FUNDAMENTALS OF NURSING

GLADYS BAUTISTA JAIME 2010

HISTORY OF NURSING Intuitive Period Apprentice Period Educated Nursing Period Page Contemporary Period |1 INTUITIVE PERIOD Nursing was untaught and instructive Beliefs and practices i. Nomads ii. Women iii. Black magic/ evil spirits (voodoo) iv. White magic/ shaman/ witch doctors v. Trephining ANCIENT CITIES AND CONTRIBUTIONS I. BABYLONIA Code of Hammurabi (Law affecting medical practice) RA 9173 Phil. Nursing Act of 2001 RA 7164 Old Phil. Nursing Act of 1991 II. EGYPT Art of Embalming (Enhance the knowledge about human anatomy) Recognize 250 diseases III. ISRAEL Moses Father of Sanitation Give laws on communicable disease Ritual circumcision IV. CHINA Materia Medica (pharmacology) Used girl clothes for male babies V. INDIA Intuitive Asepsis SUSHURUTU record of function and responsibility of nurses VI. ANCIENT GREECE Hippocrates Father of Scientific Medicine

VII.

ROME Roman Catholic Fabiola made her home as the first hospital under the Christ Era

APPRENTICE PERIOD 11TH century 1836 On the job training period From the rise of religious orders from secular orders up to the dark period of nursing up to the establishment of the 1st training school. RELIGIOUS ORDERS Knights of St. John ranks and superiority Teutonic Knights tent hospitals Knights of St. Lazarus lepers/leprosy SECULAR ORDERS St. Catherine of Siena Lady with a lamp St. Elizabeth of Hungary Patroness of Nurses Clara Barton Founder of American Red Cross St. Claire founded the 2nd order of St. Francis de Asisi Dark Period of Nursing Religious upheaval led by Martin Luther Theodore Fliedner Establish the 1st training school in Germany Kaiserwerth Institute for the Training of the Deaconesses EDUCATED NURSING PERIOD Florence Nightingale May 12, 1820 in Florence, Italy Crimean War Lady with a lamp St. Thomas School of Nursing Mother of modern nursing

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Notes: on nursing/ on hospital Environmental Theory (first theorist) Lilian Wald Founder of the Public Health Nursing Linda Richards 1st graduate as a nurse in US Initiated the use of white uniforms Use of Nurses Notes and Doctors Order

RESEARCHER development of profession

18 THEORIES AND THEORIST 1) FLORENCE NIGHTINGALE ENVIRONMENTAL THEORY Cleanliness, Light, Air, Water, Diet, Warm, Noise Free, Drainage 2) LYDIA HALL CORE, CARE and CURE Core person (therapeutic use of self/communication) Care body (bed bath, oral care, hygiene) Cure disease (medication, IV Therapy)

Mary Mahoney 1st African American Nurse Lavinia Dock Active in Protest Women has privilege to VOTE Margaret Higgins Sanger Founder of the Planned Parenthood (Family Planning) CONTEMPORARY PERIOD World War II up to the present Scientific and Technological Advancement Computer, Sophisticated Equipment, Disposable Supplies Own Nursing Law (RA 9173) ROLES AND RESPONSIBILITIES OF NURSES CAREGIVER providing care COUNSELOR supporting emotionally CHANGE AGENT modification of lifestyle CLIENTS ADVOCATE protects clients right CASE MANAGER collaborates with other member MANAGER Planning, Organizing, Delegation, Controlling TEACHER health promotion and teaching LEADER attaining goals and objectives

3) VIRGINIA HENDERSON 14 Basic Human Needs Breath normally, Eat and Drink, Eliminate, Move and Maintain Posture, Sleep and Rest, Dress and Undress, Maintain Body Temperature, Keep Clean, Avoid Danger, Communicate, Worship, Work, Play and Learn 4) HILDEGARD PEPLAU Psycho dynamic Theory 4 Phases of Nurse Patient Relationship Orientation problem identification Identification feeling of belongingness, trust, Setting GOALS Exploitation use all resources to resolve problem, IMPLEMENTATION Resolution goals met, TERMINATION Phase 5) DOROTHEA OREM Self-care Deficit Whole Compensatory 100% nurse Partially Compensatory 50-50 nurse-patient

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Supportive-Educative discharge planning and health teaching

STRUCTURAL INTEGRITY physical boundaries of human should be intact (skin and mucus membrane)

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6) MARTHA ROGERS Science of Unitary Human Beings Man is a unified whole inter-related parts 7) IMOGENE KING Goal Attainment Model Transaction (Communication Skills) 8) DOROTHY JOHNSON Behavioral Model 7 SUBSYSTEMS AGGRESSIVE self-protective behavior AFFILIATE security seeking behavior ACHIEVEMENT master of oneself DEPENDENCY nurturance seeking ELIMINATIVE moving out of wastes INGESTIVE taking-in nutrients SEX procreation and satisfaction 9) FAYE GLENN ABDELLAH 21 Nursing Problems Interrogative = ? 10) MADELIENE LEININGER Transcultural Theory Beliefs and Practice = Respect 11) MYRA LEVINE Conservational Model ENERGY Input (Food, O2, Water) = Output = Energy PERSONAL INTEGRITY self-worth/ self-identity SOCIAL INTEGRITY interpersonal needs

12) BETTY NEUMAN Health Care System Model Origins of Stressors INTRA within the person/inside INTER between friends and family EXTRA outside the person 13) SISTER CALLISTA ROY Adaptation Model Process of Adaptation INPUT stressor CONTROL manage physically and emotionally OUTPUT outcome and result FEEDBACK how it affects the next input 14) PATRICIA BENNER Stages of Expertise NOVICE bounded with rules and standards, no experience ADVANCE BEGINNER demonstrate marginally acceptable procedure, real experiences COMPETENT 2-3yrs. experience, consciously plan the care PROFICIENT 3-5yrs. Experience, perceive situation as a whole rather than in parts, HOLISTIC VIEW EXPERT highly fluid and flexible 15) ROSEMARIE RIZZO PARSE Human Becoming Theory 16) IDA JEAN ORLANDO

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Dynamic Nurse Patient Relationship 17) JEAN WATSON Caring Model Page |4 18) ERNESTINE WIEDENBACH Helping Art of Clinical Nursing SMITHS MODEL OF HEALTH Clinical Model Signs/Symptoms Adaptation Model Adapt Role Duties Performance Eudemonistic SelfModel actualization Healthy X Illness X X

Basic Metabolic Rate Activity Thyroxin Output Epinephrine/NorEpinephrine Fever

Conduction Radiation Convection Evaporation

ROUTE X RECTAL AXILLARY ORAL

STAGES OF EXPERTISE SYMPTOM EXPERIENCE subjective ASSUMPTION OF SICK ROLE accept illness and seek advice MEDICAL CARE CONTACT seek advice from professionals, validation and explanation of disease DEPENDENCY ROLE healthcare, passive communication REHABILITATION going back to the pre-illness stage, RECOVERY NURSING PROCESS: ASSESSMENT Vital Signs: TEMPERATURE HYPOTHALAMUS DETERMINED BY METABOLISM

TYMPANIC

THERMOMETER ADVANTAGE NSG.CONSIDERATI ON Most accurate 0.5-1.5 inches Most reliable 1-2 minutes Safest Pat dry before use Non-invasive 5-9 minutes Most 30min rest before convenient 2-3 minutes Most accessible Very fast Prevent puncture of TM Within seconds

N VALUES 37-38.1 35.8-37 36.537.5 36.837.9

Cleaning Before Use: bulb to stem After Use: stem to bulb Pyrexia more than normal temperature Hyperpyrexia more than 41C

TYPES OF FEVER INTERMITTENT fluctuation of temperature bet. normal and abnormal BALANCED BETWEEN HEAT PRODUCTION AND HEAT LOSS REMITTENT fluctuation of temperature but all above normal HEAT PRODUCTION HEAT LOSS RELAPSING fever with 1-2 days of normal temperature THE ROYAL PENTAGON REVIEW SPECIALIST, INC.

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CONSTANT minimal fluctuation, consistently high PULSE

KUSSMAULS deep rapid labored breathing BIOTS very shallow with apnea Sounds: STRIDOR harsh, shrill sound on inspiration - Laryngeal obstruction STRETOR snoring sound on expiration - Obstructed or narrowed airway WHEEZE squeaky musical sound on expiration - Narrow or constricted bronchus BUBBLING gurgling sound, air passing through secretions - Heard both on inspiration and expiration Volumes: TIDAL VOLUME inhalation and exhalation INSPIRATORY RESERVED VOLUME maximum air that can be inhaled after normal breathing EXPIRATORY RESERVED VOLUME - maximum air that can be exhaled after normal breathing RESIDUAL VOLUME remaining in the lungs TOTAL LUNG CAPACITY (T I E R) CHEST INDRAWING retraction Suprasternal above the clavicle Subcostal below the breast bone Intercostal between the ribs BLOOD PRESSURE Normal Value: Systole = 100-140 Diastole = 60-90 Nursing Consideration: Rested = 30minutes Position: at the level of heart and supported - Above = false low - Below = false high Palpatory BP (+30mmHg) Bell low pitch sound (Korotkoff)

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Autonomic Nervous System Pulse Sites: Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior Tibia, Dorsalis Pedis PULSE RATE: 1 month 80-180 1 year 80-140 2 years 80-130 6 years 80-120 Adult 60-100 PULSE FORCE 3 Full Bounding 2 Normal 1 Weak Thready Pulse 0 No Pulse PULSE Pressure (Systole-Diastole=PP) N= 30-40mmHg PULSE Deficit (Apical-Peripheral Pulse) RESPIRATION Medulla PONS Pneumotaxics Center (rhythmic) - Apneustic Center (deep prolonged respiration) - Aortic and Carotid Bodies Rate: APNEA cessation of breathing ORTHOPNEA inability to breathe except in upright EUPNEA normal breathing TACHYPNEA increased respiratory rate BRADYPNEA decreased respiratory rate

Rhythm: CHEYNES STOKE very deep to very shallow then apnea THE ROYAL PENTAGON REVIEW SPECIALIST, INC.

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BP Cuff Too narrow = false high - Too wide = false low Inflate 2-3mmHg at a time Too slow = false high - Too fast = false low Meniscus lower, at the level of eye to prevent ERROR OF PARALLAX Popliteal Pulse 10-40mmHg higher than the brachial artery

Wheal irregular shape, insect bite Vesicle - <.5cm (early chicken pox) Bullae - >.5cm (blister, sign of herpes) Pustule- pus HAIR Thickness/Thinness normal = thick Infection and Infestation Amount of Hair Texture of Hair Growth of Hair

PHYSICAL EXAMINATION Skin, Hair, Nails color and lesion Pale Pallor Blue Cyanosis Yellow Jaundice Red Erythema Virtiligo Patches or hypopigmented skin Lesion: FLAT non palpable Macule <1cm - Patch >1cm CIRCUMSIDE elevated form by solid mass (papule, plaque, nodule, tumor) C/E formed by free fluid Loose of Skin Surface - Erosion (epidermis, without scar) - Ulcer (epidermis, dermis, subcutaneous with scar) - Fissures (linear crack with sharp edges) Papule - <1cm (warts, acne) Plaque coalescence of papule (psoriasis) Nodule 0.5-2cm (squamous and carcinoma) Tumor - >2cm

NAILS Normal Angle = 160 angle Flat = 180angle indication of early clubbing - Long term lack of oxygen Capillary Refill Test Blanch Test - Pedia = >2seconds - IMCI = more than 3seconds - Funda = 4seconds EYES Darken the room (dilate) Pupils PERRLA Size 3-7mm Miosis constricted Mydriasis dilated Anisocona unequal Visual Acuity Snellens Chart - Normal = 20/20 - 20/200 = legal blindness Myopia near = concave Hyperopia far = convex Presbyopia loss of elasticity of lens caused by aging Astigmatism uneven curvature of the cornea EARS 4 years old up and back

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3 years old above up and back 3 years old below down and back WEBERS TEST bone conduction, lateralization of sounds - Bad Bone Conduction = conductive hearing loss - Good = sensory neural hearing loss RINNES TEST conductive hearing loss

THORAX Shape oval, elliptical (adult), equal or cylindrical (infant) Spinal Alignment Sound percussion ABDOMEN Palpation void first Dorsal Recumbent supine with knees flexed to relaxed abdominal muscle Warm hands during palpation rub Slow approach Indusperpal prevent the distortion of abdominal sounds LABORATORY EXAMS URINE routine urinalysis - 24hour urine specimen - Catheterization STOOL routine fecalysis - Guiac Stool Exam SPUTUM AFB - Blood specimen URINE Routine urinalysis - First thing in the morning - First voided (collect) - First flow is discarded (midstream catch) - Perineal Care first - Send to laboratory (ideal: add preservatives as protocol of agency) Collect 30-50ml Culture and Sensitivity 5-10ml

24hours urine specimen - First void discard - Collect with same container Catheterization - Dos: clamp below the cord (30-60mins) - Sterile syringe inserted diagonally (self-sealing) - Donts: do not collect from bag Acetic Acid Test protein - Do not heat could explode - (+) cloudiness of solution BENEDICTS TEST glucose Result Blue (-) - Green (+) - Yellow (++) - Orange (+++) - Red (++++)

STOOL Routine fecalysis - 1inch or 2.5cm/tsp - 15-30ml liquid stool (diarrhea) Guiac Stool Exam - Occult blood exam - Dont give dark color foods (red meat, Iron Supplement) - Avoid turnips and radishes False Positive for 3days False Negative vit.C 250mg/day for 3days SPINAL ALIGNMENT Lordosis lumbar region is affected Kyphosis thoracic region is affected - Best position when assessing: standing straight Scoliosis lateral deviation of spine - Best position: bending forward in 90angle SOUNDS Bronchial high pitch sound; hear over the trachea

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Page | 8 PERCUSSION Dull liver and heart Flat bones and muscles Resonance normal lung sound Hyper resonance - hyper inflated lung Tympany stomach Thorax Normal Resonance - If dull; solidation of lung tissue - Patient with Pneumonia, Emphysema and Asthma ACID FAST BACILLI Early AM collection No toothbrush, mouthwash and food Plain water only BLOOD SPECIMEN FASTING BUN = triglyceride - CREATININE = serum lipid amylase indicative for kidney function NON-FASTING CBC, Hemoglobin, Hematocrit, Serum Electrolytes, Clotting Studies BASIC NURSING SKILLS SUCTIONING POSITION Conscious: semi-fowlers - Unconscious: Side-lying or lateral to prevent aspiration PRESSURE AGE WALT PORTABLE Adult 120-100mmHg 15-10 Child 110-95mmHg 10-5 Infant 95-50mmHg 5-2 LENGTH nose to earlobe (13cm or 5inches)

Bronchovesicular moderate pitch sound; hear over main bronchi Vesicular low pitch sound; heard over the lung fields Use diaphragm for high pitch sound

Lubricant - Nasopharyngeal water soluble lubricant (KY Jelly) - Oropharyngeal sterile water TIME 5-10seconds (15sec. maximum) with 20sec. interval - 30 seconds for hyper oxygenation TECHNIQUE Never apply suction during the insertion - Apply only during withdrawal; intermittent suctioning (on&off) SIZES - Adult = 18-12 French - Children = 10-8 French - Infant = 8-5 French OXYGENATION Support combustion - No smoking - No faulty electrical devices - No friction - No wool fabrics Emergency: nurse can give 2-3liters/min. (independent) Carbon dioxide major stimuli for respiration TYPES CONCENTRATION LITERS PER MINUTE Nasal Cannula 24-45 2-6 Simple Face Mask 40-60 5-8 Partial 60-90 6-10 Rebreather 95-100 10-15 Non Rebreather 24-40-50 4-10 Venturi Mask

CATHETERIZATION Straight catheterization common Indwelling 5-10ml, inflate balloon, sterile balloon SIZES - Male: 18-16 French - Female: 14-12 French LENGTH - Male: 6-9 inches - Female: 3-4 inches THE ROYAL PENTAGON REVIEW SPECIALIST, INC.

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POSITION - Male: supine with legs slightly abducted - Female: dorsal recumbent with knees flexed LUBRICANT water soluble lubricant LOCATION - Male- tip of glands penis - Female: urethral meatus between clitoris and vagina ANCHOR - Male: lower abdomen - Female: inner aspect of thigh

- Infant: 12 French LENGTH - Lubricate: 2 inches or 5cm - Insert: 3 inches or 7cm POSITION - A: left lateral position to follow the contour - C: dorsal recumbent

NASOGASTRIC TUBE (NGT) For feeding - Gavage For irrigation Lavage Decompression preparation for surgery POSITION Feeding: high-fowlers for 30minutes LENGTH Nose Earlobe Xiphoid (50cm or 20inches) PLACEMENTS Air: aseptosyringe/stethoscope LUQwhooshing sound - Aspirate: color = greenish or yellowish - pH: Acid = <6 - Lithmus Paper: Blue to Red - X-Ray: most effective RESIDUAL VOLUME 50ml withhold the fluid (12inches) ENEMA RETENTION Oil, Carminative 12 inches 1-3 hours 105-110F COMPARISON SOLUTION HEIGHT TIME TEMPERATURE NON-RETENTION Plain NSS, Soap Suds 18 inches 5-10 minutes 115-125F

SIZES - Adult: 32-22 French - Children: 18-14 French

MEDICATIONS Traditional Five Rights: - Right Drug - Right Dose - Right Time - Right Patient - Right Route 60mg = 1gram 1tsp = 5ml/cc 1gram = 15 grains 1tbs = 3tsp = 15-30ml 1ml = 15gtts 1 cup = 240ml DRUGS - 3x check the label: - Before removing from shelves - After removing from container - Before returning to the drawer or shelves DOSE Desired Dose/Stock on Hand X Dilution PATIENT check for ID band (safest) TIME - AC = before meals - PC = after meals - PRN = as needed - STAT = immediately - BID = twice a day ROUTE - Oral and Sublingual easy absorbed thru bloodstream - Less expensive, most convenient, safest o Disadvantage remain under the tongue, if swallowed notify the physician. Dissolved by gastric juice o Cause staining of teeth

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o Contraindicated with Nausea and Vomiting Vaccine (Mantoux test) Tuberculin Test - TOPICAL dermatologic Gauge: 25, 26, 27 - Only applied at the thin layer Length: 3/8, 5/8, - Patch (Nitroglycerin Patch) clean, hairless, Degree: 10-15 proximal surface o SUBCUTANEOUS - OPTALMIC Sitting Position or Lying - OINTMENT clean, inner to outer canntus Sites: outer upper arm - Instill at the lower canntus 2drops, wait for 5mins Abdominal (insulin) to absorb Anterior Thigh - Prevent the systemic effect press nasolacrimal Ventro Gluteal and close eyes Dorso Gluteal - OTIC side-lying; use cotton tip applicator for Indications: Insulin, Vaccine, Heparin cleaning Gauge: 25, 26, 27 - Instill: allow to flow to side; to change the temp. of Length: 3/8, 5/8, meds to body temp.; absorption for 5minutes Degree: 0-90 (obese); 45 (thin and average) - INHALATION o INTRAMUSCULAR - Position: semi-fowlers / high fowlers (for full lung Ventro Gluteal best site for adult expansion) Position: Prone - Instill: nebulizer 1-2inches away from the mouth Location: Greater Trochanter Metered dose inhaler hold breath for Dorso Gluteal contraindicated for 3years 10seconds; wait for another minute before giving below another dose Position: Prone Bronchodilator with multiple medications Location: Lateral superior, upper outer Steroid Inhalation oral hygiene; cause oral fungal quadrant infection Vastus Lateralis best site for infant - VAGINAL vaginal suppository, vaginal duche Position: Sitting or Lying - Position: dorsal recumbent, remain free for 5Location: middle third anterior lateral aspect 10minutes of thigh - During irrigation BL with hips higher than the Rectus Femoris same with vastus lateralis (NT shoulders LATERAL) - RECTAL left lateral position/ Sims Position, right Deltoid 0.5-1.5ml leg flexed Position: Sitting - Insert until something has grabbed it away Location: Acromian Process 2-3 finger 20mins absorption breaths below - PARENTERAL Gauge: 20, 21, 22, 23 o INTRADERMAL Length: 1, 1 , 2 Sites: inner lower arm (skin test) Degree: 90 Upper chest and back Beneath the scapula - Z-TRACK Technique Indications: Check for allergy - Used for parenteral IRON preparations THE ROYAL PENTAGON REVIEW SPECIALIST, INC.

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Retract the skin, inject slowly, hold retraction of the skin until needle is withdrawn, do not massage Principles: Use separate needles for aspiration and injection of medication, Introduce air into the vial before aspirating, Introduce needle in quick twist

INTRAVENOUS THERAPHY TYPES OF SOLUTION - ISOTONIC plain NSS(green) , LR(dark blue) , D5W(red) - HYPOTONIC lower concentration; D.45/D.33 (light blue) - HYPERTONIC higher concentration; D5LR(pink), D5NSS(yellow) GAUGE - 16 biggest (gray) - 18 blood transfusion (green) - 20 (pink) - 22 (blue) - 24 pedia (yellow) Points to remember in IVT - Place in the non-dominant hand, distal side (metacarpal) - Select: large vein, easily palpable and naturally splinted by bone - Avoid highly visible, areas of flexion, damage by previous use and surgically compromised Nursing Consideration - Air Embolism (5ml of air) prime to remove air - Change IV site and tubing every 72hours, bottle every 24hours regardless how many cc is remaining - Regulate every 15-30 minutes

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