CLIENT CARE
ASEPSIS
SAFETY
HYGIENE
MEDICATIONS
SKIN INTEGRITY
TERMINAL CARE
Outline of review for the boards
HEATH PROMOTION AND DISEASE
PREVENTION
ACTIVITY and EXERCISE
REST and SLEEP
PAIN management
NUTRITION
FECAL ELIMINATION
URINARY ELIMINATION
OXYGENATION
CIRCULATION
Fluids and Electrolytes
History of Nursing
Intuitive Nursing
Apprentice Nursing
Dark Period of Nursing
Educated Nursing
Contemporary Nursing
History of Nursing
Intuitive Nursing
Primitive and untaught
Code of HAMMURABI
Moses- Father of Sanitation
Hippocrates- Developed standards for client
care, medical standards and need for nurses
History of Nursing
Educated Nursing
Florence Nightingale- born May 12, 1820
in Florence ITALY
Trained: Germany at Kaiserswerth School
Founded the St. Thomas School of Nursing
in England
Teachers are devoted clinical instructors solely
for teaching
The first nurse to exert political pressure on
government
Nursing in the PHILIPPINES
ENVIRONMENTAL THEORY
Relate nature with the bird- Nightingale
„The act of utilizing the environment of
the patient to assist him in his recovery‟
Theories in Nursing
INTER-PERSONAL RELATIONS Model
Remember “ PEP” talk
Hildegard PEPLAU
Therapeutic relationship:
Orientation= assist client to
“understand” problem
Identification= Client dependence, inde and
inter he recognizes his problems in this phase
Exploitation/Exploration= Derives “full
value” ini-exploit!!
Resolution= old and new goals put aside
Theories in Nursing
Nature of Nursing- Definition of Nursing
The meaning of Nursing is “VIRGIN”
Recall the 14 needs!!!!!
Associate 14 virgin HENS
Virginia HENDERSON
She believes that clients need to express their
21 nursing problems
“Faid 21”
Faye Abdellah
Theories in Nursing
GENERAL THEORY OF NURSING-
SELF- CARE
Associate “Self care “ to “ORAL care” or
“per orem”
Dorothea OREM
1. WHOLLY compensatory= unable to
control
2. PARTLY compensatory= unable to
perform SOME self care
3. SUPPORTIVE- EDUCATIVE= who
needs to learn and needs assistance
Theories in Nursing
BEHAVIORAL SYSTEM MODEL
Associate behavior with John (in
John and Marsha)
“kaya JOHN(son) magsumikap ka “
Dorothy Johnson
Theories in Nursing
Conservation Theory
“the Divine is Conservative”
“Levin” – levine, divine
Theories in Nursing
GOAL ATTAINMENT
Recall that the KING of the land has a
GOAL to attain for his kingdom
IMOGENE KING!
Her theory is applicable to the child
bearing women and their families
Theories in Nursing
UNITARY BEING: Man as
the CENTRAL Focus
“Roger , Roger, let us unite our Man
in the center of the battlefield”
The whole is greater than its parts
Martha ROGERS
She believes in the use of
the principles of NON
CONTACT therapeutic touch
Theories in Nursing
HEALTH CARE SYSTEMS model
Betty NEUMAN
Stresses, reactions to stress
and adaptation to stressors
After overcoming the stresses you
will become a “NEW- Man”
Intrapersonal stressor= illness
Extrapersonal stressors= financial
concerns, community resources
Interpersonal stressor= unrealistic
role expectations
Theories in Nursing
ADAPTATION MODEL
Individual is a BIOPSYCHOSOCIAL
ADAPTIVE system with input and
output
“associate this with a Nun”
SISTER ROY= nag a adopt ng mga
bata
Her theory supports the unity
between the client and God
Theories in Nursing
CULTURAL CARE DIVERSITY
Transcultural Nursing
Madeleine LEININGER
Theories in Nursing
DYNAMIC NURSE-PATIENT
Relationship
Associate dynamic action to the
team of ORLANDO
Ida Jean ORLANDO!!!
Go Orlando, the dynamic team!!!!!
Theories in Nursing
HUMAN BECOMING THEORY
Remember to become a „rose‟ per se
, you must be a bud first!!!!!!!!!!!!
Rosemarie Parse
Her theory emphasizes that clients are
the AUTHORITY figures and decision
makers for their personal health
Theories in Nursing
WHO, 1948
Wellness
State of well-being
Seven Components- “seven wishing
WELL”
Physical= carry out task
Social= interact with people
Emotional= express feelings
Intellectual= learn and use info
Spiritual= belief in supernatural
Occupational= leisure and work
Environmental= standard of living
in community
Health Theories
CLINICAL
Health is absence of disease
ROLE PERFORMANCE
Health is ability to fulfill
societal functions
ADAPTIVE
Heath is a creative process
of adaptation
Health Theories
EUDEMONISTIC
Health is a condition of self-actualization
ECOLOGIC
Health is interaction of three elements:
1. Agent
2. Host
3. Environment
Health Theories
Dunn
“doon, dito, dine and dire”
Four quadrants
HIGH level Wellness is functioning at the BEST
possible level
Illness and Disease
DISEASE
Alteration in body functions
ILLNESS
A state of physical, social, emotional,
intellectual, developmental or spiritual
functioning is DIMINISHED
Stages of Illness: S-A-M-D-R
SYMPTOM experiences
Client believe something is wrong
ASSUMPTION of the sick role
Excuse form work and family role
MEDICAL care contact
DEPENDENT CLIENT role
RECOVERY or REHABILITATION
Abraham Maslow’s Hierarchy of needs
Physiologic needs- oxygen, water, food
Safety and security
Love and belonginess
Self esteem
Self actualization
Abraham Maslow’s Hierarchy of needs
Safety and security
Physical safety
Psychological safety
Shelter from harm
Abraham Maslow’s Hierarchy of needs
Love and belonginess
Need to love
Need to belong
Need for affection
Abraham Maslow’s Hierarchy of needs
Self esteem
Self-worth
Self-identity
Self-respect
Self-image
Abraham Maslow’s Hierarchy of needs
Self actualization
Self-fulfillment
Spiritual fulfillment
Man and His needs
Self-
Actualization
Self-Esteem
Physiologic Needs
Man’s Need
Need is something desirable and
useful
Needs are UNIVERSAL
Needs are MET in different WAYS
Needs are influenced by different
FACTORS
Priorities may be CHANGED
Needs may be POSTPONED
Needs are INTER-RELATED
Man’s Need
Nursing goal is this area is to:
Meet the PHYSIOLOGICAL needs of the
patient
Assess the patient's perception of
his other needs
Employ nursing Interventions according to
the PERCEIVED NEEDS of the patient NOT
of the nurse
Evaluation Parameters of nursing care
(Udan)
A self-actualized person is basically a
MENTALLY healthy person
And self-actualization is the essence of
mental Health
Cultural care nursing
STRESS
A condition in which the person responds to
changes in the normal balanced state
Selye: non specific response of the body to any
kind of demand made upon it
STRESSOR
Any event or stimulus that causes an individual to
experience stress
Stress and Adaptation
SOURCES OF STRESS
1. Internal
2. External
3. Developmental
4. Situational
Stress and Adaptation
Physiological indicators of stress:
Sympathetic response
Dilated pupils
Diaphoresis
Tachycardia, tachypnea, HYPERTENSION,
increased blood flow to the muscles
Increased blood clotting
Bronchodilation
Skin pallor
Water retention, Sodium retention
Oliguria
Dry mouth, decrease peristalsis
Hyperglycemia
Stress and Adaptation
T
P
R
BP
TEMPERATURE
Pulse pressure:
Systolic pressure MINUS diastolic pressure
Pulse deficit
Apical pulse MINUS peripheral pulse
Pulsus paradoxus
Systolic pressure falls by more than 15
mmHg during INHALATION
Pulsus alternans
Alternating strong and weak pulses
Liquid Diet Vs Soft diet
Clear liquid Full liquid Soft diet
Coffee Clear liquid All CL and FL
Tea PLUS: plus:
Carbonated Milk/Milk prod Meat
drink Vegetable Vegetables
Bouillon juices Fruits
Clear fruit juice Cream, butter Breads and
Popsicle Yogurt cereals
Gelatin Puddings Pureed foods
Hard candy Custard
Ice cream and
sherbet
Food Guide pyramid
Bread, cereals, rice and pasta= 6-11 servings
Fruit and vegetables
Meat, poultry, fish, dry beans, eggs
Milk, yogurt, cheese
Fats, oils and sweets
Primary Prevention Health promotion and
Specific protection
1. ENCOURAGING MEDICAL
CONSULTATIONS AND DENTAL CHECK-
UPS
Levels of Prevention
1. ENCOURAGING MEDICAL
CONSULTATIONS AND DENTAL
CHECK-UPS
Secondary Prevention
Levels of Prevention
Secondary Prevention
Levels of Prevention
primary prevention
Levels of Prevention
Tertiary prevention
DIAGNOSTIC
EXAMINATIONS
PATIENT PREPARATION
POST TEST RESPOSIBILITIES
SPECIMEN COLLECTION
Urine
Clean-catch urine specimen
For routine urinalysis and culture and sensitivity test
Perineal care before collection
The best time to collect the specimen is early in
the morning (first voided-specimen)
Amount needed: 30-50 cc for urinalysis; 5-10 ml for
culture and sensitivity test
24 Hours urine Specimen
discard the first voided urine
Soak specimen in a container of ice
Add preservative as ordered and indicate in the
label the type of preservative added.
Second voided Urine Specimen
Ask the patient to urinate and discard the first
urine specimen and offer a glass of water
afterwards
After few minutes, ask the client to void again and
collect the specimen
Catheterize Urine Specimen
Clamp the catheter for 45 mins
Practice aseptic technique
Do not collect specimen from the urine bag
Obtain 3-5 ml of specimen for culture and
sensitivity test and 10-15 ml for urinalysis
Stool Specimen
Routine Fecalysis
Use to assess gross appearance, and presence of ova
site
Apply firm pressure at the puncture site for 5-10
minutes
Specimen should be placed in iced-container
Assess for metabolic alkalosis for patient with
vomiting, and on the other hand, observe for signs and
symptoms of metabolic acidosis for patients with
diarrhea.
Barium enema
PURPOSE: To assess the large intestines
NURSING
KEYPOINTS:
Provide a Liquid diet before the procedure.
Ensure that a laxative is given before the
procedure to promote better visualization,
and after the procedure to prevent
constipation
Report to the doctor if bowel movement
does not occur in 2 days
Instruct the patient to increase fluids and
eat foods rich in fiber
The patient should also increase intake
of fluids
Friends and Enemas
What is an ENEMA?
A solution introduced into the rectum and
large intestine for the purposes of:
1. To relieve constipation
2. To relieve flatulence
3. To administer medication
4. To evacuate feces in diagnostics or surgery
Enema types
1. Cleansing Enema= intended to remove
feces to prevent escape during surgery,
for visualization procedure and
constipation
Purposes To
1. Prevent escape of feces during
surgery
2. Prepare intestines for diagnostics
and surgery
3. Remove feces in
constipation/impaction
Enema types
24 hours before the test
Instruct patient to increase fluids and
intake of fiber-rich foods
Cardiac catheterization
PURPOSES: To measure oxygen concentration, saturation,
tension and pressure in various chambers of the heart. To
determine a need for cardiac surgery.
NURSING KEYPOINTS:
Check for informed consent
Assess allergy to iodine
NPO for 6-8 hours before the procedure
Check for distal pulses after the procedure
Check for bleeding at the arterial puncture site and apply
pressure
Keep a 20 lbs sandbag at the bedside as a pressure instrument
if bleeding occurs
Keep the patient flat on bed with the lower
extremities hyperextended for 4-6 hours
Neurovascular assessment must be performed distal to the
catheter insertion site and report any abnormal findings
Catheterization, urinary
PURPOSE: To determine residual urine and obtain sterile specimen. It can
be a straight catheter, suprapubic, indwelling catheter, and external device
catheter.
NURSING ALERT:
Know the necessary facts:
Principles Male Female
Position Supine Dorsal recumbent
Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in.
French number or
Circumference #14- 16 #18
Length of tube to
be inserted 2-3 in. 6-9 in.
Balloon size 5-10 ml. 5-10 ml
(30 ml)Can be used to
achieve hemostasis
of the prostatic area
following prostatectomy
the bladder
The catheter bag should not be allowed to
lie on the floor
Do not allow the drainage spout to touch
the collection receptacle or on the toilet
bowl when draining it
Chest X-RAY
PURPOSE: To detect abnormalities of
the organs in the thoracic area
NURSING KEYPOINTS:
Remove any metallic object before
the procedure
Lead shield for women of childbearing age
Computerized Tomography (CT)
Definition
1. Cross-sectional visualization of the brain determined
by computer analysis of relative tissue density as an
x-ray beam passes through; also known as
computerized axial tomography (CAT) scan
2. Provides valuable information about location and
extent of tumors, infarcted areas, atrophy, and
vascular lesions
3. May be done with or without intravenous injection of
dye for contrast enhancement
Computerized Tomography (CT)
Computerized Tomography (CT)
Computerized Tomography (CT)
Nursing care
1. Explain procedure; inform the client that it will be
necessary to lie still and that the equipment is complex
but will cause no pain or discomfort; infants and
cognitively impaired or anxious clients may need to be
sedated
2. If the facility is small, arrange transportation to a larger
facility that has the required equipment
3. Evaluate for possible allergy to iodine, a component of
the contrast material
4. Withhold food for approximately 4 hours prior to testing;
dye may cause nausea in sensitive patients
5. Remove wigs, clips, and pins prior to the test
6. Evaluate client's response to procedure
NURSING ALERT:
If contrast medium will be used, assess for
any allergy to iodine and instruct the patient to
be on NPO for 4 hours prior to the procedure
spaces (claustrophobia)
on NPO; liquid diet if local anesthesia will be used.
Monitor intake and output.
After: Force fluids as prescribed.
Administer sitz bath for abdominal pain.
Pink-tinged or tea-colored urine is expected.
Notify the doctor if bright red urine or clots occur.
Doppler ultrasound
PURPOSE: Evaluates patency of veins and
arteries in the lower extremities.
NURSING KEYPOINT:
Inform the patient that it is painless.
Doppler UTZ
ECG (Electrocardiogram)
PURPOSE: Records electrical waves of
the heart.
NURSING KEYPOINTS:
Instruct the patient to lie still, breathe
normally during the procedure
the test.
ST segment elevation or T wave inversion,
indicates MI
EEG (Electroencephalogram)
PURPOSES: Records the electrical activity of
the brain, detects intracranial hemorrhage
and tumors
NURSING KEYPOINTS:
Advise the client to shampoo hair before and
after the procedure
If the electrode gel is non removed by
shampooing, the patient may use acetone
Withhold stimulants, antidepressants,
tranquilizers, and anticonvulsants for 24-48
hours prior to the test
Fasting Blood Sugar level
PURPOSE: Detects diabetes mellitus
NURSING KEYPOINTS:
Normal blood sugar level is 80-120 mg/dl
A blood sugar level of more than 140
mg./dl confirms diabetes.
Gastric analysis
PURPOSES: This test is used to detect
ulcers, and to rule-out pernicious anemia.
It may also be done to analyze acidity,
appearance and volume of gastric
secretions
NURSING KEYPOINTS:
In gastric ulcer, HCL is normal,
In duodenal ulcer, HCL is elevated.
Refrigerate gastric samples if NOT tested
within 4 hours.
IVP (Intravenous pyelography)
PURPOSE: Visualization of the urinary tract
NURSING KEYPOINTS:
Check for the consent.
NPO for 8-10 hours before the procedure
Administer laxative to clear bowels before the procedure.
Check for allergy to iodine, seafoods or shellfish before
the procedure since the procedure requires the use of iodine
based dye.
Keep epinephrine at the bedside to counteract possible
allergic reaction. IVP requires the use of a contrast
medium while KUB does not.
Inform the patient about the possible salty taste that may
be experienced during the test.
Increase fluid intake after the procedure to facilitate excretion
of the dye.
KUB
PURPOSE: Determines the size, shape and
position of kidneys, ureters and bladder.
NURSING KEYPOINT:
No special preparation needed.
Liver biopsy
PURPOSE: To determine liver disorders.
NURSING KEYPOINTS:
Check for the consent.
Obtain the result of blood tests before biopsy
since bleeding may occur
Let the patient assume left side or supine
during biopsy
Instruct the patient to inhale, exhale and hold breath
during the insertion of to stabilize position of the liver
and prevent accidental puncture of the diaphragm
Position the patient on the Right side after liver
biopsy with pillows underneath to prevent bleeding
Bedrest for 24 hours after the procedure
Lumbar Puncture
PURPOSE: To withdraw CSF to
determine abnormalities.
NURSING KEYPOINTS:
Before the procedure: empty bladder and bowel.
Position: C-position. (fetal posistion)
During the procedure: needle is inserted between L3
- L4 or L4-L5 to prevent accidental puncture to the
spinal cord since the spinal cord ends at L2.
After: Position the patient flat for 6-12 hours to prevent
spinal headache. Increase fluid intake.
Mammography
PURPOSE: Detects the presence of breast tumor.
NURSING KEYPOINTS:
Instruct the patient not to use deodorant, talcum
powder, lotion, perfume or any ointment on the day of
exam as these may give false-positive result
Let the patient know that her breasts will be
compressed between 2 x-ray plates
Provide teachings related to Self-breast examination
Done 7 days after menstruation
Position: lying down with pillow under the shoulder of
the breast being examined or sitting in front of a
mirror while raising the hands of the side of the breast
being examined.
Mantoux test
PURPOSE: A test to determine exposure to TB
NURSING KEYPOINTS:
A positive test yields an induration of 10 mm. or more for
foreign born children below 4 years old
An induration of 5 mm or more is considered positive in patients
with HIV, with treated TB, and if he has had a direct exposure
TB Patients.
BCG may cause false positive reaction.
Assess for previous history of PTB and report immediately to
the doctor
Result is read after 48-72 hours
MRI (Magnetic Resonance Imaging)
PURPOSE: Provides cross-sectional images of
brain tissues, more detailed than a CT scan.
NURSING KEYPOINTS:
Contraindications:
pregnant women,
obesity (more than 300 lbs.),
claustrophobic patients,
patients with unstable vital signs
patients with metal implants like pacemaker, hip
replacements and jewelries.
Magnetic Resonance Imaging (MRI)
Definition
1. This procedure utilizes magnetism and radio waves
to produce images of cross-sections of the body
2. The MRI machine registers the existence of odd-
numbered atoms in the cross sections of the body,
yielding data about the chemical makeup of the
tissues
3. MRI can produce accurate images of blood vessels,
bone marrow, gray and white brain matter, the spinal
cord, the globe of the eye, the heart, abdominal
structures, and breast tissue, and can monitor blood
velocity
Magnetic Resonance Imaging (MRI)
Nursing care
1. Assess ability to withstand confining surroundings
because client must remain in the tunnel-like machine
for up to 90 minutes; open MRI may be an option for
clients who cannot tolerate closed spaces
2. Instruct client to toilet prior to test, since this will be
impossible during the procedure
3. Advise client to remove jewelry, clothing with metal
fasteners, dentures, hearing aids, and glasses prior to
entering scanner
Magnetic Resonance Imaging (MRI)
malabsorption and blood.
NURSING KEYPOINT:
Avoid aspirin, red meat and vitamin C
three days before the test as these may
give a false positive result.
Tonometry
PURPOSE: Measures intraocular pressure.
NURSING KEYPOPINTS:
Normal reading is 12-21 mm Hg
A reading of 25 mm Hg indicates glaucoma.
Urinalysis
PURPOSE: To assess characteristics of urine.
NURSING KEYPOINTS:
First voided morning sample preferred: 15 ml.
Use clean container
Decreased specific gravity: diabetes insipidus
Increased specific gravity: diabetes mellitus,
dehydration, SIADH
(+) Protein: PIH, nephrotic syndrome.
(+) Glucose: Diabetes mellitus, Infection
Urine Collection
As fresh as possible
Mid stream clean
catch
First morning
specimen best, but for
most purposes
doesn’t make much
difference
Hematuria
Even small amounts of blood are visible
1 part per 1000 is easily seen
Urine collection, 24 hour
PURPOSE: Determines the excretion of substances
from the kidneys, adrenal glands and the stomach.
NURSING KEYPOINT:
Required for ACTH test and schilling‟s test
(B12 absorption),
Discard the first voided urine
Place urine output in a clean container preserved in
ice chest
Thank
You!