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FUNDAMENTALS

OF NURSING

Fundamentals of Nursing Practice

SRG Integrals 2nd^ Ed. Fundamentals of Nursing 1

FUNDAMENTALS OF NURSING

I. NURSING

DEFINITION OF NURSING

Henderson - Assisting the individual (sick or well) in the performance of those activities contributing to health, or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge- and in doing so, promote independence as much as possible. Nightingale - is providing the most favorable environment to an individual for nature to act in order to promote reparativeness“ ”and maintenance of health and well being. Watson - is caring Modern definition - a science and an art that focuses on promoting quality of life as determined by persons and families, throughout their life experiences from birth until the end of life. Table 1.0 Definition of Nursing GOALS OF NURSING • Promotion of Health –promoting a healthy lifestyle • Prevention of illness –early detection and treatment • Restoration of health –curing and healing, rehabilitation • Care of the dying –maintaining dignity and peaceful death

SCOPE OF NURSING CARE

• Individual • Families • Communities SRG Integrals 2nd^ Ed. Fundamentals of Nursing 2

the importance of validating the need and evaluating care based on observable outcomes. Myra Levine Views nursing as human interaction: the dependency of individuals on one another. Levine identifies four principles of conservation: (1) conservation of energy, (2) conservation of structural integrity, (3) conservation of personal integrity, and (4) conservationof social integrity Conservation theory Imogene King Presents a theory of goal attainment from an open system conceptual framework that integrates personal systems, interpersonal systems, and social systems. Goal –attainment theory Martha Rogers Rogers developed the principles of homeodynamics, which focus on the wholeness of human beings, the unitary nature of human beings and their environment, and the nature and direction of human and environment change. Science of unitary man THEORISTS THEORY KEYWORD Callista Roy Major emphasis is on the person as an adaptive system. To further describe the client of nursing, the four adaptive modes are identified as physiological, self- concept, role function, and interdependence Adaptation model Betty Neuman Focuses on the whole person and that persons’ reaction to stress. Her model can be used in illness or wellness. Nursings’ major concern is to help the client system attain, maintain, or regain stability Client Systems model Prevention as Intervention Jean Watson Science of caring is built on a framework of seven assumptions and ten carative factors. She emphasizes the interpersonal nature of caring, describes the nurse as a co- participant with the client, and includes the soul as an important consideration. Science of caring Carative factors Rosemarie Rizzo Parse Emphasizes free choice of personal meaning in relating value priorities, concreting of rhythmical pattern in exchange with the environment, and cotranscending in many dimensions as possibilities unfold. Human Becoming theory Madeleine Leininger focuses on the importance of understanding the similarities (universalities) and differences (diversities) of peoples across cultures Transcultural nursing Margaret Newman Health as expanding consciousness. Humans are unitary being in whom disease is a manifestation of the pattern of health. Consciousness is the information capability of the system which is influenced by time, space, Expanding consciousness

and movement and is ever-expanding. Table 1.1 Theoretical Foundations in Nursing

II. HEALTH, WELLNESS and ILLNESS

HEALTH

Nightingale, 1969 Ability of the person to maintain a state of wellness, and using every power an individual possess to the fullest extent WHO 1948 Is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO Ottawa Charter for Health Promotion 1986 ” Is a "resource for everyday life, not the objective of living", and "health is a positive concept emphasizing social and personal resources, as well as physical capacities." Table 2.0 Definitions of Health WELLNESS  Wellness is generally used to mean a healthy balance of the mind-body and spirit that results in an overall feeling of well-being  It is the physical state of good health as well as the mental ability to enjoy and appreciate being healthy and fit. MODELS OF HEALTH AND WELLNESS  CLINICAL MODEL –health is viewed as absence of signs and symptoms  ADAPTIVE MODEL –a person is healthy if he/she can adapt to the different stressors of life.  ROLE PERFORMANCE MODEL –an individual is healthy if he can satisfy societal roles, or ability to fulfill his/her duty or work  EUDAEMONISTIC MODEL –refers to the actualization of ones potentials Figure 2.0 Maslows Hierarchy of Needs ’ PHYSIOLOGIC NEEDS SAFETY AND SECURITY SELF-ESTEEM LOVE AND BELONGINGNESS SELF-ACTUALIZATION

III. NURSING INFORMATICS

Nursing Informatics

• is the integration of computer, information, and nursing science.  Assists the management and processing of nursing data, information, and knowledge to support nursing practice, education, research, and administration.  is the science of using computer information systems in the practice of nursing. (Kozier et.al) TELE-NURSING - the branch of telehealth that involves actual nursing and client interaction through the medium of information technology. Benefits of Tele-nursing:  Nurses can actually view healing wounds  can access physiological monitoring equipment to measure physical indicators such as vital signs  provide routine assessment and follow-up carewithout the client having to travel to the health care agency for an appointment. E-HEALTH - is a client-centered World Wide Web-based network where clients and health care providers collaborate through ICT mediums to research, seek, manage, deliver, refer, arrange, and consult with others about health related information and concerns LEVEL OF EXPERTISE AND COMPETENCIES IN NURSING INFORMATICS Levels of Expertise:  Beginner, entry or user level - indicates nurses who demonstrate core nursing informatics competencies.  Intermediate or modifier level - indicates nurses who demonstrate intermediate nursing informatics competencies.  Advanced or innovator level of competency - indicates nurses who demonstrate advanced and specialized nursing informatics competencies Competencies:  Technical - are related to the actual psychomotor use of computers and other technological equipment.  Utility - related to the process of using computers and other technological equipment within nursing practice, education, research and administration  Leadership - are related to the ethical and management issues related to using computers and other technological equipment within nursing practice, education, research and administration

PLANNING

 Purpose: To develop an individualized, goal oriented and therapeutic care plan  Stages of planning:

1. Assign priorities to the nursing diagnosis
2. Establish client goals / outcome
3. Select appropriate nursing interventions
4. Document the nursing diagnosis, expected outcomes and interventions.
5. Evaluate the effectiveness of the plan of care S PECIFIC How^ the^ nurse^ will^ know^ the^ clients’^ responsehas^ changed. M EASURABLE What^ the^ client^ will^ do,^ when^ it^ will^ be^ done,and^ to^ what extent. A TTAINABLE Relate^ with^ the^ client^ in^ formulating^ expected outcomes R EALISTIC Includes^ clients’^ health^ capabilities T IMELY Time^ estimate^ for^ outcome^ attainment. IMPLEMENTATION  Purpose: To assist client meet desired goals/outcomes and promote maximum level of functioning  Activities: - Reassessment of Clients and their response to care - Determination of any need for assistance - Implementation of nursing interventions  Types :
6. Independent: nurses are licensed to act related to their knowledge and skills.
7. Interdependent/ Collaborative: carried out by a nurse with collaboration of other healthcare team.
8. Dependent: carried out by a nurse in collaboration with the physician. EVALUATION  Purpose: to determine the effectiveness of the care plan and its corresponding actions whether to continue, terminate, or modify the care plan.  Activities: o Collects and compare data with the outcome o Relate nursing actions to clients’ goals o Conclude problem status  Evaluation may be: 1. Ongoing : done while or immediately after implementing the nursing intervention. 2. Intermittent: performed at specified intervals, such as thrice a week. 3. Terminal : performed to indicate the clients’ condition at the time of discharge.

V. PHYSICAL ASSESSMENT

- is an organized systemic process of collecting objective data based upon a health history and head-to- toe or general systems examination. - It provides the foundation for the nursing care plan in which observations play anintegral part in the assessment, intervention, and evaluation phases. CONSIDERATIONS IN PREPARING A PATIENT FOR A PHYSICAL ASSESSMENT: • Establish a Positive Nurse/Patient Rapport. • Explain the Purpose for the Physical Assessment. • Obtain an Informed, Verbal Consent. • Ensure Confidentiality of All Data. • Provide Privacy From Unnecessary Exposure. • Communicate Special Instructions to the Patient. PURPOSES FOR PERFORMING A PHYSICAL EXAMINATION: • To determine the patient's physiological function. • To arrive at a tentative diagnosis when there is a health problem or disease. Provides data for planning intervention • To confirm a diagnosis of disease or dysfunction. • To evaluate the effectiveness of prescribed medical treatment and therapy. EQUIPMENT AND SUPPLIES USED FOR PHYSICAL EXAMINATION: 1 .Aromatic substances - Test functioning of first cranial nerve (olfactory) (ex. vanilla, coffee) 2 .Cotton balls - Assess sensory system for light touch 3 .Gloves —reduce risk for transmission of microorganism

4. Laryngeal mirror - Metal instrument with mirror to inspect pharynx and oral cavity
5. Ophthalmoscope - Lighted instrument attached to a battery tube to visualize the eyes’ interior
6. Otoscope - Special ear speculum that attaches to an ophthalmoscope to visualize external and middle ear (eardrum)
7. Penlight / Flashlight to test pupillary reaction to light and third, fourth, and sixth cranial nerves (oculomotor, trochlear, and abducens)
8. Percussion hammer - Instrument with rubber head to test reflexes
9. Safety pin - Disposable sharp object to assess pain, sensory system
10. Tape measure - Calibrated in cm to measure circumference
11. Tongue depressor - Wooden tongue blade to inspect oral cavity and stimulate gag reflex to assess ninth and tenth (glossopharyngeal and vagus) cranial nerves
12. Tuning fork - Metal fork that vibrates when tapped and is used to perform Rinne test to assess eighth (acoustic) cranial nerve
13. Lubricant - Facilitates insertion of instruments into body cavities
14. Drape - Covers exposed body parts

HEALTH HISTORY:

• Biographic information • Chief complaint • Present health status • Health history • Family history • Psychosocial factors • Nutrition History of Present illness includes : • Statement of general health before illness • Date of onset • Characteristics at onset • Severity of symptoms • Course since onset • Associated signs and symptoms • Aggravating or relieving factors • Effect on activities • Treatments tried and results Past Health History –any diseases and illness experienced in the past which includes childhood illnesses and immunization status, any recent surgeries, admission, or recurrent illnesses. Family Health History –any hereditary condition which makes the client susceptible of developing a disease.

VITAL SIGNS

• Also called Cardinal signs PURPOSE  To obtain baseline measurement of the patients’ vital signs  To assess patients’ response to treatment or medication  To monitor patients’ condition after invasive procedures REFERS TO THE MEASUREMENT OF TPR BP “ – ”  Temperature  Pulse Rate  Respiratory Rate  Blood Pressure GENERAL EQUIPMENT NEEDED:  oral thermometer (Slim tip)  rectal thermometer (stubby, pear-shaped tip)  Electronic thermometer : Battery-powered display unit with a sensitive probe(blue for oral and red for rectal) covered with a disposable plastic sheath for individual use  Alcohol swab  Stethoscope  Watch with second hand  Sphygmomanometer with proper cuff size Age Temperature( ° C) Pulse Respiratory Cycles/min BP (mmHg) Newborn 36. 8 80 – 180 30 – 80 73 / 55 1 Year 36. 8 80 – 140 20 – 40 90 / 55 5 – 8 years old 37 75 – 120 15 – 25 95 / 57 10 years old 37 50 – 90 15 – 25 102 / 62 Teen 37 50 – 90 15 – 20 120/ Adult 37 60 - 100 12 – 20 120/ Elderly 37 60 - 100 15 – 20 130/ Table 5.1 Variations in Vital Signs by Age

TYPES of TEMPERATURE A. Core Temperature  Measured thru tympanic and rectal routes B. Surface Temperature  Measured thru oral and axillary routes, skin patch or temperature –sensitive tape ALTERATIONS IN BODY TEMPERATURE: 1.Pyrexia- temperature above the usual range. (hyperthermia)  Above 40°C –hyperpyrexia 2.Fever  Intermittent - fluctuation of body temp. at regular intervals between periods of fever and periods of  normal or subnormal Temperature  Remittent- fluctuations above Normal of more than 2 °C  Relapsing –a fever that subsides and after few days returns.  Constant –a fever with minimal temperature fluctuations

3. Hypothermia –a body temperature of 35 degrees Celsius or lower resulting from cold weather exposure or artificial induction 4. Frostbite –freezing of the bodys’ surface areas (earlobes, fingers, and toes) in extremely low temperatures 5. Heat Stroke - a critical increase in body temperature ( 41 degree Celsius to 44 degree Celsius) resulting from exposure to high environmental temperature **ROUTES FOR ASSESSING BODY TEMPERATURE:

1. Oral** –accessible and convenient • Contraindications:  Infants and very young children  Patients with oral surgery  Unconscious or irrational patients  Seizure-prone patients  Mouth breathers and pts. with oxygen 2. Axilla - safest and non invasive  Least accurate 3. Rectal – most reliable measurement • Contraindications:  Rectal abnormalities  Diarrhea  Certain heart conditions  Immunosuppressed 4. Tympanic –accessible, less invasive • Contraindications:  Presence of ear ache  Significant ear drainage  Scarred tympanic membrane PULSE Conversion:  Fahrenheit to Celsius °C= (°F-32) x 5/  Celsius to Fahrenheit °F= (°C x 9/5) + 32

•Wave of blood created by contraction of the left ventricle of the heart. SITES

1. Temporal –accessible; used routinely for infants and when radial pulse is not accessible 2. Carotid - used routinely for infants and during shock or cardiac arrest when other peripheral pulses are too weak to palpate ; used to assess for cranial circulation 3. Apical –used to auscultate heart sounds and assess apical - radial pulse o ( Pulse deficit = Apical pulse –radial pulse; taken simultaneously) 4. Femoral –assess circulation to the legs and during cardiac arrest 5. Brachial –used in cardiac arrest of infants and used to asses for lower arm circulation and to auscultate for BP 6. Radial –used routinely to assess for character of peripheral pulses in adults 7. Popliteal –used to assess circulation to the legs and to auscultate leg blood pressure 8. Posterior Tibial –used to assess circulation to the feet 9. Dorsalis Pedis - used to assess circulation to the feet CHARACTERISTICS OF PULSE: • Rate –number of beats per minute; assess this by compressing an artery with the pads of three fingers.  A client in pain will have elevated pulse; an athlete may have lower  Bradycardia: a pulse that is below normal rate.  Tachycardia: a pulse that is above normal rate.

• Rhythm –pattern or regularity of beats and interval between each beat.  Pulse rhythm is the spacing of the heartbeats.  When the intervals between the beats are the same, the pulse is described as normal or regular.  When the pulse skips a beat occasionally, it is described as intermittent or irregular • Volume/amplitude –amount of blood pumped with each heartbeat.  Pulse volume describes the force with which the heart beats.  Factors affecting pulse volume: o the volume of blood in the arteries, o the strength of the heart contractions o the elasticity of the blood vessels • Cardiac Output 5-6 – Liters of blood is forced out of the left ventricle per minute • Measuring Radial Pulse:

1. Inform client of the site at which you will measure the pulse rate
2. Flex clients’ elbow and place lower part of arm across chest.
3. Place your index and middle finger on inner aspect of clients’ wrist over the radial artery and apply light but firm pressure until pulse is palpated
4. Count pulse rate by using second hand on a watch:  For a regular rhythm, count number of beats for 30 seconds and multiply by 2.  For an irregular rhythm, count number of beats for a full minute, noting number of irregular beats.  When counting for the first time, count for a full minute • Measuring Apical Pulse: NURSING ALERT: Pulse Force/ Pulse Volume Grading: +3: bounding pulse +2: normal +1: thready pulse, weak or difficult to feel 0: absent pulse

A. Kussmauls ’ - Faster and deeper respiration without pauses in between panting B. Apneustic - Prolonged grasping breathing followed by extremely short inefficient exhalation C. Dyspnea - difficulty of breathing D. Orthopnea -DOB unless patient is sitting; can breathe only when in an upright position. E. Cheyne-Stokes - is the term for cycles of breathing characterized by deep, rapid breaths for about 30 seconds, followed by absence of respirations for 10 to 30 seconds.

• It usually precedes death in cerebral hemorrhage, uremia, or heart disease. F. Wheezing - narrowing of airways, causing whistling or sighing sounds G. Stridor - high-pitched sounds heard on inspiration with laryngeal obstruction H. Crackles/ Rales - sound caused by air passing thru fluid or mucus in the airways usually heard on inhalation I. Gurgles/ Rhonchi - sound caused by air passing thru airways narrowed by fluids, edema, muscle spasm usually heard during exhalation ; course , dry, wheezy or whistling sound Table 5.4 Breathing Pattern and Sounds BLOOD PRESSURE • Pressure exerted by blood to the blood vessel wall • SYSTOLIC - ventricular contraction • DIASTOLIC - Ventricular relaxation • AVERAGE: 120/80 mmHg DETERMINANTS: • Pumping action of the heart • Peripheral vascular resistance • Blood volume • Blood viscosity TECHNIQUES • The direct method (CVP) • The indirect method (sphygmomanometer and stethoscope) • Common site : brachial artery • Contraindications for brachial artery: o Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal dialysis o Surgery involving the breast, axilla, shoulder, arm, or hand o Injury or disease to the shoulder, arm, or hand, such as trauma, burns, or application of a cast or bandage FACTORS AFFECTING BLOOD PRESSURE

• Age - Children normally have lower blood pressure at birth (80/60), which gradually increases until the age of 18 when it becomes equal to the normal adult pressure. Older adults frequently have higher blood pressure due to a decrease in blood vessel elasticity. • Sex - Men • Body Built - Obese • Exercise - Muscular exertion temporary • Pain - Physical discomfort • Emotional Status - Fear, worry, or excitement • Disease States and Medication -Some disease conditions and/or the medications influence the blood pressure. POINTS TO REMEMBER WHEN ASSESSING BLOOD PRESSURE • Select an appropriate cuff size. • Wrap the blood pressure cuff on the arm 1 inch above clients’ brachial pulsation. • Position arm at heart level, extend elbow with palm turned upward. • Palpate brachial artery, turn valve clockwise to close and compress bulb to inflate cuff to 30 mm Hg above point where palpated pulse disappears, then slowly release valve (deflating cuff), noting reading when pulse is felt again. • Place bell piece over brachial artery below the level of the chest • With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff until manometer registers 30 mm Hg above diminished pulse point identified • Slowly turn valve counterclockwise so that mercury falls at a rate of 23 – mm Hg per second. Listen for five phases of Korotkoffs’ sounds while noting manometer reading:

1. A faint, clear tapping sound appears and increases in intensity (phase I). –Systolic pressure
2. Swishing sound (phase II).
3. Intense sound (phase III).
4. Abrupt, distinctive muffled sounds (phase IV).
5. Sound disappears (phase V) –Diastolic Pressure • Deflate cuff and wait for 2 minutes if reassessment is needed CONDITIONS RELATED TO BLOOD PRESSURE A. Hypotension refers to a systolic blood pressure less than 90 mmHg or 20 to 30 mm Hg below the clients ’ normal systolic pressure. CAUSES: • Decreased blood volume (e.g., hemorrhage) • Decreased cardiac output (e.g., myocardial infarction [heart attack]) • Decreased peripheral vascular resistance (vascular dilation) (e.g., shock) • Orthostatic hypotension (postural hypotension) refers to a sudden drop of 25 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the client moves from a lying to a sitting or a sitting to a standing position. Orthostatic hypotension usually occurs with aging and is a common antiadrenergic side effect of several medications, such as chlorpromazine hydrochloride. B. Hypertension refers to a persistent systolic pressure greater than 135 to 140 mm Hg and a diastolic pressure greater than 90 mm Hg. DIAGNOSIS of hypertension is based on the average of two or more readings taken at each of two or more visits after an initial screening. FAULTY TECHNIQUES that constrict blood flow will produce a false high pressure reading: