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Module 1 Fundamentals of Nursing
Module 1 Fundamentals of Nursing
Nursing Theorists
Proponent Theory
Callista Roy Adaptation Theory
Dorothea Orem Self- Care and Self Care Deficit
Faye Abdellah Identification of 21 Nursing Problems
Florence Nightingale Environmental Theory
Hildegard Peplau Interpersonal Model
Imogene King Goal Attainment Theory
Jeam Watson Human Caring
Lydia Hall Care, Core, Cure
Madeleine Leninger Transcultural Nursing
Martha Rogers Science of Unitary Human Beings
Myra Levine Four Conservation Principles
Rosemarie Parse Human Becoming
Virginia Henderson Identification of 14 Basic Needs
Nursing Process
A-ssessment
D- iagnosis
P-lanning
I-mplementation
E-valuation
Nursing Procedures
Nursing Responsibilities:
Nursing Responsibilities:
• Is an x-ray study of the cerebral circulation with a contrast agent injected into a selected
artery (femoral)
• Visualize aneurysm
Nursing Responsibilities:
Electroencephalography (EEG)
Nursing Responsibilities:
• Shampoo hair
• Avoid stimulants 24-48 hrs before
• Proper placement of electrodes
• Explain the procedure, assure the client he/she will not receive electrical shock.
• The nurse needs to check doctor’s order regarding the administration of antiseizure
medication prior to testing.
• Inform the client that the standard EEG takes 45 to 60 minutes and 12 hours for sleep EEG.
Lumbar Puncture
Nursing Responsibilities
• Genupectoral position
• Obtain signed consent.
• Void before procedure
• Flat on bed 6-8 hrs reduce the incidence of headache.
• Increase OFI
• Prepare 3 test tubes
▪ microorganisms
▪ nutrients
▪ blood cells
Cardiac Enzymes
Electrocardiography (ECG)
ECG Changes
2D ECHO
Cardiac Catheterization
Purpose:
Nursing Responsibilities:
Pre procedure:
C-onsent
A-nesthesia (local)
R-ecord baseline vs
I-odine
Post Procedure:
A-ssess VS
E-CG - dysrhythmias
Pulse Oximetry
B – Blanch test
C – color removal
D – detects O2 sat
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• PaO2, PaCo2, pH
Nurse’s Responsibilities:
Bronchoscopy
Lung Scan
Thoracentesis
Nursing Responsibilities:
• Pre-procedure:
o Informed consent
o Ask pt. to sit upright while leaning on the tray table.
o Instruct the client to hold still
• Post-procedure:
o Position pt. on the UNAFFECTED SIDE.
o Apply pressure dressing & assess puncture site for bleeding & crepitus
o Monitor for signs of pneumothorax, air embolism & pulmonary edema
Sputum Collection
Thoracentesis
Suctioning
Principles:
Artificial Airway/Tracheostomy
Purposes:
• To administer oxygen
• To suction secretions
• To by-pass upper airway obstruction
Tracheostomy
• A curved tube (plastic/metal) is inserted through the opening and into the trachea to keep
airway open
• Inserted using a laryngoscope
• Can be temporary or permanent
• Can be cuffed or cuff less
Parts:
• Outer cannula (Main shaft)-inserted into the trachea. Cloth or tape is tied through the flange
around the neck of the patient to keep it in place
• Inner cannula- it is the part being removed for cleaning (hydrogen peroxide and NSS)
• Obturator- it is inserted into the tube to guide the outer cannula during initial placement. It is
kept in the bedside in case of dislodgement.
Principles:
• Semi fowlers
• Don sterile gloves
• Use hydrogen peroxide and NSS in cleaning the cannula
• Tie should not be too tight which might compress the jugular vein
• KEPT IN THE BED SIDE: Obturator and Suction Machine
Coughing exercise
• Upright position
• Contraindicated: post brain, spinal or eye surgery
• Take two slow deep breaths; on the third breath, hold for few seconds, cough twice without
inhaling in between
• May splint surgical incisions
• Every 2 hours while awake
Incentive spirometry
A breathing device that provides visual feedback that encourages patient to sustain deep voluntary
breathing and maximum inspiration.
Chest Physiotherapy
• Postural drainage
• Percussion
• Vibration
Contraindications:
• ICP more than 20mmHg, head and neck injury, active hemorrhage, recent spinal surgery, active
Postural Drainage
• When = morning, at bedtime, 30 minutes – 1 hour before or 1-2 hours after meal
• Each position = assumed for 10 – 15 minutes
• Entire treatment should last only for 30 minutes
Percussion
• Rhythmical force provided by clapping the nurse’s cupped hands against the client’s thorax
• Over affected segment for 1-2 minutes
Vibration
• Perform by contracting all the muscles in the nurse’s upper extremities to cause vibration while
applying pressure to the client’s chest wall
• One hand over the other
Enema
Purpose
Procedure:
• Container height:
o Retention: 12 “above the rectum
o Non- retention: 18 “above the rectum
• Temperature: NOT MORE THAN 42 degree Celsius
Types of Enema
1. Cleansing Enema- height of container is 18 inches from the point of entry. Instruct the patient to hold
the fluid for 10-15 minutes
2. Carminative Enema- release gas, it distends the rectum and colon stimulating peristalsis. Uses about
60-80ml of fluid
3. Oil Retention-given to soften feces and lubricate the rectum and anal canal. Uses 90-120ml of oil
(mineral, cotton seed, olive) and kept in place for 1-3 hours
Endoscopy
Pre- procedure:
• NPO 8 – 12 h
• Consent
• Remove dentures
• Conscious sedation
• Anticholinergics
• Local anesthetics
Post Procedure:
• NPO 2 – 4 h
• Check for gag reflex
• WOF fall back of tongue
• Monitor for bradycardia and dysrhythmias
Gastric Analysis
NPO 12 h
HOW:
• NGT
• Collection of gastric contents every 15 min for 1 hour
RESULT:
Pre- procedure:
Indications
F-eeding
I-rrigation
D-ecompression
Me-dication
Measurement:
a. Swallowing
b. Nasal obstruction
c. Alertness
Position
(+) Resistance
• W - ithdraw
• R - elubricate
• R – einsert
• (-) talking
• Cough, DOB
PLACEMENT:
1. X-ray
3. Auscultate
Urinalysis
• Exact microbe
• Result is final only after 5-7 days
• Same collection process but less amount
Opthalmoscopy
• Opthalmoscope
• Used in determining cataract
• Dim the light and focus light of opthalmoscope in the eye
Otoscopy
• Otoscope
• A cannula is inserted in the external auditory canal
Rhinoscopy
• Rhinoscope
• Hyperextend the neck
Models of Health
Judith Smith
Clinical Model
Adaptive Model
• Capable of adjusting
• Although there is infirmity, he is able to find ways to cope.
Eudemonistic Model
• Individual perception affects modifying factors which may influence likelihood of action
• Health-illness Continuum
• health axis “Favorable/Unfavorable environment”
Quadrants:
1. Symptom experience
5. Convalescence/ Rehabilitation
DOCUMENTATION or CHARTING
• STAT – now
• Ad lib – as desired
• PRN – as required
• OD – right eye/ once a day
• OS – left eye
• OU – both
• AD – right ear
• AS – left ear
• AU – both ears
• Ss – half
POSITIONING
• Sitting
• High Fowlers (90%)
• Orthopneic position (leaning on a table, hands extended)
• Supine, Back Lying, Dorsal, Horizontal Recumbent
• Flat on Bed – no pillow
• Dorsal Recumbent – legs flexed to relax abdominal muscles, abdominal palpation/ exam –
followed by diagonal draping
• Standing/Erect
• Prone/ Face – lying position
• Sim’s Position, Left- lateral, Side-lying
– Rectal exam, suppository insertion, enema administration
• Knee Chest position/ Geno-pectoral position/ Jack Knife position
– Rectal exam, dysmenorrhea
• Lithototomy – stirrups
• Trendelenburg – foot up; head down
• Reverse trendelenburg – head up, foot down
• Modified trendelenburg – only 1 leg up for shock
Oral – contraindicated in brain damage, mental illness, retarded, problem with nose and mouth, tooth
extraction, contraption in nose and mouth, altered LOC, dyspnea, seizures, 7 y/o below
Rectal – contraindicated in imperforate anus, rectal polyps, Hirschsprung’s disease, diarrhea, increase
ICP, cardiac disease (may cause vagal stimulation)
Axillary – 3mins
***Temperature can be checked every 30 mins since hypothalamus can only fluctuate the temperature
every 30 mins
Hyperpyrexia: 41 ̊ degrees +
1. Onset / Chill phase: up HR, up RR, shivering, cold skin, cessation of sweating
2. Course / Plateau phase: absence of chills, feels warm, up HR, RR, thirst
Average: 36 ̊ - 38 ̊ degrees
Death: 34 ̊ degrees
Types of Fever
Nursing interventions
VITAMIN DEFICIENCIES
Vit A (Retinol)
Vit D (Calciferol)
o Spinal deformity
o Stunted growth
Vit E (Tocopherol)
Vit K (Menadione)
• Anti-hemorrhagic
• Deficiency: hemorrhage, bleeding
Vit B1 (Thiamin)
Vit B2 (Riboflavin)
Vit B3 (Niacin)
Vit B6 (Pyridoxine)
• Deficiency: Neuritis
Vit C (Ascorbic)
Types of Diet
Regular
Clear liquid
Full liquid
Soft diet
Bland
Low residue
• No bulky foods, apples or nuts, fiber, foods having skins and seeds
• Rectal disease
High calorie
Low calorie
Diabetic
High protein
Low fat
Low cholesterol
Low sodium
PAIN
• Subjective
• May have psychogenic pain as well
• Acute – less than 6 months
• Chronic – more than 6 months
• Intractable – not relieved
Pain threshold
DEATH
Post-mortem care