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FUNDAMENTALS

NURSING PROCESS Is a systematic, organized method of planning, and providing quality and individualized nursing
care. It is synonymous with the PROBLEM SOLVING APPROACH (CBQ)
 The term nursing process was introduced in 1955 by Lydia Hall

Unique characteristic of the Nursing Process(CBQ)

S ystematic – ordered sequence , organized with each activity
U niversal – applicable to any nursing situation
I nterpersonal – Human interaction is at the heart of nursing.
T his is client-centered, goal-directed and outcome oriented.
E fficient and Effective – essential
D ynamic – steps overlap and flow

Steps: ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation

Phases Description Purpose
Assessment Collection of data like subjective and To establish a database
objective(CBQ)
Diagnosis Interpret/Analyzing and synthesizing data To identify health problems, risks, and
(CBQ) strengths.
Planning Prioritize problems(CBQ) To develop an individualized care plan
Implementing to carry out, to perform, to intervene or to do To assist the client to meet desired
something. (CBQ) goals/outcomes

Evaluation Goal assessment / outcome evaluation To determine whether to continue, modify, or

Also known as Reassessment phase(CBQ) terminate the plan of care

1. Assessment
Activities: Collecting , organizing and documenting client data(CBQ)

Sources of Data:
A. Primary source – Client/patient(CBQ)
B. Secondary source - family members or other support persons, other health
professionals, records , reports, laboratory/diagnostic analyses, and relevant
literature

2 types of Data:

SUBJECTIVE DATA OBJECTIVE DATA

o Covert data
o Non measurable, non observable
o Information verbalized or stated by the
client. – (CBQ)
o Symptoms are SUBJECTIVE
o Overt data
o Measurable and observable data
o Remember to include your senses:
smell, hearing, touch and sight.
o Signs are OBJECTIVE

S hortness of breath – (CBQ O bserved from the client – (CBQ)

U nwell feeling, nausea, dizziness
B ody pain ( any form of PAIN e.g. headache,
cramping abdomen) (CBQ)
J oint pain and joint stiffness
E xhaustion/fatigue
C hief complaints of patient – (CBQ)
T innitus and vertigo
I tchiness or pruritus
V isual disturbances ( blurred/double vison)
E motions/ feelings ( anxiety)
B ody movement, posture and gait
J aundice, pale, cyanosis, redness
E xamination/test results ( laboratory)
Collected in physical examination
T remors
I ncised wound ( or any types of wound)
V ital signs ( Temp, BP, RR, HR)
E echymosis/ hematoma, rashes and bleeding.
(CBQ)

Four basic methods or techniques that are used for physical assessment:

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Techniques Description Assessments

Inspection uses the sense of sight to identify Always begin with inspection(CBQ)
specific characteristics of the
individual Visual exam of body, including
bodymovement and posture(CBQ)

Palpation using the sense of touch
- to gather information about
temperature, turgor, texture,
moisture, vibrations, and shape –
(CBQ)
Use of fingertips - skin texture, swelling,
pulsation, and determining presence of lumps
-Ulnar surface of hand to fifth finger is most
sensitive to vibration.

*Manipulation – examiner moves -Dorsal surface is better for assessing

the body part by applied force. temperature
(CBQ)
Take note: Palpate tender areas last

Percussion Act of TAPPING / STRIKING one
object against another for the
purpose of producing sound by
vibrations. (CBQ)
Direct- tapping the body DIRECTLY
with the fingertips of the dominant
hand
Tympany (loud intensity, as heard over a
gastric air bubble, stomach and intestines
or puffed out cheek)
Hyper resonance- (very loud, as heard over
an emphysematous lung)
Resonance (loud, as heard over a normal
lung)

Indirect - use of both hands, the
striking hand contacts the stationary
hand fixed on the persons skin.
Auscultation The act of listening to sound
produced within the body with the
aid ofstethoscope(CBQ)
Dullness (medium intensity, as heard over the
liver, spleen and other solid/dense organs)
Flat - when no air is present, over thigh
muscles or bone or over tumor
2 sides of stethoscope:
Bell used to detect low-frequency sounds (
abnormal heart sounds like S3 & S4 murmurs)

Diaphragm to detect high-frequency sounds (

normal heart sound like S1&S2 , breath and
bowel sounds)
Take Note:
 The CORRECT order for abdominal assessment is inspection, auscultation, percussion,
palpation (I-A-Pe-Pa)
 Palpation is the last step in abdominal assessment.
 Auscultation follows assessment because percussion and palpation can alter the frequency
and intensity of bowel sounds.

2. Diagnosis
Activities: Analyzing, interpreting and synthesizing data
3 Parts of Diagnosis statement
P= Problem
E =Etiology/cause
S =Signs and Symptoms

3. Planning
Activities: Set priorities and goals/outcomes; formulate an action plan
SMART GOALS

S pecific: Well-defined, clear to all what needs to be accomplished

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M easurable: Concrete criteria to measure progress towards goal.

A ttainable: Make sure the goal is within reach for the patient
R ealistic: Is the patient willing to working towards the goal?
T imed: Need a time frame for when the goal will be met.

4. Implementation / Intervention
Activities: carry out or discharge plan into action
Documentation: After implementing the plan, it must be documented.
Take Note: If its Not documented, it is NOT done

3 types of interventions

1 – Independent(CBQ)
o Care nurse caan provide based on her knowledge and within scope of profession
o Does not need doctors order
o Examples: Health teaching, positioning and morning care procedures

2 – Dependent
o Interventions that the nurse initiates as a result of physician order
o It needs doctors order
o Examples: medication administration, nasogastric tube, tube feedings, urinary catheterization,
oxygen level supplementation.

3 – Collaborative or interdependent
o Interventions that the nurse carries out in collaboration with other health care team
professionals
o Examples: Physical Therapy, Occupational therapy, laboratories, radiology)
1. An interdependent function of nurse is when the nurse_____________:
a. Irrigates a feeding tube that appears obstructed.
b.Gives ice chips to a client who has an order of NPO.
c.Applies a dry sterile dressing to an abdominal incision.
d.Helps a client choose foods rich in protein from an ordered diet.

2. A nurse decide to give partial bath to a client instead of a complete bath. The nurse is working.___________:
a.Independently b. Interdependently c. Dependently d. Collaboratively
Rationale: Full or partial bed baths can be administered regardless of the activity order written by the primary
health-care provider because it is an independent function of the nurse.

3. A nurse works with a skin care team. The nurse is functioning______________:

a.Dependently b. Interdependently c. Collaboratively d. Independently

4. A nurse initiates a visit from member of the clergy for a terminally ill client. The nurse is
functioning______________:
a.Interdependently b.Collegially c.Independently d.Dependently

5. When a nurse uses a straight catheter to obtain a urine specimen for laboratory test, the nurse is
functioning______________:
a.Dependently b.Interdependently c.Independently
d.Collegially

5. Evaluation
Activities: Determine the effectiveness of nursing care. Outcome assessment. (CBQ)Reassessment
phase and revision of care plan.
 Goal was met: client response is the same with desired outcome
 Goal was partially met: desired outcome is partially attained
 Goal was not met: desiredoutcomeis NOT attained

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VITAL SIGNS / CARDINAL SIGNS

Vital Signs Description

Temperature measurement of the balance between heat lost and heat produced by the
body
Regulated by Hypothalamus(CBQ)
Pulse the pressure of the blood felt against the wall of an artery as the heart
contracts and relaxes, or beats(CBQ)
Regulated by Autonomic Nervous System.
o Sympathetic nervous system (SNS)
o Parasympathetic nervous system (PNS)
Respiration reflect the breathing rate of the patient; process of taking in Oxygen and
expelling Carbon Dioxide from the lungs and respiratory tract
Medulla oblongata – primary respiratory control center(CBQ)

Blood pressure force exerted by the blood against the arterial walls when the heart
contracts or relaxes(CBQ)

Pain an unpleasant sensory and emotional experience associated with actual

or potential tissue damage or described in terms of such damage

Pain: the 5th vital sign(CBQ)

Take note: In taking the vital signs of a child, It should be arranged from the least invasive
procedure to the MOST invasive ( RR-PR-Temp-BP ) (CBQ)

BODY TEMPERATURE
heat of the body measured in degrees
Difference between production of heat and loss of heat from the body

HEAT PRODUCTION:
H eat is primarily produce by FOOD METABOLISM(CBQ)
E xercise / Physical activity
A drenaline ( Epinephrine and norepinephrine)
Thyroxine stimulates increase in basal metabolic rate
Shivering and vasoconstriction for heat conservation

METHODS OF HEAT LOSS

Radiation Heat moves from the warm body to the cool surface/object but NOT in direct
contact with the body
Example: placing a cold item beside the incubator
*placing newborn under radiant warmer prevents radiation heat loss. (CBQ)

Conduction Heat loss to a colder object by DIRECT CONTACT

Example: cold stethoscope, cold hands, cold thermometers, cold cribs without
linens(CBQ)

*warming objects, hands prior examining newborn prevents conduction.

*placing warm blanket in examining table prevents conduction.
*skin to skin contact after birth to utilize conduction of maternal heat to neonate.

Convection Heat is lost from the body surface to the cold air
Example: circulating cold air, air condition, electric fan, cooling ducts, open
windows or doors. (CBQ)

*wrapping the newborn with warm dry blanket, placing cap or bonnet, prevents
convection(CBQ)
*closing doors, windows, and turning off the electric fan prevents convection.

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Evaporation Water changes from a liquid to a vapor

Example: The baby is wet with amniotic fluid
Insensible evaporation of moisture from the respiratory tract, mucosa of mouth and
perspiration from skin

*drying the newborn immediately after birth and bath prevents evaporation. (CBQ)

TYPES of TEMPERATURE
A. Core Temperature - Temperature of the deep tissues of the body. Example: abdominal cavity ,
pelvic cavity ( tympanic and rectal )
B. Surface Temperature- Temperature of the skin, subcutaneous tissue, fats. rises and falls (
oral and axillary )

FACTORS AFFECTING BODY TEMPERATURE

H ormone/sex : woman fluctuate in body temp more than men; progesterone raise body temp(CBQ)
E nvironment: body responds to changes in environmental temperatures
A ge: Infants ( immature regulatory system) and elderly ( loss in subcutaneous fats)
T ime of the day: highest between 8pm to 12 midnight; lowest between 4-6 am (CBQ)

M eals : slight increase in temperature, 20-30 minutes after eating

E xercise: muscles generates heat
Antibiotics (cephalosporins, penicillins etc), methyldopa, phenytoin drugs
L ifestyle: Smoking increases body temperature.
S tress/ emotions: Sympathetic system stimulation; epinephrine and norepinephrine
Take Note: DIURNAL VARIATION/ CIRCADIAN RHYTHM – temperature normally fluctuates over the day
following circadian rhythms, with lowest levels around early morning highest in the late afternoon and at night(CBQ)
COMMON SITES OF TEMPERATURE TAKING
ROUTES DESCRIPTION RESULT WITHIN
Tympanic Fastest, safe and accurate route 1 – 2 seconds – (CBQ)
Rectal Most accurate but most invasive(CBQ) 2 – 3 minutes – (CBQ)
Oral Most convenient and most accessible 3 – 5 minutes
Axillary Safest, non invasive, least accurate 5 – 10 minutes

1. Tympanic
E ar drum / aural temperature
A ccurate and fastest(CBQ)
R esult within 2 seconds – (CBQ)
Insertion of probe: insert only ¼ to ½ inch to tympanic– (CBQ)

o Infant and children less than 3 years old: pull the pinna down and back. (CBQ)
o Adult and children more than 3 years old: Pull the pinna up and back. (CBQ)

CONTRAINDICATIONS:
O titis externa/ear infections
T enderness and ear pain
I mpacted cerumen
C erebrospinal fluid ( CSF ) otorrhea

2. Rectal
P lace client into SIMS position – (CBQ)
U se thermometer has a short rounded bulb with a red tip. (CBQ)
W ater-soluble lubricant ( apply to the tip ) to ease insertion; promote comfort
I nsert: 0. 5 (½ inch) for infants ( not > 1 inch) and 1.5 inches for adults(CBQ)
T ime for 2 – 3 minutes(CBQ)

CONTRAINDICATIONS:
R ectal surgeries, rectal trauma, rectal bleeding, imperforate anus
E xternal and internal hemorrhoids
C ardiac conditions : may result to vagal stimulation causing bradycardia
T aking anticoagulant drugs.
A nal fissures and colostomy
L oose bowel movement ( diarrhea) and patient with immunosuppression.

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3. Oral route
O ral thermometer has a long slender bulb with a blue tip
R ight or left frenulum / under the tongue insertion(CBQ)
A lert: Wait 15 – 30 minutes after smoking, eat hot/cold food
L et it in place for 5 – 10 minutes; ask client to close mouth

CONTRAINDICATIONS:
M outh breathers and patients with oxygen
O ral disease or oral surgery
U nconscious or confuse/disoriented
T ube feeding ( Nasogastric )
H ave a seizure
S ix years old below children(CBQ)

4. Axillary
Axillary is 0.5°F to 1°F lower than oral temperature
R ecommended route for patient with diarrhea and oral problems(CBQ)
M ust be place in a dry arm pit

P lace thermometer probe/tip at the center of arm pit (CBQ)

I nstruct client to keep the arm flexed across the chest
T ake temperature for 10 minutes.

Normal range of body temperature:

Method Range in °Celsius ) Range in °Fahrenheit

Tympanic 37.0 – 38.0 98.6 – 100.4
Rectal 37.0 – 38.0(CBQ) 98.6 – 100.4
Oral 36. 5 – 37. 5 97.7 – 99.5
Axillary 36.0 – 37.0 96.8 – 98.6
CONVERSION OF BODY TEMPERATURE
Celsius to Fahrenheit: (°C × 9/5) + 32 = °F Or °C x 1.8 + 32 = °F

Example: What is 37.5 °C in Fahrenheit?

Formula: 37.5°C x 1.8 = 67.5 + 32 = 99.5°F

Fahrenheit to Celsius: (°F − 32) × 5/9 = °C Or °F – 32 ÷ 1.8 = °C

Example: What is 100.8 °F in Celsius?
Formula: 100.8 – 32 = 68.8 ÷ 1.8 = 38.2°C(CBQ)

Thermometer technique:

Cleaning before use wipe thermometer in spiral/ rotating manner from BULB TO STEM – (CBQ)
Cleaning after use wipe thermometer in spiral/ rotating manner from STEM TO BULB– (CBQ)

BE SURE YOU SHAKE DOWN THE THERMOMETER BEFORE USE up to 35-36 C!

Thermometer technique requires the use of 8 cotton balls

Take reading at eye level to avoid ERROR OF PARALLAX
If the eye level is higher than the level of the meniscus, it will cause a false LOW reading(CBQ)

Normothermia temperature is within the "normal" range

Pyrexia Also known as Fever / Febrile a temperature above the normal range due
to an increase in the body's temperature set point.
Hyperpyrexia when a fever exceeds 41 °C / 106 °F; it is a medical emergency, brain
damage. (CBQ)

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Hyperthermia Elevation in body temperature above normal range that occurs without a
change in the hypothalamic set point
Hypothermia Core body temp below 95 °F or 35 °C
Poikilothermia inability to regulate one's body temperature ( cold blooded)

Types Description
Intermittent The body temperature alternates at regular intervals between periods of fever and
periods of normal or subnormal temperatures. On and off fever in 24 hours
period. (CBQ)
 Example of disease is malaria

Recurrent/Relapsing Short febrile periods of a few days are interspersed with periods of 1- 2 days of normal
temperature.
 Example of disease is the Tick-borne Borrelia recurrentis bacteria
Constant The body temperature fluctuates minimally but always remains
abovenormal.(CBQ)
The body temperature remains consistently elevated and fluctuates less than 2
degrees C
 Example of disease is typhoid fever

Remittent A wide range of temperature fluctuations (more than 2C) occurs over the 24-hour
period, all of which are above normal.(CBQ)
 Example of disease is influenza

Defervescence of fever/ Decline of fever

Lysis gradual decline of fever example from 41 declines gradually to 40
C(CBQ)
Crisis sudden decline of fever example 42 declines suddenly to 37.8 C
less than an hour(CBQ)

PULSE

P atient palm is facing upwards.

U se your index (first finger) and middle fingers on their wrist, at the base of their thumb.
L ocate pulses by PALPATION technique
S lower pulse in supine position; higher pulse in standing and sitting(CBQ)
E xamine and count the pulse for 1 full minute ( irregular pulse and apical pulse) (CBQ)
S tethoscope is used for assessing apical pulse and fetal heart tone ( auscultation)

NOTE: Do not use your thumb to measure a pulse, your thumb has a pulse of its own, reading will be inaccurate.

COMMON BOARD QUESTIONS!

B oys/males have lower heart rate than females ( higher pulse rate in females) (CBQ)
O ld age/elderly are more prone to bradycardia
A short, fat person may have a higher rate than a tall, slender person.
R educe or lower heart rate in lying position and increase in standing position
D o not use thumb in pulse taking ( it has its own pulse) (CBQ)

PULSE ASSESSMENT
Rate Number of pulsations per minute
Rhythm time between each pulse
Intensity Force or volume
(a) Strength of pulsations
(b) Strong, bounding, weak, thready
Condition of artery Normally soft and elastic

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PULSE ASSESSMENT
PULSE SITES LOCATION AND USES
Temporal pulse palpated on the temple directly in front of the ear with the index finger.
o Used when radial pulse is NOT accessible

Carotid artery pulse palpated on the neck below the jaw and lateral to the larynx/trachea.
(CBQ)
o Used in cases of cardiac arrest
o Pulse check site for CPR in adults and children(CBQ)
o Used to determine circulation to the brain
o DO NOT take the pulses on both sides of the neck at the same
time

Apical pulse
A – At the apex of the heart, NOT PALPABLE, use stethoscope. (CBQ
P – Point of maximal impulse (PMI) (CBQ
I – Intercostal space, left mid-clavicular line
 Birth to 3 years old – 4th intercostal space
 7 years old above – 5th intercostal space
C – Commonly used for infants and children up to 3 years old.
A – Accurate and MOST reliable(CBQ)
L – Located just below nipple line

TAKE NOTE: Apical Heart rate is commonly used in conjunction with some
medication before administration like ( digoxin)(CBQ)
Brachial artery pulse palpated on the anterior aspect of the elbow.
o Used to measure blood pressure with a stethoscope and
sphygmomanometer. (CBQ)
o Used as pulse check site in CPR of INFANTS(CBQ)
Radial artery pulse palpated immediately above the wrist joint near the base of the thumb
o MOST accessible and preferred site in pulse taking. (CBQ)
Femoral pulse palpated over the ventral thigh between the pubic symphysis and anterior
superior iliac spine ( located in groin area)
o most sensitive in assessing for septic shock and is routinely
checked during resuscitation
o Used to detect coarctation of the aorta(CBQ)
Absent or diminished femoral pulse is a classic characteristic of
coarctation of aorta(CBQ)
Popliteal pulse palpated on the posterior or back of the knee; this pulse is more difficult to
palpate as compared to other pulse sites. (CBQ)
Posterior tibial pulse palpated posterior and inferior to the medial malleolus
Dorsalis pedis pulse palpated in the groove between the first and second toes slightly medial on
the dorsum of the foot
o commonly used to monitor limb circulation

Pulse Deficit:
P ulse deficit is the difference between apical and radial pulse
U sing the same watch ; needs 2 person then count simultaneously.
L isten to apical pulse( for 1 full minute), and the other person is palpating radial pulse
S ubtract the Apical pulse rate to radial pulse rate
E qual result is normal ( difference should be zero )
 If there is a difference, it is called the pulse deficit.
NOTE: An apical pulse will never be lower than the radial pulse.

ASSESSMENT PARAMETERS / CHARACTERISTICS OF PULSE

AGE GROUP PULSE RANGE
Newborn 120 – 160 beats per minute(CBQ)
Infants (1 – 12 months) 80 – 140 beats per minute
Infant during sleep may decrease to 100(CBQ)
Infant while crying as high as 180. (CBQ)
Elderly 60 – 100 beats per minute(CBQ)

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ABNORMAL ASSESSMENT FINDINGS:

A. Bradycardia - Slow pulse rate less than 60/ minute and must immediately be reported ( Brady means slow)
. – (CBQ)
o Drugs that can slows down heart rate
B eta-blocker and calcium channel blockers ( Metoprolol and Diltiazem)
R anitidine ( H2 blocker)
A miodarone
D igoxin ( lanoxin) anddigitalis– check apical HR first!!!
Y es!morphineand opiates can also cause bradycardia.

Take note: Atropine sulfate is the first-line drug of choice to treat bradycardia

B. Tachycardia - Rapid heart rate over 100/ minute, and must be reported. ( tachy means fast) – (CBQ)

o Drugs that can cause fast heart rate

T heophylline – (CBQ)
A nticholinergic, antihistamines, and amphetamines
C ocaine and caffeine(CBQ)
H ydralazine
Y es! Dopamine and Epinephrine increases heart rate

o Factors affecting a pulse increase:

F ever and Pain

E xercise, excitement, excessive caffeine
A nxiety and fear
R espiratory drugs like : decongestant and albuterol
S hock, Injury and illnesses ( hyperthyroidism)

RESPIRATION

CHARACTERISTICS OF RESPIRATION
Age Group Type of breathing Normal Rate
Newborn Diaphragmatic/abdominal breathing 30 – 60 breaths per minute(CBQ)
Adults Costal/thoracic breathing 12 – 20 breaths per minute(CBQ)

Number of breaths per minute is represented by 1 second Inspiration + 2 seconds Expiration (I:E ratio is 1:2)
(CBQ)

FACTORS AFFECTING RESPIRATION

R espiratory depressant drugs (morphine decreases RR ) (CBQ)
E xercises and Emotions ( increases RR)
S tress ( increases RR)
P ersons age, Caffeine and atropine increases RR (CBQ)
I ncrease ICP ( decreases RR)

NORMAL BREATH SOUNDS

Vesicular Soft, blowing, or rustling sounds inspiration/expiratory ratio ( 3:1)
normally heard throughout most
of the lung fields. (CBQ)
the most commonly auscultated
breath sounds,

Bronchial Hollow, tubular sounds that are inspiration/expiratory ratio ( 1:3)

lower pitched.
auscultated over the trachea

Bronchovesicular Normal sounds in the mid-chest inspiration/expiratory ratio ( 1:1)

area or in the posterior chest

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between the scapula.

bronchial breath sounds heard
near the trachea and the alveoli
with the vesicular sound

ASSESSMENT FINDINGS

ASSESSMENTS DESCRIPTION KEYWORDS

Eupnea NORMAL quite breathing 12 – 20 breaths per minute

Dyspnea Breathlessness or shortness of breath; labored or AIR HUNGER

difficult breathing (CBQ) *Position to Fowler's

Orthopnea Shortness of breath that occurs when lying Relieved by upright position (sitting
flat/recumbent position(CBQ) or standing)
Bradypnea Abnormally SLOW breathing rate ( slow respiration) Less than 12 breaths per minute
Tachypnea Abnormally FAST breathing rate (rapid respiration) More than 20 breaths per minute

Apnea Absent or CESSATION of breathing(CBQ) RESPIRATORY ARREST(CBQ)

Hyperpnea Deeper respiration but with NORMAL RATE Increase in depth of respiration

Cheyne stokes Periods of faster and deeper breaths, followed by WAXING & WANING respiration
very short or no breaths (apnea), and repeat in DEATH RATTLE breathing
cycles usually taking 30 seconds to 2 minutes AGONAL breathing(CBQ)
(occurs shortly before death)

Biot's Groups of quick, shallow inspirations followed by Faster and deeper than normal
regular or irregular periods of apnea (10 to 60 with abrupt pauses in between
seconds) each breath
Kussmaul’s Faster and deeper respiration without pauses in Seen among patients with severe
between panting. metabolic acidosis, particularly
heavy labored breathing with a diabetic ketoacidosis (DKA) in
FRUITYODOR(CBQ) DIABETIC CLIENTS and kidney
failure(CBQ)

ADVENTITIOUS/ABNORMAL BREATH SOUNDS

Types Description
Rales/ Crackles Clicking, rattling, or crackling
caused by air passing thru fluid or mucus in the airway, sound heard during inspiration
Rales can be further described as moist, dry, fine, and coarse.

Fine crackles is normal to newborn at birth. (CBQ)

Crackles in adult is a sign of pulmonary edema/lung congestion(CBQ)
Rhonchi Coarse crackle sound that is wetter than a rale, usually heard during exhalation,
suctioning recommended
Stridor Loud, harsh, high pitched respiratory sound.
'croaking' to 'crowing' sound heard during inhalation.

High-pitched, musical breathing sound caused by a blockage in the upper airways like
trachea, pharynx and voice box (larynx)
Wheeze High-pitched, whistling and sighing sound when air moves through narrowed breathing
tubes in the lungs. This is heard most commonly in asthmatics

Stertor ''clucking'' noise, or the SNORING like inspiratory sound.

IV. BLOOD PRESSURE or Arterial blood pressure: pressure exerted on the walls of arteries when the blood is
pumped out of the heart ( Force of the blood against the arterial walls) (CBQ)
o Measured in millimeters of mercury (mmHg)

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SYSTOLE the highest pressure; pressure of the CONTRACTION AND EJECTION of blood into
blood as a result of contraction of the aorta (CBQ)
ventricles Afterload is the tension in the wall of the heart
during systole

DIASTOLE the lowest pressure; pressure of the blood RELAXATION AND FILLING of chambers of
when ventricles are at rest heart with blood (CBQ)
Preload is the passive wall stress (or tension) at
the end of diastole
Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of
mercury. ( DIASTOLE is subtracted from SYSTOLE) (CBQ)

Example: In 120/80 mmHg, pulse pressure is approximately 40 mmHg. ( 120 – 80 = 40 mmHg)

KOROTKOFF SOUNDS
Phase I – TAPPING sound (systolic pressure)
Phase II – SWISHING sound ( sounds that increase as the cuff is deflating)
Phase III – KNOCKING sound ( occurs with each heartbeat)
Phase IV – MUFFLING sound ( indicates diastolic pressure in children)
Phase V – SILENCE ( diastolic pressure)
Auscultatory gap – no sound, silence as cuff deflates for 30 - 40 mm common with hypertension
Factors affecting Blood pressure:
A ge, BP rises w/ age
B ody built ( OBESITY predispose to hypertension)
C irculatory problems ( blood viscosity)
D rugs like dopamine, dobutamine, epinephrine
E motions, Exercise, Stress

TAKE NOTE: Based on the latest guidelines, the normal blood pressure now is BELOW 120/80. Under this
guideline, 120/80 is now clinically categorized as elevated blood pressure.
BP of 130 – 139 systolic and diastolic of 80 –89 is Hypertension stage 1. (CBQ)
BP of higher than 140/90 is hypertensive stage 2, above 180/120 is hypertensive crisis. (CBQ)

Assessment Findings:

HYPOTENSION HYPERTENSION
Low blood pressure High blood pressure

Systolic pressure is consistently between 85-110 Hypertension is called a "silent killer".

mmHg Hypertension is a major cause of premature death
worldwide.
Signs and Symptoms: dizziness or lightheadedness,
pale, fainting *Consistent elevation with 2 readings in 4 – 6 hours
apart.
Dangerous with symptoms of shock : One of the global targets for non-communicable
Hypo-Tachy-Tachy:(CBQ) diseases is to reduce the prevalence of hypertension by
25% by 2025 (baseline 2010).
o Hypotension
o Tachycardia Hypertension damages
o Tachypnea B rain and heart , K idney, E yes
*Pale, cold clammy skin
TWO TYPES:
Types of Hypotension A. Primary hypertension
o UNKNOWN CAUSE
a. Orthostatic Hypotension: also o MOST COMMON ( 95%)
known as postural hypotension, is o OBESITY
a symptomatic fall in blood
pressure following quick standing B. Secondary hypertension
from a seated or supine position. ( o IDENTIFIABLE CAUSE
prevented by getting up in bed o KIDNEY/RENAL PROBLEM
slowly) o HYPERTHYROIDISM

DIET: D.A.S.H

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b. Postprandial Hypotension: after Dietary Approaches to Stop Hypertension (DASH) is a

eating meal diet plan that helps to lower blood pressure

c. Severe: drastic drop in BP that can Complications of Hypertension

cause organ failure or death in C erebrovascular accident ( stroke)
hours H eart failure and M.I. ( heart attack)
E ye problems
d. Natural Mediated Hypotension: C hest pain / Angina
standing for long periods of time K idney failure

RISK FACTORS OF HYPERTENSION

NON MODIFIABLE MODIFIABLE
Non modifiable risk factors are risk factors that Modifiable risk factors are risk factors that CAN BE
CANNOT BE CHANGED. CHANGED.(CBQ)

A ncestral/Family history of hypertension O besity and overweight(CBQ)

G ender and Genetic factors I nactivity
E thnicity L ack of sleep
o African Americans are at greater risk Y es! Stress is modifiable
K idney disease and diabetes
O ld age older than 65 D rinking alcohol
I ntake of fatty foods
E xcessive salt intake
T obacco smoking
S edentary lifestyle

1. To ensure accuracy in taking the BP, you must:

B efore assessment; rest for 5 minutes, 30 minutes if ingested caffeine or nicotine. (CBQ)
P osition in comfortable sitting position. Arms at the level of the heart. Feet flat in floor

T o begin blood pressure measurement, use a properly sized blood pressure cuff.
A pply cuff's bladder at least 80% circumference and 2/3 length of the upper arm. (CBQ)
K eep the cuff SNUGLY, Lightly press the stethoscope's bell over the brachial artery.
I inflate the cuff to 180 then release air from the cuff at a moderate rate (2-3mmHg/sec). (CBQ)
N ote for the Korotkoff sounds ( first sound: systolic, disappearance: diastolic)
G et another reading after 1 – 2 minutes to verify accuracy (CBQ)

Some don'ts when taking BP.

A. Do not take on arm with IV in place.
B. Do not take on arm with cast on.
C. Do not take on side with mastectomy or other breast surgery.
Enema Administration
Enema : Instillation of a solution into the rectum and large intestine
Position: Left-side position ( Sim's) (CBQ) Infant/Children: Dorsal recumbent position.
Cleansing Enema
 primarily to remove feces, pre-op, before diagnostic procedure

Examples:
 Hypotonic Enema (Tap water enema) – (CBQ)
 Isotonic Enema ( Normal Saline)
 Hypertonic enema (Fleet)
 Soap suds enema (Castile Soap) – (CBQ)

LOW CLEANSING ENEMA

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o clean the RECTUM and SIGMOID COLON only– (CBQ)

o container height ranges 12-18 inches above the rectum
o client maintains a LEFT LATERAL POSITION ONLY– (CBQ)

HIGH CLEANSING ENEMA:

o clean as much of the colon as possible
o container height ranges 12-18 inches above the rectum– (CBQ)
o client changes from a left lateral position to the dorsal recumbent position to the right lateral position to
cover all surface– (CBQ)
Carminative Enema
 Given to expel flatus. the solution instilled into the rectum releases gas
Retention enema
 Introduces oil or medication into the rectum and sigmoid colon
 the liquid is retained 1-3 hours
 May be used in unconscious patients or coma.
 Softens the feces to lubricate the rectum
 Use of MINERAL OIL, OLIVE OIL, COTTONSEED. – (CBQ)

Return Flow Enema aka Harris Flush

 expels gas
 alternating flow of 100-200 mL of fluid into and out of the rectum. – (CBQ)
TAKE NOTE:
E nsure solution be warm: 37°C (NEVER GIVE A COLD ENEMA, IRRITATIVE) – (CBQ)
N O to LATEX allergy because the tubing of enema is made of latex
E nsure to lubricate rectal tube.
M aintain SIM's or LEFT lateral position with the right leg flexed– (CBQ)
A dminister SLOWLY– (CBQ)
 If patient complains cramping (stop the flow and ask to take several deep breaths)
 If notes blood in the return fluid and rectal bleeding (Stops the instillation and obtain vital signs)

HYDROTHERAPY : refers to the therapeutic use of water, including hot tubs, cold water treatments, ice packs,
vapors, saunas, mineral springs, hot springs, sitz baths, wet towel applications, water exercises, and water massage.
(CBQ)
CRYOTHERAPY / COLD THERMOTHERAPY/HEAT

COLD HOT

Cold Application Hot Application

C ontrols bleeding by VASOCONSTRICTION
O ffers ANESTHETIC EFFECT ( relieve pain) H ealing of wounds ( promotes circulation)
L owers body temperature O pen blood vessels ( VASODILATION)
D ecreases EDEMA T o promote MUSCLE RELAXATION(CBQ)
S edative ( induces sleep)
REMEMBER:
Cold constricts vessels and retains heat REMEMBER:
Cold is usually best for a fresh injury, like a bruise or a Dilates vessels and releases heat(CBQ)
sprain. Heat relax muscles, joints, and blood vessels
Cold should only be used for the first 48 hours or so after Watch for burns or if your skin becomes numb,
an injury. blistered, or red.

HEAT CONTRAINDICATIONS
COLD CONTRAINDICATION: 1. Fresh injury
1. Open wounds. 2. Active hemorrhage.
2. Impaired Circulation. 3. Non-inflammatory Edema.
3. Allergy or Hypersensitivity to cold 4. Localized malignant tumor.
5. Skin disorder that causes redness or blisters.

GENERAL PRECAUTION:

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 Keep a towel between your skin and the heat/cold source.

 Don’t apply heat/cold for more than 15-20 minutes at a time.

SITZ BATH PROCEDURE

Definition It is a form of Hydrotherapy (water therapy), which increases the blood flow
to the pelvis and abdominal area.
Sitz bath is therapeutic bath used to heal and cleanse the area around the
perineum(CBQ)

Also known as HIP BATH

Sitz bath is a MOIST HEAT procedure.
Bath Tub / basin filled with hot water 3 to 4 inches
Water Temperature 40 – 43 °Celsius or (105 – 110 F)
Purpose To aid healing a wound
To induce menstruation.
To induce voiding in urinary retention
To relieve pain, congestion and inflammation
Duration 15 – 20 minutes
Position Sitting in a tub
Submerged buttocks, lower back and the upper thigh in the tub
NOTE: FEET must be OUT of the TUB(CBQ)
Indication H emorrhoids
E pisiotomy and after vaginal delivery
A nal fissures and fistulas
L acerations of perineum
S urgeries of the rectum
Contraindications Menstruating or pregnant women
Assessment CHECK BLOOD PRESSURE after for hypotension. (CBQ)

DRY HEAT AND MOIST HEAT THERAPY

DRY HEAT MOIST HEAT

H ot packs Warm moist compress

E lectric heating pads Sitz baths
A quathermia pad Warm soaks
T hermal blanket and Diathermy

H ot water bags/bottles – FILL 2/3 only(CBQ)

H eat Lamp – gooseneck lamp containing 60 watt bulb,
applied 18-24 inches from the body
H eat Cradle – 25-watt luminous bulb, applied
18 inches away from the patient

THERAPEUTIC MASSAGE
Definition manipulation of soft tissues of the body including muscles, connective tissue, tendons,
ligaments and joints using varying degrees of pressure and movement.

Indication L ow Immunity
A nxiety and stress
M inor injuries
A rthritis
S ome forms of pains (Headaches, migraine, Back pains)

Duration ideally be for 60 to 90 minutes

Contraindication C irculatory problems (thrombosis, Varicosities, phlebitis)

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O steoporosis
N ervous or psychotic conditions
T umors or Undiagnosed lumps
R ecent operations
A ny PAINFUL AND SWOLLEN AREAS and congested vessels(CBQ)
S kin diseases ( leprosy, scabies)
MASSAGE SEQUENCE AND TECHNIQUES
Effleurage Smooth, gliding long stroke used to relax soft tissue .
most basic massage movement and is often used as a linking movement to other
massage techniques. (CBQ)

TAKE NOTE: BEGIN MASSAGE WITH EFFLEURRAGE AND END WITH

EFFLEURRAGE.

Petrissage Squeezing, rolling, wringing up, picking up of muscles or kneading that follows after
effleurage

Friction Deep, circular movements that cause layers of tissue to rub against each other, helping
to increase blood flow and break down scar tissue

Vibration Oscillatory movements that shake or vibrate the body

Tapotement A short RHYTHMIC PERCUSSION, alternating tap done with cupped hands, fingers, or
the edge of the hand primarily used to "wake up" the nervous system and also as a
stimulating stroke which can release lymphatic build up in the back.

TAKE NOTE: Tapotement should not be used on a particularly bony area or

on broken or varicose vein

SLEEP HYGIENE

SLEEP HYGIENE: A series of recommendations and practices designed to improve sleep quality, quantity, and
daytime alertness.

S tick to a sleep schedule, DRINK A GLASS OF WARM MILK BEFORE BED(CBQ)

L imit daytime naps. Exercising before sleep is NOT advisable.
E nsure a quite, relaxed and non stimulating room
E lectronic gadgets like cellphones, watching TV, playing radio should be AVOIDED (CBQ)
Pay attention to what you eat and drink ( AVOID EATING HEAVY MEALS BEFORE SLEEP)
 Avoid caffeinated foods and drinks like coffee, chocolates, soda, tea.

TAKE NOTE
MILK contains TRYPTOPHAN ( natural sedative component that induces sleep)

SLEEP DISORDERS
Bruxism Involuntarily grinding or clenching of the teeth while sleeping.
Insomnia difficulty in falling asleep and/or maintaining sleep when no other cause is
found for these symptoms
Narcolepsy Excessive daytime sleepiness (EDS) often culminating in falling asleep
spontaneously but unwillingly at inappropriate times(CBQ)
Cataplexy a sudden weakness in the motor muscles that can result in collapse to the
floor. (CBQ)
Night terror abrupt awakening from sleep with behavior consistent with terror
Nocturia A frequent need to get up and urinate at night.
Enuresis bed-wetting, in which the person does not arouse from sleep, but the
bladder nevertheless empties.
Sleep apnea, obstructive sleep Obstruction of the airway during sleep, causing lack of sufficient deep
apnea sleep, often accompanied by snoring.
Stops of breathing of at least ten seconds, 30 times within seven hours of
sleep, classifies as apnea.

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somnambulism Sleepwalking or engaging in activities that are normally associated with

wakefulness (such as eating or dressing), which may include walking,
without the conscious knowledge of the subject. (CBQ)
Somniphobia dread/ fear of falling asleep or going to bed.

Somniloquy Sleep talking

Nocturnal emission Wet dream, sex dream or sleep orgasm
involuntary ejaculation of semen during sleep

3 types according to the TYPE of MUSCLE CONTRACTION

Isometric Exercise Isotonic Exercise Isokinetic Exercise

*STATIC or setting exercises *DYNAMIC exercises (moves) *RESISTIVE exercises, they can be
(tenses) *Muscles contract WITH JOINT isotonic or isometric exercises.
*Muscle contracts WITHOUT JOINT MOVEMENT *individual moves or tenses against
MOVEMENT resistance.
S quatting, push up *WEIGHT LIFTING
P lanking W alking and burpees
E xerting pressure against a solid A DL's and ROM's
object Most physical conditioning
W all sitting exercises

AEROBIC EXERCISE ANAEROBIC EXERICISE

Cardio exercises
Aerobic means with the use of oxygen Anaerobic means without oxygen
Muscles use oxygen Muscles use glycogen from carbohydrates to burn fat.

EXAMPLES: EXAMPLES:
D ancing P ush ups, planking
W alking, jogging, running U se of high-intensity interval training (HIIT)
R owing  Jump/jumping rope, squatting, plyometric
S wimming and cycling S printing, Sits up, biking
H eavy lifting and pushing
 Weight lifting exercises
ACTIVE VERSUS PASSIVE EXERCISE
ACTIVE EXERCISE PASSIVE EXERCISE

Active, voluntary muscle contraction by the patient
Performed by patients who are able to move each joint
without assistance
Example: Patient flexing her own arms. (CBQ)
Another person like the nurse who moves each joint for
a patient who is not able to exercise. ( performed by the
nurse to her patient) (CBQ)
Example: nurse flexing the arms of her patient

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