Fundamentals of Nursing

1-Decumentation.
2.Vital signs.
3. Patient's safety & Infection
control(A sepsis, infection
control, and wound care).
4. Gastrointestinal intubation.
5. Urinary and Bowel elimination.
6. Drug administration.
 Documentation

A. Characteristics
Entries in patient's record should be
chronological, clear, concise,
comprehensive(complete), accurate, true,
honest, relevant, current (timely ), organized,
compliant with standards.
B.Documentation include
All aspects of nursing process, Plan of care ,
Admission, transfer, transport, and discharge,
 Documentation
Medication administration, Incident report, Patient
education,Verbal orders and telephone orders,
Collaboration with other health care
professionals, Date, time,
signature, title.
C.Types of the patients health records:
1-Traditional (Source oriented client record) it
organized according to the source of information.
2-Problem Oriented Medical Record(POMR):
organized according to the patient's specific
problem.
 Documentation
Common components of a problem
oriented record:
1- Database: contain initial health information.
2. Problem list: contain a number( list) of patients
health problems.
3. Plan of care: identify methods for solving each
health problem.
4. Progress notes: describe the patient's
response to treatment and changes in the
patient's condition.
 Documentation
D. Documentation methods:
1- Narrative charting: used in source oriented
record, involve writing information about the patient
and patient's care in chronological order. It is a time
consuming to write and read. Each health care
person write on a separated form (BULK)
2. SOAP charting : type used in problem oriented
record.
S= subjective.
O= Objective.
A= Analysis of data.
P= Plan of care.
 Documentation
Some agencies extended SOAP to SOAPIER,
focus on pertinent information, each care
given involved in patient care make entries in
the same location.
3. PIE charting: similar to SOAPIER but
assessment documented in a separated form.
4. Charting by exception: limits the amount
of writing to information that is abnormal or
deviates from writing standards ( efficient).
2. Vital signs
Are objective data that indicate how well or poorly
the body is functioning.
( Body temp., pulse rate, resp. rate, and blood
pressure).
Medical terms:
Apnea: period in which there is no breathing.
Bradypnea: slow resp. rate or below average.
Tachypnea: resp. rate that is more rapid than normal.
Dyspnea: difficult or labored breathing.
Cheyne stokes resp. : gradual increase and then
gradual decrease in depth of resp. followed by a
period of apnea.
Vital signs
Hyperventilation: abnormal prolonged rapid and deep
breathing.
Hypoventilation: a condition in which a reduced
amount of air entering the lungs.
The body's temp. regulation center is hypothalamus.
Vital signs normally the lowest at 4- 5 am.
To change body temp. from centigrade to Fahrenheit = C
X 9/5 + 32= F
To change body temp. from Fahrenheit to centigrade = F
- 32X 5/9 = C
The patient is considered to be in danger when his body
temp. reaches beyond 41.0o centigrade ((105.8 F)
Vital signs
Medical terms:
-Febrile:
- Hypothermia: body temp. below normal average.
- Hyperthermia: body temp. above normal average.
- Pyrexia:
Death usually occurs when body temp. fall below 30.0o
centigrade (86.0 F).
The correct term for rapid pulse is tachycardia.
The correct term for irregular pattern of heart beat is
arrhythmia.
The condition in which a person is aware of his own
heart contraction without having to feel the pulse is
palpitation.
Vital signs
The correct term for rapid and weak pulse is thready.
The respiration regulation centre in the brain is
medulla.
The relationship between pulse and respiration is 4-5 : 1.
Pulse pressure : subtract systole reading from diastole
reading.
Pulse deficit: the difference between apical and radial
pulse.
False high B/p reading most likely to occur when B/p cuff
is too narrow.
The lowest reading of B/p while the patient is lying down.
Strong emotions increase B/p such as fear and anxiety.
3. Patient's safety and infection
control
-The first step(action) the nurse must take into
action when an accident occurs is to check the
condition of the involved patient. The last action
is to enter all the information on an accident
report.
A sepsis:
The term used of harmful microorganisms is
pathogen, while the term used to describe
harmless is nonpathogenic.
Aerobic:
Anaerobic:
Port of entry is any break in the skin.
infection control
Other ports for entry of microorganisms into the
human body are (mouth, nose, eye, ear, throat,
rectum, urethra).
Vehicles of transmission are: hands, contaminated
equipments, and instruments.
Soap and detergents are example of antimicrobial.
Antiseptic: chemical agents used to decrease the
growth of microorganisms on living tissues.
Disinfectants: substance that is capable of destroying
or killing microorganisms but not necessary spores.
Infection that the patient acquires in hospitals is called
nosocomial infection.
infection control
The single most effective way to prevent
nosocomial infection is practicing careful hand
washing.
Surgical sepsis means areas and equipments are
free from microorganisms must be protected
from contamination.
The term infection refers to condition in which
microorganisms are presented and the host is
injured.
The primary goal of infection control is to
prevent the spread of infectious microorganisms .
 infection control
Gloves are used as a barrier when an infectious disease is
transmissible by direct contact or contact with blood
or body substances.
Standard precautions are best described as infection
control measures to be used when caring for all
patients in hospital regardless of their infection state.
Wound care:
Types of wounds:
1. Incision : a clean separation of skin and tissues with
smooth even edges.
2. Laceration: a clean separation of skin and tissues in
which edges are torn and irregular.
infection control
3. Abrasion: surface of the skin layers are scraped
away.
4. Avulsion: Stripping away of large area of skin and
underlying tissues leaving cartilage and bone
exposed.
5. Ulceration: Shallow area which skin and mucus
membrane are missing.
6. Puncture: An opening in skin, underlying tissues,
mucus membrane by a narrow,
sharp, and pointed object.
-During the inflammation process which of the
following characteristics occurs first: decrease
function, pain, redness, or swelling.
 infection control
- If dressing seems to be painful give the prescribed
pain medication 15 – 30 minutes before the start of
dressing.
Wound repair:
1.Inflammation: physiologic response that occurs
immediately after tissue injury, lasts about 2-5 days.
2.Regeneration: replacement of damaged cells with
new identical cell during wound healing.
3.Granulation: Pinkish red tissues containing
capillaries projections.
4.Remodeling: wound undergoes changes and
maturation, may last 6 month – 2 years. Wound
contracts and the scar shrinks.
 infection control
The common purposes of dressing of a
wound are:
1. To keep wound clean and restrict entry of
organisms.
2. To absorb drainage.
3. To control edema and bleeding when applied
with pressure.
4. To protect the healing area from further injury.
5. Help to hold antiseptic medication next to the
wound.
 infection control
Wound healing:
First intention: wound edges are directly next
to one another.
Second intention: Widely separated wound
edges must heal inward toward the center.
Third intention: temporarily separated wound
edges are eventually brought together at a
later time.
 Naso-gastric Intubation
Highly concentrated tube feeding can result in
diarrhea.
Lack of fibers in a tube feeding can result in
constipation.
To prevent the blockage of NG tube feeding flush
the tube with water and clamp it after each
feeding.
The process of removing a poisonous substances
through gastric intubation is called lavage.
Feeding tube obstruction may occur if the formula
is administered at rate of less 50 ml/hour.
 Naso-gastric Intubation
Gastric residual: the volume of liquids left in the
stomach after allowing a sufficient time for emptying
to occur.( more than 100 ml.)
A bolus feeding: instillation of a large volume of
liquid nourishment into the stomach in a fairly short
time.
Rapid instillation of liquid nourishment may lead to
nausea and vomiting.
The purposes NG intubation:
1.To administer oral medication if the patient is unable
to swallow.
2. To obtain samples of secretions for diagnostic tests.
 Naso-gastric Intubation
3. Lavage to remove poisonous substances from the
stomach.
4. To remove gas and secretions from stomach and
bowel.
5.To control gastric bleeding.
Methods for determining if NG tube in the
stomach:
1. Aspirate fluids from the stomach( clear, brownish,
yellow ,or green).
2. Auscultation of the abdomen. Instill 10 ml or more of
air.
4. Chest x-ray.
5.Putting NG tube in a glass of water and observe for
bubbling.
Naso-gastric Intubation
Obtaining NEX measurement: put the first mark on the
tube at the measured distant
From the nose to the earlobe( nasal pharynx-tip at the
back of the throat), the second mark at the point where
the tube reach the xiphoid.
Urinary elimination:
Knowledge of medical term related to urinary
system is very important.
Urinary suppression: the kidneys are not forming urine.
Residual urine: Urine retained in the bladder after a
patient voids.
Stress incontinence: increased intra abdominal pressure
causes urine to be released.
Pyuria: pus in the urine.
 Urinary elimination
Urine is formed in the kidneys.
The average adult will desire to empty his/her
bladder when it contain 200 – 300ml of urine.
Average amount of urine produced every 24 hours
by healthy adult is about 1200 ml.
Reasons of urinary catheterization:
1. Keep incontinent patients dry.
2. Relieving bladder distention.
3.Assessing fluids balance accurately.
4.Keep bladder from becoming distended during or
after urinary surgeries.
 Bowel elimination
5.Measuring residual urine.
6.Obtain sterile urine specimen.
7. Instilling medication within the bladder
(chemotherapy).
Bowel elimination:
Constipation: is best described as a condition
in which stool becomes hard, dry, and requires
straining for elimination.
Symptoms of fecal impaction : patient may expel
liquid stool around the impacted mass.
 Bowel elimination
Most measures of relieving fecal impaction is
administration of oil retention enema.
The reason for using digital method is to break
up the fecal mass.
An excess amount of gas within the intestinal
tract is called flatulence. While expelling
the gas is called flatus.
Large percentage of gas in the bowel comes
from a swallowed air.
One is most helpful to relieve intestinal
obstruction is insertion of a rectal tube.
Bowel elimination
Following a large enema defecation occurs within
5-10 minutes.
A repeated tap water enema can results in fluid
imbalance.
Hypertonic enema increase fluid volume in
intestine and by acting as local irritant.
Oil retention enema: lubricate and soften the
stool.
The purposes of rectal enema:
1-Cleanse the lower bowel.
2. Soften stool.
 Bowel elimination
3. Expel flatus.
4. Smoothes irritated mucus membranes.
5.Outline the colon during the diagnostic X-Ray.
6.Treat worms and parasitic infestations.
Medication administration:
1- Oral medication:
Knowledge of usual abbreviations such as tid, qid,
q.od, stat, q.h, q.d, bid,q.6h.
Medication order should never be implemented if
the nurse questions any part of the order.
Medication administration
Most health agencies check narcotic supplies at the
change of each shift by two nurses.
To ensure that medications are prepared and
administered correctly the nurse should use the FIVE
RIGHTS.
The minimum number of times the nurse should check
the label when preparing to give medication is three
times.
The first action to take when a medication error takes
place is to check the patient.
When administering medication via NG tube that is
being used for suction, clamp the tube for at least one
half an hour after instilling medication to allow
for absorption.
Medication administration
-60 mg of a drug is ordered that is supplied in tablets
containing 20 mg per tablet.
How many tablet should administered? Answer 3
tablets.
Topical and inhalant medication.
To ensure good absorption when applying an ointment
is to clean the area with soap and water, and warm
the ointment to body temperature.
When administering ear drops to an adult, the ear
should be gently pulled upward and backward, for
child pull the ear downward and backward.
The term sublingual administration of the drug under
the tongue.
 Medication administration
Parenternal medication.
IM- Dorsogluteal, vastus lateralis, deltoid.
SC- Upper arm, thigh, abdomen, back.
IV- Blood vessels.
Intradermal- inner aspect of the forearm.
The common site for giving IM injections is into
the gluteal maximus is dorsogluteal site.
The common site for giving IM injections into
anterior aspect of the thigh is the rectus femoris.
 Medication administration
The preferred IN injection site for an infant is the
rectus femoris site.
IM injection into deltoid muscle should be limited
to 1ml of solution, while IM injection into
dorsogluteal muscle should be limited to 3-5 ml
of solution.
The angle of SC injection in fat person 1/2 inch
needle with 90o angle. while in thin person 1/2
inch needle with 450 angle.
The angle of syringe and needle for intradermal
injections is 10 – 15 degree.
Medication administration
Needle size for SC injections is usually 25 gauge with
1/2 – 5/8 length.
The primary reason for using Z tract technique is to
seal off the medication in the muscle.
IV medication:
Iv medications are added to a large volume of solution
by the nurse.
An intermittent infusion is one in which IV
medications is given over a short period of time.
Bolus administration of IV medications has the
greatest potentials for causing life threatening
reaction.
Medication administration
To avoid a risk for circulatory overload it would
be appropriate to administer medication using
volume control set.