Fundamentals of Nursing

Review Part 1
by Sir V
 PERIODS IN THE HISTORY OF NURSING
INTUITIVE - Prehistoric times to early Christian era
NURSING - Nursing is based on instincts, performed out of
compassion and is for women only
- TREPHINING - drilling a hole in the skull with a rock
or stone without anesthesia to drive out evil spirits

APPRENTICE - Founding of religious orders (11th century) to

NURSING establishment of Kaiserswerth Institute for Training of
Deaconesses (1836)
- On-the-job training
- Nursing without formal education
- Dark Period
- Care was done by crusaders, prisoners and religious
orders
- Nursing went down to its lowest level
 PERIODS IN THE HISTORY OF NURSING
EDUCATED - June 15, 1860 – Florence Nightingale School of
NURSING Nursing opens
- Nursing influenced by:
* trends resulting from wars (Crimean, Civil)
* arousal of social consciousness
* increased educational opportunities for women
- Nursing evolved as an art and a science
CONTEMPORARY - World War II to present
NURSING - Licensure of nurses started
- Specialization of hospital and diagnosis
- Training of nurses in diploma programs
- Development of baccalaureate and advance
degree programs
- Marked by scientific and technological
development as well as social changes
4. We are currently living in the contemporary period
of nursing. How can Nurse Angel characterize
Contemporary Nursing from other periods in the
nursing history?
a. Nursing is strongly influenced by the result of the
post-war era.
b. Nursing is marked by technological developments
as well as social changes.
c. Nursing practice is based on the findings of the
latest research studies.
d. Nursing is no longer just confined in bedside care.
 BENNER S LEVELS OF NURSING PROFICIENCY
• NOVICE
– Beginning nursing student, or any nurse entering a situation in
which there is no previous level of experience
– Learns through a specific set of rules or procedures

• ADVANCED BEGINNER
– Nurse with some level of experience with the situation
– Identifies meaningful aspects of nursing care

• COMPETENT
– Nurse who has been in the same clinical position for 2-3 years
– Can anticipate nursing care and establish long-range goals
– Understands the specific care required by the type of client
BENNER S LEVELS OF NURSING PROFICIENCY

• PROFICIENT
– Nurse with 3-5 years of experience
– Perceives client s situation as a whole
– Focuses on managing care

• EXPERT
– Nurse with diverse experience
– Has an intuitive grasp of an existing or potential clinical
problem
5. Having the knowledge of Benner s levels of nursing
expertise, Nurse Angel categorizes the head nurse
of her unit as a proficient nurse. This level is
different from the other levels in nursing expertise
in the context of having:
a. A holistic understanding and perception of the
client
b. The ability to learn via a specific set of rules or
procedures
c. The ability to anticipate nursing care and establish
long-term goals
d. An intuitive and analytic ability in new situations
 ROLES AND FUNCTIONS OF THE NURSE
• Caregiver • Leader
• Communicator • Manager
• Teacher • Case Manager
• Client advocate • Clinician
• Counselor • Research consumer
• Change agent
Situation 2: Nurses assume a number of roles when
they provide care to clients. Maria is staff nurse in a
medical ward and deals with different kinds of
medical cases.
6. Nurse Maria makes sure that she carries out the
physician s orders as immediately as possible. She
also ensures that the emotional and spiritual well-
being of the client is addressed. By this, Nurse Maria
assumes the role of a:
a. Caregiver
b. Advocate
c. Communicator
d. Counselor
 EXPANDED CAREER ROLES FOR NURSES
• Advanced Practice Nurse – umbrella term for an
advanced clinical nurse that includes:
– Clinical Nurse Specialist
– Nurse Practitioner
– Nurse Midwife
– Nurse Anesthetist
• Nurse Educator
• Nurse Administrator
• Nurse Researcher
• Nurse Entrepreneur
7. Nurse Maria is also currently
undergoing training to become an
oncology nurse. After completing
this, Nurse Maria will be considered
a:
a. Clinical nurse specialist
b. Nurse practitioner
c. Nurse manager
d. Nurse researcher
 NURSING THEORIES
NURSING THEORIST KEY EMPHASIS
Florence Nightingale Environmental manipulation
Hildegard Peplau Interpersonal relations in nursing
Virginia Henderson 14 basic needs of clients
Lydia Hall Care-Core-Cure Model
Dorothea Orem Self-care deficit theory of nursing
Dorothy Johnson Behavioral systems model
Faye Glenn Abdellah 21 nursing problem areas
Ernestine Weidenbach Prescriptive theory
 NURSING THEORIES
NURSING THEORIST KEY EMPHASIS
Myra Levine Four principles of conservation
Imogene King Goal-attainment theory
Martha Rogers Science of unitary human being
Sr. Callista Roy Adaptation model
Betty Neuman Health care system model
Jean Watson Theory of transpersonal caring
Madeleine Leininger Transcultural nursing
Rosemarie Rizzo Parse Theory of human becoming
 MODELS OF HEALTH AND WELLNESS
Clinical Model Health is the absence of disease.
Role Performance Model Health is the person s ability to fulfill
societal roles.
Adaptive Model Health is a creative process.
Eudemonistic Model Health is the actualization or
realization of a person s potential.
Agent-Host-Environment When the 3 variables are in balance,
or Ecologic Model health is maintained.

Health-Illness Continuum Health and illness can be viewed as

opposite ends of a health continuum
11. Nurse Betty is also aware of the different
models of health and she knows how these
relate to illness or injury. She knows of a
client who works all day at her job as a
seamstress even though an x-ray of her lung
indicates a tumor. Which model of health is
applied in this situation?
a.Clinical model
b. Role performance model
c. Eudaemonistic model
d. Adaptive model
 LEVELS OF PREVENTION
PRIMARY LEVEL Prevent or delay the
actual occurrence of a
disease
SECONDARY Early detection for early
LEVEL treatment

TERTIARY LEVEL Prevention of

complications
Rehabilitation
 LEVELS OF PREVENTION
Health education
Breast self-examination
Immunizations
Establishment of wellness
Newborn screening
Risk assessments
Environmental sanitation
Testicular self-examination
Acute care in the hospital
Family planning services
Referring to support groups
 LEVELS OF PREVENTION
Health education PRIMARY
Breast self-examination SECONDARY
Immunizations PRIMARY
Establishment of wellness TERTIARY
Newborn screening SECONDARY
Risk assessments PRIMARY
Environmental sanitation PRIMARY
Testicular self-examination SECONDARY
Acute care in the hospital SECONDARY
Family planning services PRIMARY
Referring to support groups TERTIARY
13. Being a staff nurse at the female surgical
ward, Nurse Betty has patients who
underwent colostomy procedures. How will
she promote tertiary prevention to these
patients?
a. Encourage them to undergo regular follow-up
checkups.
b.Teach them how to perform proper colostomy
care.
c. Refer them to a colostomy support group.
d.Provide them with daily dietary instructions.
NURSING PROCESS - systemaBc, organised, step by step- 5 steps
 NURSING PROCESS
ASSESSMENT = Data Gathering + Organize Data +
Validation + Documentation
DIAGNOSIS = Analysis + Synthesis + Problem ID +
P.E.S
PLANNING = Prioritization + Outcome ID + Nursing
Order
IMPLEMENTATION = Care + Reassessment
EVALUATION = Reassessment + Compare with
Expected Outcome + Revise NCP
 ASSESSMENT

Types of assessment - iniBal, on-going, emergency & Bme-lapsed

Sources of Data- Primary & secondary

Types of Data- SubjecBve & ObjecBve

AcBviBes during assessment:

Collect, organize, compare with standards and document

CollecBng the Data

- establish rapport/trusBng relaBonship

simple way: greeBng the pt, introducing self &
explaining procedure
- Interview - Open and closed-ended quesBon

-Physical Exam
- Review of record/history
DIAGNOSIS - based on the collected data
- RESPONSES (+/-) of client to his illness

Types: Actual - problem exists

Possible- problem may develop but circumstances are vague
Risk- problem may develop and circumstances are present
Wellness - healthy client
Syndrome- 2 or more problems are present and are interrelated
 3-part Nursing Diagnosis statement: PED/PES
2-part statement: PE

Correct Problem statement:

Let’s check:
Immobility related to inability to stand and sit.
Fluid volume excess related to sudden weight gain.
Impaired skin integrity related to bedsore
IneffecBve airway clearance related to tenacious secreBons as evidenced by
DOB, use of accessory muscles of respiraBons
 PLANNING- Goal se_ng with the paBent
Expected outcomes- basis whether goal is met

PrioriBze the problems

Maslow’s
ABC
Maslow’s Hierarchy of Needs:
Physiological
Safety & Security
Love and Belongingness
Self-esteem
Self-ActualizaBon
GUIDELINES IN WRITING GOALS AND
EXPECTED OUTCOMES
1. Client-centered
2. Singular goal or outcome
3. Observable
4. Measurable
5. Time-limited
6. Mutual factors
7. Realistic
 PROCESS OF IMPLEMENTING
• Reassessing the client
• Determining the nurse s need for
assistance
• Carrying out the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
PHYSICAL ASSESSMENT - CHILDREN

• INFANT
– Auscultate and record HR and RR first
– Head to toe direction
– Perform traumatic procedures last
– Elicit reflexes as body part is examined; elicit
Moro reflex last
– Avoid abrupt, jerky movements
 PHYSICAL ASSESSMENT - CHILDREN

• TODDLER
– Inspect body area through play
– Initially, use minimal physical contact
– Introduce equipment slowly
– Auscultate, percuss, palpate whenever quiet
– Perform traumatic procedures last
– Allow to inspect equipment
– Praise for cooperative behavior
 PHYSICAL ASSESSMENT - CHILDREN
• PRE-SCHOOL CHILD
– Prefer standing or sitting
– Prefer parent s closeness
– If cooperative, proceed in head-toe direction
– If uncooperative, proceed as with toddler
– Offer equipment for inspection
– Make up a story about the procedure
– Use paper-doll technique
– Give choices when possible
 PHYSICAL ASSESSMENT - CHILDREN
• SCHOOL-AGE CHILD
– Prefers sitting
– Younger child prefers parent s presence; older
child may prefer privacy
– Head-toe direction
– Examine genitalia last in older child
– Allow to wear underpants
– Give gown to wear
– Explain purpose of equipment and significance of
procedure
PHYSICAL ASSESSMENT - CHILDREN
• ADOLESCENT
– Same as with school-age child
– Offer option of parent s presence
– Head-toe direction
– Allow to undress in private
– Give gown and expose only area to be examined
– Explain findings during examination
– Emphasize normalcy of development
 SAFETY ACROSS THE LIFESPAN
• NEWBORNS AND INFANTS
– ACCIDENTS – leading cause of death in infancy
• Burns
• Suffocation or choking
• Automobile accidents
• Falls
• Poisoning

– Parents should be informed of the following:

• Common hazards in and around the home
• First aid: CPR, interventions for airway obstruction
 SAFETY ACROSS THE LIFESPAN

• TODDLERS
– Fascinated by potential dangers (i.e., pools, busy
streets) à need for constant supervision
– Prevent accidents by:
• Use approved car restraints
• Remove or secure items that may be a safety hazard
• Inspect for or remove sources of lead
 SAFETY ACROSS THE LIFESPAN

• PRESCHOOLERS
– Very susceptible to injuries because of their
activeness and are often very clumsy
– Prevention:
• Keep matches, medicines and poisons out of reach
• Begin safety education for the child – how to cross
street, ride bicycles, etc.
• Parents must maintain careful surveillance
 SAFETY ACROSS THE LIFESPAN

• SCHOOL-AGE CHILDREN
– Often imitate actions of parents and superheroes
with whom they identify
– INJURIES – leading cause of death
• Motor vehicle crashes
• Drownings
• Fires
• Firearms
• Outdoor activities and recreational equipment
 SAFETY ACROSS THE LIFESPAN
• ADOLESCENTS
– Set limits on automobile use
– At risk for sports injuries
– Suicide and homicide – leading causes of death

• YOUNG ADULTS
– Motor accidents – leading cause of death
– Other causes: drowning, fires, burns and firearms,
suicide
 SAFETY ACROSS THE LIFESPAN
• MIDDLE-AGED ADULTS
– Motor vehicle crashes – leading cause of
accidental death
– Decreased reaction times and visual acuity – make
them more prone to accidents

• ELDERS
– Injury prevention – major concern
– Fires, at risk for wandering, falls
KÜBLER-ROSS S STAGES OF GRIEVING

DENIAL
ANGER
BARGAINING
DEPRESSION
ACCEPTANCE
• DENIAL
– Refuses to believe loss is happening
– Unready to deal with practical problems
– May assume artificial cheerfulness

• ANGER
– Resists the loss and may strike out at everyone
and everything

• BARGAINING
– Postpones awareness of the reality of the loss
– May express feelings of guilt or fear of
punishment for past sins, real or imagined
• DEPRESSION
– Finally realizes the full impact and significance of the
loss
– Grieves over what has happened and what cannot be
– May feel overwhelmingly lonely or may withdraw
from interactions

• ACCEPTANCE
– Accepts loss
– May have decreased interest in surroundings and
support people
– May wish to begin making plans
 BIOETHICAL PRINCIPLES
• AUTONOMY
– Right to make one s own decisions

• NONMALEFICENCE
– The duty to do no harm
– Act in such a way to avoid causing harm to clients

• BENEFICENCE
– Doing good
– Implement actions that benefit clients and their
support persons
 BIOETHICAL PRINCIPLES
• JUSTICE
– Fair, equitable, and appropriate treatment according to
what is due or owed to persons

• FIDELITY
– To be faithful to agreements and promises

• VERACITY
– Practice of telling the truth
 CharacterisBcs of Human Needs

Need is something desirable and useful

Needs are UNIVERSAL
Needs are MET in different WAYS
Needs are influenced by different FACTORS
PrioriBes may be CHANGED
Needs may be POSTPONED
Needs are INTER-RELATED
Scope of Nursing PracBce:

Involves four areas (KOZIER)

Promoting health and wellness
Preventing illness
Restoring health
Care of the dying
 Nursing Jurisprudence
The Philippine Nursing Act of 2002 (RA
9173) IS THE BEST GUIDE THE NURSE
CAN UTILIZE as it defines the scope of
nursing practice
 CONSTITUTION

LEGISLATIVE BRANCH EXECUTIVE BRANCH JUDICIARY BRANCH

STATUTORY LAW ADMINISTRATIVE LAW COMMON/PRIVATE LAW

CIVIL LAW CRIMINAL LAW

Standard of proof is preponderance of the evidence Standard of proof is guilt beyond reasonable doubt

Contracts
Torts
N-P R
Felony Misdemeanor

Manslaugther
Intentional
Unintentional
Fraud Assault & Battery
Defamation Fraud
Negligence
Assault & Battery
False Imprisonment
Malpractice
Invasion of Privacy
 Professional Negligence
n NEGLIGENCE
n Commission or omission of an act pursuant to
a duty, that a reasonably prudent person in
the same or similar circumstance would do or
would not do and the acting or the non-acting
of which is the proximate cause of injury to
another person or property
 Elements of Negligence
1. Existence of a duty on the part of the
person
2. Failure to meet the standards of due care
3. The forseability of harm resulting from
failure to meet standard
4. The breach of the standard resulted in
an injury to the plaintiff
 Examples of Negligence
1. Failure to report observation to the
physician
2. Failure to exercise the degree of
diligence
3. Mistaken identity
4. Wrong medicine, wrong calculation,
wrong route and wrong doses
 Examples of Negligence
5. Defects in the equipment such as
stretchers and wheelchairs thay
may lead to falls
6. Errors due to family assistance
7. Administration of medicine without
a doctor s prescription
 Res ipsa loquitur
n Three conditions are required to establish a
negligence WITHOUT proving specific conduct
1. That the injury was of such nature that it
would not normally occur unless there was a
negligent act
2. That the injury was caused by an agency
within control of the defendant
3. That the complainant himself did not engage in
any manner that would tend to bring about the
injury
 MALPRACTICE
n IMPROPER or unskillful cafre of apatient
by a nurse
n Stepping beyond one s authority with
serious consequences
n NEGLIGENCE or carelessness of a
professional personnel
n Negligent act committed in the course o
professional performance
 Consent
n A free and rational act that presupposes
knowledge of the thing to which consent is
being given by a person who is legally
capable of giving consent
 Informed consent
n Elements:
1. The diagnosis and explanation of the condition
2. Fair explanation of the procedures and
consequences
3. Description of alternative treatments
4. Description of benefits to be expected
5. Material rights
6. The prognosis, if refused
 LEGAL DOCTRINES
• RESPONDEAT SUPERIOR
– Let the master answer for the acts of the
subordinate
– A lawsuit for a negligent act performed by a nurse will
also name the nurse s employer

• RES IPSA LOQUITUR

– The thing speaks for itself
– The harm cannot be traced to a specific health care
provider or standard but does not normally occur
unless there has been a negligent act
 LEGAL DOCTRINES
• FORCE MAJEURE
– An irresistible force , one that is unforeseen or
inevitable
– Circumstances such as floods, fire, earthquakes,
and accidents fall under this doctrine
– Nurses who fail to render service during these
circumstances are NOT held negligent
 LEGAL PROCEEDINGS
• COMPLAINANT/PLAINTIFF – accuser
• RESPONDENT/DEFENDANT – the accused
• SUBPOENA/COURT SUMMONS – directs a
witness to appear and give testimony on the
date and time ordered
• SUBPOENA DUCES TECUM – order that
requires a witness to bring records, papers
and the like which may be in his possession
and which may help clarify the matter
 LEGAL PROCEEDINGS
• TESTIMONY OF FACTS – witness testifies only on what
she knows based on facts
• TESTIMONY OF OPINION – only given by expert
witnesses
• HEARSAY EVIDENCE – repetition of what the witness
has heard others say à not admissible in court
• PRIVILEGED COMMUNICATIONS – statements
uttered in good faith and are NOT permitted to be
divulged in a court of justice
• ANTE-MORTEM STATEMENTS – considered hearsay
evidence except when made by a victim of a crime
 Patient’s Bill of Rights
1. Right to considerate & respectful care.
2. Right to be informed about diagnosis, possible treatments and likely outcome
and to discuss this information with the health care provider.
3. Right to know the names and roles of the persons who are involved in the care
4. Right to consent or refuse a treatment
5. Right to have an advance directive
6. Right to privacy
7. Right to expect that medical records are confidential
8. Right to review the medical record and to have information explained
9. Right to expect that the hospital will provide health services
10. Right to know if the hospital has relationships with outside parties that may
influence treatment or care
11. Right to consent or to take part in research
12. Right to be told of realistic care alternatives when hospital care is no longer
appropriate
13. Right to know about hospital rules that affect treatment, and about charges
and payment methods
Clark’s Rule:
Child’s Dose= Adult Dose X wt of child in lbs
150 lbs
Young’s Rule: ( 2 years old and above)
Child’s Dose = Age in years x Adult dose
Age in yrs + 12
Fried’s Rule: ( Infant up to 2 years old)
Child’s Dose = Infant age in months x adult dose
150
Description Temperature Application

Very Cold Below 15C or 59F Ice bags

Cold 15C-18C or 59F-65F Cold Packs

Cool 18C-27C or 65F-80F Cold Compress

Tepid 27C-37C or 80F -98F Sponge Bath

Warm 37C-40C or 98F -104F Warm Bath, aquathermia pads

Hot 40C-46C or 104F-115F Hot soaks, Hot compress

Very Hot above 46C or above 115F Hot water bags