies. For example, distraction, counseling and massage techniques
are ways to release endorphins, which close the gate. This prevents or reduces the
client’s perception of pain.

*Perception is the point at which a person is aware of pain.

-The reaction to pain is the physiological and behavioral responses that occur after pain
is perceived (e.g. crying, or moving away from painful stimuli)

Pain threshold is the point at which a person feels pain.

Pain tolerance to pain is the point at which there is an unwillingness to accept pain of
greater severity or duration. Tolerance depends on attitudes, motivation, and values.

2. Pain Assessment
 Routine Clinical Approach to Pain Assessment and Management (“ABCDE”)
o Ask about pain regularly. Assess pain systematically.
o Believe the client and family in their report of pain and what relieves them.
o Choose pain control options appropriate for the client, family and setting.
o Deliver interventions in a timely, logical, and coordinated fashion.
 Non-Pharmacological Pain Relief Measures
o Reducing Pain Reception and Perception . A simple way to promote comfort is
by removing or preventing painful stimuli
o Anticipatory Guidance. Giving clients detailed descriptions of all medical
procedures, expected post-operative discomfort and instruction aimed at
decreasing treatment and mobility-related pain can decrease self-reported pain,
analgesic use and post-operative length of stay.
o Distraction. Pleasurable sensory stimuli reduce pain perception by the release
of endorphins. Distraction directs a client’s attention to something else and
thus can reduce the awareness of pain and even increase tolerance.
o Cutaneous stimulation. The stimulation of the skin to relieve pain. A massage,
warm bath, ice bag and transcutaneous electrical nerve stimulation (TENS) are
simple ways to reduce pain perception.

 Relaxation techniques provide clients with self-control when pain occurs, reversing the
physical and emotional stress of pain. Relaxation strategies include simple relaxation,
imagery and music assisted relaxation.
o In Guided imagery the client creates an image in the mind, concentrate on that
image, and gradually becomes less aware of pain. Initially ask the client to think
of a pleasant scene of experience that promotes using all senses.

3. Pharmacological Pain Therapy

 Analgesics. The three (3) types of analgesics are:
o 1. Non-opioid analgesics
  Including acetaminophen, tramadol, (Ultram) and non-steroidal anti-
inflammatory drugs (NSAIDs) are effective in treating mild to moderate
pain.
 One exception is ketorolac (Toradol), which is an injectable analgesic
NSAIDs that is comparable to morphine efficacy.
 NSAIDs acts by inhibiting the synthesis of prostaglandins and by
inhibiting the cellular responses during inflammation. Most NSAIDs act
on peripheral nerve receptors to diminish transmission and reception of
pain stimuli.
 Acetaminophen acts on central nervous system prostaglandins.

o 2. Opioid analgesics
 Are generally used for severe pain. They are legally distinct from
narcotics; therefore, opioids should no longer be referred as narcotics.
 Opioids analgesics include codeine, morphine, hydromorphone
(Dilaudid), fentanyl, oxycodone, prophoxyphene (Darvon), and other
natural and synthetic mediations.
 Meperdine HCL (Demerol) is no longer a drug of choice and is rarely
used because of the potentials to cause seizures and severe side effects
of nausea and vomiting.
 Opioids act on the central nervous system to produce a combination of
depressing and stimulating effects.
 Opioids analgesics such as morphine act on higher centers of the brain
and spinal cord by binding with opiate receptors to modify perception
of and reaction to pain.
 Morphine is a derivative of opium. It raises the pain threshold
(reducing pain perception), reduces anxiety and fear (components of
the reaction to pain) and includes sleep.
o 3. Adjuvants
 Such as sedatives, anticonvulsants, steroids, antidepressants,
antianxiety agents and muscle relaxants enhances pain control or
relieve other symptoms associated with pain, such as anxiety,
depression, and nausea. They may be given alone or with analgesics

 Patient-controlled analgesia
o Clients benefit from having control over pain therapy.
o A safe method for postoperative, traumatic, labor and delivery, sickle cell crisis,
cancer, and end-of-life pain management that most clients prefer to
intermittent injections.
o A drug delivery system that allows clients to administer pain medications when
they want them.
o Has been an effective form of pain management in older adults and in children
as young as 10 years of age.
 o Systematic PCA usually involves intravenous drug administration, but it can also
be given subcutaneously.
 Placebo effect
o Placebos are dose forms that contain no pharmacologically active ingredients
(e..g. normal saline injection or sugar pill)
o Belief that a medication will work and trust in the nurse increase the likelihood
of pain relief.
 Local anesthetics
o Local anesthesia is the loss sensation to a localized body part.
 Epidural analgesia
o A form of local anesthesia and an effective therapy for the treatment of post-
operative, traumatic, chronic non-cancer and cancer pain.
o It permits control or reduction of severe pain without the sedative effects of
opioids.

4. Nursing Principles for Administration Anesthesia

 Know the client’s previous response to analgesics
o Determine whether relief was obtained.
o Ask whether a non-narcotic was as effective as a narcotic.
o Identify previous doses and routes of administration to avoid undertreatment.
o Determine whether the client has allergies.
 Select proper medications when more than one is required.
o Use NSAIDs or opioids for mild to moderate pain.
o The concurrent use of opioids and NSAIDs often provides for more effective
analgesia than either drug class alone.
o Use of NSAIDs can help reduce opioids side effects.
o In older adults, avoid combination of opioids.
o Remember that morphine and hydromorphone are the opioids of choice for
long-term management of severe pain.
 Know the accurate dosage.
o Remember that doses at the upper end of the normal range are generally
needed for severe pain.
o Adjust doses, as appropriate, for children and other clients.
o Dosage typically requires adjustment over time.
o Know the comparative potencies of analgesics (refer to drug manual or
pharmacy) in oral and injectable form.
 Assess the right time and internal for administration
o Administer analgesics as soon as pain occurs and before it increases in severity.
o Do not give analgesics only on “as needed” schedules. An around-the-clock
administration is best.
o Given analgesic before pain-producing procedures or activities.
o Know the average duration of action for a drug and a time of administration so
that the peak effect occurs when pain is most intense.
  Choose the right route
o Intravenous and oral routes are preferred.
o Intramuscular and subcutaneous administration should be avoided because
those routes can be painful and absorption is not reliable.
o
5. Restorative and continuing care
 Morphine infusions. A dose of morphine, delivered continuously over 24 hours, is
usually slowly infused into a peripherally inserted central catheter or a subclavian placed
catheter.
 Hospice. Hospices are programs that provide care for the terminally ill. The program
helps terminally ill clients continue to live at home in comfort and privacy with the help
of the health care team. Pain control is a priority.
 Pain clinics. A comprehensive pain center can treat clients in the hospitals or in
outpatient clinics.
 End-of-Life Care. Emphasize the need to provide maximum pain relief by increasing
(titrating) the dosage of the medication to meet the clients pain control needs.

II. Nursing Skills no. 6 EXERCISE

RANGE OF MOTION EXERCISES
Exercise is a physical activity for conditioning the body, improving health, and maintaining
fitness. Which are used to keep the muscles and joints of the patients strong and flexible.

Range of motion is a basic technique used for the examination of movement into a therapeutic
intervention. It refers to an activity aimed at improving movement of a specific joint. This motion is
influenced by several structures: configuration of bone surfaces within the joint, joint capsule,
ligaments, tendons, and muscles acting on the joint.

Range of motion is used in nursing to exercise the joints sequentially, starting with the neck and
moving down the toes. The exercises are best done in the same sequence its time. Be careful to do them
gently, so as not to injure the patient. Never force any part of the body to move. Work slowly, and carry
out each exercise for the arms and legs the same number of times on both sides of the body each time.
Put each joint needing exercise through the range of motion procedure a minimum of three times, and
preferably five times. Avoid overexerting the patient; do not continue the exercises to the point that the
patient develops fatigue. You’ll discover the patient’s range of motion is reach when movement beyond
a certain point would require force or cause pain.

Encourage the patient (and his family) to maintain a range of motion which permits and
facilitates activities of daily living. In teaching the patient to carry out his own exercises makes sure he
understands how to do each one… he does exercise as many times a day as he supposed to … and he
asks questions about matters he doesn’t understand.
 Range of motion exercise is an exercise that are performed either by patient himself or by the
nurse in case of helpless patient to mobilize all joints through their full range of motion.

PURPOSES:

1. To increase muscle strength and endurance

2. Promote and maintain joint mobility

3. To improve patient participation

4. Facilitate comfort for the patient

5. To increase joint flexibility

6. To improve physical activity

7. To prevent contractures and shortening of muscles

8. To maintain normal physiological function.

TYPES:

1.Active ROM Exercises

 The patient performs the exercise independently.

2. Passive ROM (PROM) Exercises

 The exercise is performed for the patient by the nurse or a physical therapist.
 When passive ROM is applied, the joint of an individual receiving exercise is completely
relaxed while the outside force moves the body part, such as leg or arm, throughout the
available range. Injury, surgery, or immobility of the joint may affect the normal joint
range of motion.

3. Active assisted/resisted ROM Exercises

 This is performed by a patient with some assistance.

INDICATIONS

1. Improved cardio-pulmonary function

2. Reduced blood pressure
3. Increased muscle tone and strength
4. Greater physical endurance
5. Increased weight loss
6. Reduced blood glucose level
7. Decrease low-density blood lipids
8. Improve physical appearance
9. Increase bone density
10. Regularity of bowel elimination
 11. Promotion of sleep
12. Reduce tension and depression

CONTRAINDICATIONS

1. Any illness/disorder where there is increased used of energy

2. Increased blood circulation
3. Swollen and inflamed joints

SCIENTIFIC PRINCIPLE OF ANATOMY & PHYSIOLOGY

1. Abduction – moving a body part away from the midline of the body
2. Adduction – moving a body part toward the midline of the body
3. Extension – straightening a body part
4. Flexion - bending a body part
5. Rotation - turning the joint
6. Internal rotation – turning the joint inward
7. External rotation – turning the joint outward
8. Plantar flexion – bending the foot down at the ankle
9. Pronation – turning the joint downward
10. Supination – turning the joint upward
11. Inversion – turning the sole of the food towards the midline
12. Eversion – turning the sole of the foot away from the midline

GUIDELINES IN PERFORMING ROM EXERCISES

1. Start the ROM from the head down to the toes, bilaterally.
2. Do not grasp the joint directly.
3. Do not grasp fingernail or toenail.
4. Be sure to support the distal and proximal end of the limbs.
5. Support important joints like thumb, hip, knee, and ankle.
6. Move joint twice or thrice, depending on the condition of the patient.
7. Return body parts to normal anatomical position.
8. Move each joint through full range of motion
9. Check for resistance during movement, seeing to it they do not produce pain.
10. Avoid friction while lifting the body part, don’t drag.
11. Assess for change in the vital signs, extreme fatigue, etc.

Prepared by:

NEMIA G. FLORANO, MMEM

Level 1 Coordinator
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

RANGE OF MOTION EXERCISES

DEFINITION

 It is the movement of a joint through its full range in all appropriate planes.
PURPOSE

 Maintenance of current joint functions

 Restoration of joints function that has been lost through disease, injury or lack of use.
 To strengthen muscles.
CONTRAINDICATIONS

 Client with heart and respiratory disease for Range of Motion (ROM) increases the
demand for circulation.
 Range of Motion (ROM) exercise should not be performed if the joints are swollen or
inflamed or if there has been injury to the musculoskeletal system in the vicinity of the
joints.
SPECIAL CONSIDERATIONS
Types of Range of Motion (ROM) Exercises
1. Active- care provider instructs client to perform the movements
2. Active Assistance- carries out Range of Motion (ROM) with both client and care
provider.
3. Passive – ROM performed by care provider on the client’s immobilized joints.
EQUIPMENTS

 BP apparatus
 Stethoscope
 Thermometer
 Paper and pen (for recording)

PROCEDURE RATIONALE
1. Consult with the physician on the client’s medical diagnosis.  To determine whether Range of
Motion (ROM) is appropriate or
contraindicated with the client’s
condition
2. Wash hands  For infection control.
3. Identify client  To be sure you are carrying out
procedure to the right client.
4. Provide privacy.  Range of Motion (ROM) procedure
needs a quiet environment.
5. Explain to the client the procedure  To decrease anxiety and encourage
client’s cooperation.
6. Client must be in supine position.  To avoid strains.
7. Raise the entire bed to a comfortable working level.  To maintain proper body mechanics.
8. Take initial vital sign. And repeat in between procedure.  To have a baseline basis and monitor
unjustified alteration in vital signs that
may hinder the procedure.
9. Follow the procedure below in order to administer Range of  Joints are exercised sequentially, from
Motion (ROM) to one side of the body. the neck downwards.
 Every joint should be adequately
exercised.
a. NECK  To preserve muscle tone and joint
a.1. Flexion- position the head as if looking at the toes. flexibility.
a.2. Extension- position the head as if looking straight ahead.
a.3. Hyperextension- position the head as if looking up the
ceiling.
a.4. Lateral Flexion- client moves head towards one shoulder
and then to the other.
a.5. Lateral Rotation- client moves head in twisting motion
from side to side.
b. SHOULDER  To preserve muscle tone and joint
b.1. Flexion- raise arm forward and overhead flexibility
b.2. Extension- return arm to the side of the body.
b.3. Vertical Abduction- swing arm out and up.
b.4. Vertical Adduction- move arm downward to the body.
b.5. Internal Rotation- swing the arm up and across the body.
b.6. External Rotation- rotate the arm and back, keeping the
elbow at the right angle.
c. ELBOW  To preserve muscle tone joint flexibility
These movements can be performed in conjunction with the
shoulder.
c.1. Flexion- cupping the elbow in the hand, bend the arm.
c.2. Extension- straighten the arm.

d. WRIST  To preserve muscle tone and joint

d.1. Flexion- grasping the palm with one hand and supporting flexibility.
the elbow with other hand, bend the wrist forward.
d.2. Extension- straighten the wrist
d.3. Radial Deviation- bend the wrist towards the thumb.
 d.4. Ulnar Deviation- bend the wrist towards the little finger
d.5. Circumduction- move the wrist in circular motion.
e. FINGERS AND THUMB  To preserve muscle tone and joint
e.1. Flexion- bend the fingers and thumb un to the palm. flexibility
*flexion of thumb to the other fingers.
e.2. Extension- return them to their original position.
e.3. Abduction- spread the fingers.
e.4. Adduction- return the fingers to closed position.
e.5. Circumduction- move the thumb in circular motion.
e.6. Opposition- touch the end of the thumb to each of the
fingers in turn.
f. HIP AND KNEE  To preserve muscle tone and joint
f.1. Flexion lift the leg, bending the knee as far as possible flexibility.
towards the client’s head.
f.2. Extension- return the leg to the surface of the bed and
straighten.
f.3. Abduction- move leg outward to edge of bed.
f.4. Adduction- bring leg back to midline.
f.5. Internal Rotation- roll entire leg inward.
f.6. External Rotation- roll entire leg outward.
g. ANKLE  Maintaining ankle flexion helps to
g.1. Dorsiflexion- cup hill using forearm, bend ankle toward prevent foot drop.
upper body.
g.2. Plantar Flexion- cup hill and push ankle downward to
point toes.
g.3. Circumduction- rotate the foot in the ankle, moving it first
in one direction and then in the other
h. TOES  To preserve muscle tone and
h.1. Flexion- bend toes downward. flexibility.
h.2. Extension- bend toes up
i. SPINE  Done to an individual who is able to
i.1. Extension- stand straight. stand alone
i.2. Flexion- bend forward from the waist.
i.3. Hyperextension- bend backward form the waist.
i.4. Lateral Flexion- bend toward the side, first left, then right.
1.5. Rotation- twist from the waist to the side, first left then
right.
10. Wash hands  For infection control
11. Keep client in comfortable position  To provide rest, because ROM
exercise is tiring on the part if the
client.
12. Document  For record purposes.
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: http://uep.edu.ph Email: uepnsofficial@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

PERFORMANCE EVALUATION CHECKLIST

RANGE OF MOTION EXERCISES

PROCEDURE Able to Able to Not able
perform perform to
(2) with perform
assistanc (0)
e
(1)
1. Consult with the physician on the client’s medical diagnosis.
2. Wash hands
3. Identify client
4. Provide privacy.
5. Explain to the client the procedure
6. Client must be in supine position.
7. Raise the entire bed to a comfortable working level.
8. Take initial vital sign. And repeat in between procedure.
9. Follow the procedure below in order to administer Range of
Motion (ROM) to one side of the body.
a. NECK
a.1. Flexion- position the head as if looking at the toes.
a.2. Extension- position the head as if looking straight ahead.
a.3. Hyperextension- position the head as if looking up the ceiling.
a.4. Lateral Flexion- client moves head towards one shoulder and
then to the other.
a.5. Lateral Rotation- client moves head in twisting motion from
side to side.
b. SHOULDER
b.1. Flexion- raise arm forward and overhead
b.2. Extension- return arm to the side of the body.
b.3. Vertical Abduction- swing arm out and up.
b.4. Vertical Adduction- move arm downward to the body.
b.5. Internal Rotation- swing the arm up and across the body.
b.6. External Rotation- rotate the arm and back, keeping the elbow
at the right angle.
c. ELBOW
 These movements can be performed in conjunction with the
shoulder.
c.1. Flexion- cupping the elbow in the hand, bend the arm.
c.2. Extension- straighten the arm.

d. WRIST
d.1. Flexion- grasping the palm with one hand and supporting the
elbow with other hand, bend the wrist forward.
d.2. Extension- straighten the wrist
d.3. Radial Deviation- bend the wrist towards the thumb.
d.4. Ulnar Deviation- bend the wrist towards the little finger
d.5. Circumduction- move the wrist in circular motion.
e. FINGERS AND THUMB
e.1. Flexion- bend the fingers and thumb un to the palm.
*flexion of thumb to the other fingers.
e.2. Extension- return them to their original position.
e.3. Abduction- spread the fingers.
e.4. Adduction- return the fingers to closed position.
e.5. Circumduction- move the thumb in circular motion.
e.6. Opposition- touch the end of the thumb to each of the fingers
in turn.
f. HIP AND KNEE
f.1. Flexion lift the leg, bending the knee as far as possible
towards the client’s head.
f.2. Extension- return the leg to the surface of the bed and
straighten.
f.3. Abduction- move leg outward to edge of bed.
f.4. Adduction- bring leg back to midline.
f.5. Internal Rotation- roll entire leg inward.
f.6. External Rotation- roll entire leg outward.
g. ANKLE
g.1. Dorsiflexion- cup hill using forearm, bend ankle toward upper
body
g.2. Plantar Flexion- cup hill and push ankle downward to point
toes.
g.3. Circumduction- rotate the foot in the ankle, moving it first in
one direction and then in the other
h. TOES
h.1. Flexion- bend toes downward.
h.2. Extension- bend toes up
i. SPINE
i.1. Extension- stand straight.
i.2. Flexion- bend forward from the waist.
i.3. Hyperextension- bend backward form the waist.
i.4. Lateral Flexion- bend toward the side, first left, then right.
1.5. Rotation- twist from the waist to the side, first left then right.
10. Wash hands
11. Keep client in comfortable position
12. Document
Remarks:
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Grade: _______

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Clinical Instructor Student’s Signature