THEORETICAL FOUNDATIONS

OF NURSING

Theory – set of concepts to explain a phenomenon

Paradigm – pattern

4 Metaparadigms of Nursing
• Person - Most important because knowing the client
will make your nursing care individualized, holistic,
ethical, and humane.
• Health
• Environment
• Nursing

Concepts of Man
• Man is a biopsychosocial and spiritual being who is
in constant contact with the environment.
• Man is an open system in constant interaction with a
changing environment.
• Man is a unified whole composed of parts, which are
interdependent and interrelated with each other.
• Man is composed of parts, which are greater than and
different from the sum of all his parts.
- Simply saying, you cannot remove 1 system
from man.
• Man is composed of subsystems and suprasystems.
- Subsystem (within)
Example: biological, psychological,
emotional.
- Suprasystem (outside)
Example: Family, community, population
 CONCEPTS OF NURSING 3. Exploitation (accept service of nurse)
4. Resolution
Florence Nightingale
• Act of utilizing the environment of the patient Virginia Henderson
to assist him in his recovery. • 14 Fundamental needs of the person

Sister Callista Roy Faye Abdellah

• Theoretical system of knowledge that • Typology of 21 Nursing problems
prescribes a process of analysis and action • Patient-centered approach
related to the care of the ill person. - The client’s needs are the basis of the
nursing problems
• Self-esteem
• Love and belongingness Martha Rogers
• Safety and Security • Nursing is a humanistic science dedicated to
- Being free from harm or danger the compassionate concern with maintaining and
2 forms: Physical safety (free from promoting health and preventing illness and
physical harm) and Psychological safety caring for and rehabilitating the sick and
(explaining the procedure to the patient) disabled.

• Physiologic (priority) Levels of prevention

- If all the needs are within the Primary – Health promotion and disease
physiologic level High Priority needs – prevention
(life threatening needs) Airway, Secondary – Treatment, curative
Breathing, Circulation Tertiary – Rehabilitation
- Medium priority needs – (Health
threatening needs) Elimination, Dorothea Orem (Self-care and Self-care deficit
Nutrition, Comfort, theory)
- Low Priority needs – (Person’s • Helping or assisting service to persons who are
developmental needs) wholly or partly dependent, when they, their
parents and guardians, or other adults
NURSING THEORISTS responsible for their care are no longer able to
give or supervise their care.
Florence Nightingale
• Environment Theory I.e. – completely assisted, partially assisted, and
• May 12, 1830 – August 13, 1910 self-assisted.
• Environmental sanitation
ANA (American Nurses Association)
Hildegard Peplau • Nursing is the protection, promotion, and
• Psychodynamic Theory of Nursing optimization of health and abilities, prevention
• Interpersonal Process of illness and injury, alleviation of suffering
• Phases of Nurse-patient relationship: through the diagnosis and advocacy in the care
1. Orientation (client seeks) of individuals, families, communities, and
2. Identification (independence, populations (2003).
dependence)
Abraham Maslow’s Hierarchy of needs
• Self-actualization Dorothea Orem
• Self-care and Self-care Deficit Theory
Lydia Hall • Universal self-care requirement
• 3 C’s: (nutrition, oxygenation)
1. Core (therapeutic use of self) – Patient developmental self-care requirement
2. Care (nursing function) – Nurse (developmental tasks)
3. Cure (medical) – Doctor health care deviation self-care requirement
• 3 Nursing systems:
Jean Watson - wholly compensatory
• Human Caring Theory - partially compensatory
• Caring is an innate characteristic of every - supportive-educative compensatory
nurse.
• 10 Carative factors Dorothy Johnson
• Behavioral Systems Theory
Ida Jean Orlando-Pelletier • Man is composed of subsystems and these
• Dynamic Nurse-Patient Relationship Model systems exist in dynamic stability.

• Nursing Process Theory Martha Rogers

- Nursing as a process involved in • Science of Unitary Human Being
interacting with an ill individual to meet • Unitary man is an energy field in constant
an immediate need. interaction with the environment.
• Four Practices Basic to Nursing
- Observation, reporting, recording, and Imogene King
actions • Goal Attainment Theory
• Interacting systems framework
Madeleine Leininger • Nurses purposefully interact with the patient
• Transcultural Theory of Nursing and mutually set the goal, explore, and agree to
means to achieve the goals.
Myra Levine
• 4 Principles of Conservation Betty Neuman
1. Conservation of energy • Total Person Model
2. Conservation of structural integrity of • 3 types of stressors:
the body intra-personal, extra personal, interpersonal
3. Conservation of personal integrity • Primary, secondary, tertiary levels of
4. Conservation of social integrity prevention
• The goal of nursing is to assist individual
Sister Callista Roy families and groups in attaining and maintaining
• Adaptation Model a maximal level of total wellness by purposeful
• Individuals cope through biophysical social interventions.
adaptation
• 4 mode of adaptation Parse
- Role function, interdependence, • Theory of Human Becoming
physiological, self-concept
• emphasizes how individual chose and bear • Presence of Prayer, Open mindedness,
responsibility for patterns of personal health Stimulation, Understanding, Respect,
Relaxation, Empathy
Patricia Benner
• Novice – Expert Theory Mila Delia Llanes
Stage 1: Novice • Conceptual model on Core Competency
Stage 2: Advance beginner Development
Stage 3: Competent (2-3 years)
Stage 4: Proficient (3-5 years) Ma. Irma Bustamante
Stage 5: Expert • The effects of the Nursing Self-Esteem
• Skills acquisition Enhancement (NurSe) Program to the Self-
Esteem of Filipino Abused Women
Joyce Travelbee
• Human to Human Relationship Sr. Letty Kuan
• Retirement and Role Discontinuity
Ernestein Weidenbach
• Clinical Nursing: A Helping Art
St. Elizabeth of Hungary - Patroness of nurses
Nola Pender St. Catherine of Siena – The 1st lady with the
• Health Promotion Model lamp

Clara Barton – Founder of American Red

FILIPINO NURSING THEORISTS Cross

Carmencita Abaquin Fabiola – Wealthy Matron who donated her

• Chairman of Board of Nursing wealth to build a hospital the Christian world
• PREPARE ME intervention
T. Fliedner – Founder of the first organized
• P – presence which in
school of nursing
• RE – reminisce therapy
• P - prayer Rose Nicolet – Helped establish the first school
• Re - relaxation of nursing in the Philippines
• ME – medication
Lilian Wald – Founder of Public Health
Sr. Caroline Agravante Nursing

• The CASAGRA Transformative Leadership HISTORICAL DEVELOPMENT

model OF NURSING
• 5 C’s for Transformational leadership: Intuitive
creative, caring, critical, contemplative, collegial - Practiced during the prehistoric era, nursing
was untaught, rendered by the mothers (by
Carmelita Divinagracia intuition, it is the woman who is more caring).
• COMPOSURE Behavior for wellness - Out of love, sickness caused by black spirits,
• COMpetence based on instinct
- Shamans, spells, rituals
* Trephining – boring a hole into a skull without - 3 months of study from Kaiserswerth
anesthesia to release evil spirits - Developed her own training “Nightingales
System of Nursing Education” which is
* Egyptians – art of embalming, anatomy and implemented in St. Thomas Hospital in London
physiology - Correlate theory and practice, updates,
continuing education, research, self-supporting
* Moses – Father of Sanitation, asepsis, art of
nursing school (separate from hospital)
circumcision
- Changed image of nursing, revolutionized
* China – material medica – book of practice
pharmacology - Professionalized as a nursing
- Notes of Nursing: What it is, What it is not,
* Babylonians – Bill of Rights, Code of Notes on Hospitals
Hammurabi (made by King Hammurabi which - Nursing as a profession is not as old as
include freedom to refuse treatment), medical mankind but nursing as an act itself is.
fee
Contemporary
* India – Shushurutu – list of function of the
- Modern nursing practice
nurse – combination of masseur, caregiver

* Romans – Fabiola – a rich matron who Anastacia Giron-Tupas

contributed her home to serve as first hospital - Grand lady of Philippine Nursing
- Founded PNA (Philippine Nurses Association)
“Apprentice”
- Known as the “on the job training” period, Hilaria Aguinaldo – Development of Red
under the supervision of a more experienced Cross Loreto Tupas – Dean of Florence
person, but yet there is no formal education. Nightingale of Iloilo
- Experienced (through trial and error) nurse Melchora Aquino – Tandang Sora, cared for
teaches new volunteer nurses who usually came wounded soldiers
from religious orders
- Nursing the sick and wounded from the wars HISTORY OF NURSING IN THE
PHILIPPINES
Charles Dickens – novel “Martin Chuzzlewit”
about Sairy Gump and Betsy Prag - First true nursing law (Act 2808)
(exemplification of nurses in the Dark Period of - Board of Examiner for Nurses (BEN)
Nursing) - 1 Doctor and 2 Nurses
- 1920 – First board examination
Pastor Theodore Fliedner (Protestant) – first
- Anna Dulgent – first board exam topnotcher
training school for Nursing, “Deaconess School
of Nursing”, 6 months program at
GN Program (Graduate Nurse) – 1 year
Kaiserswerth,Germany
After World War II, BSN degree for four years
was given by UST (1946). Managerial, teaching
“Educated” and supervision position. Equal to Master’s
Florence Nightingale School of Nursing degree.
- First theory author, first nurse-researcher
- Lady with a Lamp/ Mother of Modern Nursing RA 877 – BEN is composed of BSN
1966 – Master’s degree needed First hospital – Hospital de Real de Manila
RA 6136 – can administer intravenous meds as (1577)
long as physician, violation of professional
autonomy; did not materialize but instead nurse 1578 – San Lazaro Hospital, Intramuros –
prepared medication and doctor administered leprosy and mental illness
until 1992 but it had conflict with the drug Hospital de San Gabriel – Chinese General
administration principle of “administer what you Hospital
prepare”
1960s – 5-year curriculum Aliping sagigilid and aliping namamahay – first
1976 – 4-year curriculum; GN program was volunteer nurses who served as apprentice in the
phased out, practicing GNs must go back to 4th first hospitals
year to earn a BSN degree but they won’t take
board exam anymore since they are already 1878 – Escuela de Practicantes (UST)
licensed - First school for Nursing (short-lived)
1980 – overlapping of 4 and 5 year curriculum
1906 – Iloilo Mission Hospital School for
graduates
Nursing
RA 7164 (1992) – IV training for nurses by
- 6 months training, no board exam
ANSAP, signed by Cory Aquino, valid only
(NON-EXISTENT)
after 2 months
RA 9173 (2002) – New Nurse Practice Act Mission Hospital (1901) – still existent

HEALTH, DISEASE, AND ILLNESS 1907 – PGH Hospital, St. Lukes Hospital, St.
Paul Hospital
Health – Defined as merely the absence or
Normal Hall in PNU is used as training ground –
presence of disease or infirmity. WHO defined
Same instruction (central school idea) for 6
health as a state of complete physical, mental,
months then go back to hospital
and social well-being and not just merely the
absence of disease or infirmity. Act 2493 (1915) – Medical act which included
Sec.7 & 8 about nursing practice which
Disease – Malfunctioning of the body system. mandated registration and examination

Illness – It is a state wherein the person’s

physical, emotional, and social well-being is Models of Health
thought to be diminishing. Felt by the patient. It
is highly subjective. Judith Smith Clinical Model
- Absence of the signs and symptoms of a
• 2 types disease.
Acute – Sudden onset, short duration, may or - Narrowest
may not require immediate intervention.
Chronic – Gradual/slow onset, long duration, Role Performance Model
lessen complications or debilitating effects of - Able to perform job
the condition for the client to be able to function
given the limitations of the condition. Adaptive Mod el
- Capable of adjusting
- Although there is infirmity, he is able to find Schumann’s Stages of Illness Behaviors
ways to cope. 1. Symptom experience
2. Assumption of sick role
Eudemonistic Model 3. Medical care contact
- Individuals are able to achieve the apex of 4. Dependent client role
Maslow’s Hierarchy of needs (self- 5. Convalescence/ Rehabilitation
actualization).
- Maximization of potential and mission in life Opposite of health is illness, not disease
- Fulfillment of his purpose in life
STRESS
Levell and Clark Ecologic Model of Health • Organisms reacts as a unified whole
- Epidemiological triad –agent, host, • Fabric of life
environment
- Any of these triad must be manipulated or Models of Stress
enhanced to maintain health Response Based Model (Selye)
– Non-specific response of the body to any
Multiple Causation Theory of Disease demand made upon it
- Health is affected by different factors in the
environment Transaction-based Model
– Individual perceptual response rooted in
Rosenstoch – Becker’s Health Belief Model psychological and cognitive process
- Individual perception affect modifying factors
which may influence likelihood of action Stimulus Based Model
– Disturbing or disruptive characteristics within
Travis’ Illness-Wellness Continuum the environment
- Health is in a spectrum which moves into
polarity of directions Adaptation Model
- Premature of death Disability/Disease – Anxiety provoking stimulus
Symptoms Signs Awareness Education – People experience anxiety and increased stress
Growth High level wellness when they are unprepared to cope with stressful
situations
Dunn’s High Level Wellness Grid
- Health-illness Continuum CRISIS
- Health axis “Favorable/Unfavorable - disequilibrium, not merely psychological but
environment” physiologic as well (shock)
Quadrants: - spontaneous resolution is 6 weeks
1. High level wellness in a favorable - grieving process: 4 years
environment
2. Emergent high levels in Level Wellness Stressor
in an unfavorable environment - Internal/ intrinsic
3. Poor Health in an Unfavorable - External / extrinsic
Environment - Developmental/ Maturational
4. Poor health in a favorable environment - Situational

Eustress – helpful stress

Distress – harmful to health - Mobilization of defense
- Decreased body resistance
Body adapts to the changes in the environment - Increased hormone level
which leads to Homeostasis (Walter B. Cannon)
• Resistance
Cloud Bernard – called homeostasis as
- Repel of stressor; overcome
“therapeutic milieu”
- Adaptation
Adaptation - change to maintain integrity of the - Normalization of hormone levels and
environment vital signs
- Increase in body resistance
Models of Adaptation - Going back to pre-stress state

Biological/Physiological – GAS and LAS; • Exhaustion

compensatory physical changes - Unable to overcome stressor
- Decreased energy level
Emotional/Psychological – involves a change in
- Breakdown in feedback mechanism
attitudes or behavior
- Organ/tissue damage; decreased
Socio-cultural – changes in the person’s physiological function
behavior in accordance with norms, conventions - Exaggeration of General Adaptation
and beliefs of various groups. Response Sympathoadrenal-medullary
Response (SAMR)
Technological – involves the use of modern - Activation of sympathetic system which
technology stimulated adrenal medulla
Principles of Homeostatic Mechanisms - Release of epinephrine and
- Automatic, self-regulatory norepinephrine > inc. physiological
- Compensatory activities
- Negative feedback except for uterine - Sympathetic stimulation (inc. HR, RR,
contraction during labor BP, visual perception, metabolism –
- Has limits glycogenolysis in liver, dec. GI, GU)
- Propranolol (Inderal) –
One physiologic error is corrected by several bronchoconstriction
homeostatic mechanisms
Adrenocortical Response
STRESS RESPONSE Anterior pituitary gland Adrenocorticotropic
Lazarus’ Stress Response Theory hormone adrenal cortex
General Adaptation Syndrome (GAS) – a (1) release of aldosterone kidneys increase
physiological response is a systemic response Na reabsorption
Local Adaptation Syndrome (LAS) - Only a (2) release of cortisol fats & CHON
part of the body catabolism glucose

General Adaptation Syndrome Stages

• Alarm Neurohypophyseal Response
- Awareness of stressor Posterior pituitary gland release
- Increase in vital signs
 (1) Antidiuretic hormone kidneys inc. Na, (2) Lymphocytes, Monocytes, or
H2O reabsorption dec. urine output, Macrophages – suggests chronic
inc. blood volume, inc. BP infection.
(2) Inc. oxytocin (aids in ejaculation/sperm
motility) uterine contraction (3) Eosinophils – allergy

(4) Basophils – healing

Methods to decrease stress:
- Progressive relaxation – muscle tension III. Exudating
- Benzon relaxation method – dimming the light, Types of Exudate
music • Serous – plasma (watery)
- Yoga, meditation • Sanguineous/hemorrhages – blood
- Ventilation of feelings • Serosanguinous – pink
• Pus – purulent/ suppurative
Local Adaptation Syndrome • Catarrhal – mucin
Inflammatory Response • Fibrin fibers – fibrinous
- All infections cause an inflammatory
response. IV. Reparative
- Not all tissue damage results in
inflammation. Phagocytosis – ingestion of foreign substances
- Inflammation can heal spontaneously as Macrophages Monocytes
long as the body can manage
Chemotaxis – movement of substances to a
I. Vascular Stage chemical signal Healing methods:
• Cold compress for first hours then warm
(1) Vasoconstriction which limits injury and compress after
contain damage (transient) • Nutrition and fluid intake

(2) Release of chemical mediators – kinins Types of wound healing

Primary Intention – Wound edges are well
- Bradykinin – most potent vasodilator/ approximated (closed), minimal tissue damage
universal pain stimulus, inc. chemical i.e. surgically created wound; this can be done
activity warmth (calor), redness (rubor) with stitches, staples, etc.

- Prostaglandin Secondary Intention – Wound edges are not well

approximated, moderate to extensive tissue
(3) Capillary permeability swelling damage and edges can’t be brought together i.e.
(tumor), pain (dulor), temporary loss of Decubitus ulcer
function (function laesa)
Tertiary Intention – “Delayed primary
II. Cellular Stage intention”, suturing or closing of the wound is
(1) Neutrophils – bands and segmenters in delayed i.e. due to poor circulation in the area
differential count; first one to arrive. If
elevated, it suggests acute infection NURSING PROCESS
A – Assessment
D - Diagnosis
P – Planning Data Collection – first step in assessment
I - Implementation • Primary/ Secondary
E – Evaluation • Object (over)/ Subjective (covert)

An overlapping of process can be noted since it Methods of Gathering Data Interview

is cyclic
• Therapeutic and non-communication

• Health history
- Medical history – disease focused
(physiological)
- Nursing history – needs, psychosocial
dimension, spiritual aspects
ASSESSMENT
• Personal space
Types - Intimate Space – 1 ½ foot
- Initial assessment - Personal Space – 1 ½ - 4 feet
- Problem focused assessment - Social Space – 4 –12 feet
- Emergency assessment - Public Space – 12–15 feet
- Time-lapsed assessment
Observation
Steps in assessment • Use of senses to gather data
1. Collection of data • Clinical eye – comes with practice and
2. Validation of data experience
3. Organization of data
4. Categorizing or identifying patterns of Examination
data • Inspection, Palpation, Percussion, Auscultation
5. Making influences or impressions of (general)
data • Inspection, Auscultation, Percussion, Palpation
(abdominal)
After data collection, synthesis, analysis and • Syndrome – “syndrome”
validation are performed • Possible – vague/ unclear – possible/probable
Prioritization of Nursing Diagnosis
DIAGNOSIS • Airway, breathing, circulation
Problem + etiology +defining symptoms
*Guided by the NANDA PLANNING
Knowledge deficit – kulang sa kaisipan • Short Range
Knowledge deficiency – kulang sa kaalaman • Long Range
(preferred) Self-care deficit – acceptable * Must be SMART (Specific, Measurable,
Attainable, Realistic, Time bound)
Types of Nursing Diagnosis Classify as dependent, interdependent, and
• Actual collaborative
• Risk for/ Potential for
• Wellness - readiness and enhancement/ achieve IMPLEMENTATION
higher level of functioning • Reassess if the patient still needs intervention
• Determine if you need assistance 1. Source Oriented Recording – narrative
• Carry out intervention, ensure that we have account by nurse; all the sheets in the patient’s
background chart (Standing Order, Physician’s Order etc.)
• Document
2. Problem Oriented Recording (POR) –
Process of implementing problems ranked according to priority by the
- Reassess client health care team, date dissolved, progress notes,
- Determine nurses’ needs for assistance problem list
- Implementing nursing interventions a. FDAR – Focus, Data, Action, Response
- Supervising the delegated care (patient)
- Documenting nursing activities
b. SOAPIER – subjective, objective,
EVALUATION assessment, planning, implementation,
Purposes of evaluation evaluation, revision
Determine the:
- Client’s progress or lack of progress 3. Computer Assisted Recording – problem with
- Overall quality of care provided privacy
- Promote nursing accountability
4. Flow Chart
Guidelines for evaluation
5. Charting by Exception (CBE) – only
- Systemic process
significant change is documented
- On-going basis
- Revision of the plan of care when
Case Management done with a Critical Pathway
needed
Variance
- Involve the client, significant others, and
– Comprehensive and make sure that it won’t
other members of the health team
legally be implicated
- Must be documented
PHYSICAL EXAM (Plan Order)
Process - nurse Structure - system Outcome –
- Cephalo-caudal
patient
o Inspect, palpation percussion, auscultation
DOCUMENTATION or CHARTING
STAT – now o Inspection, auscultation, percussion, and
Ad lib – as desired palpation sequence on abdomen to prevent
PRN – as required stimulation of peristalsis and for the patient to
OD – right eye/ once a day follow a more comfortable to least comfortable
OS – left eye examination
OU – both - Focused Assessment – on specific
AD – right ear part/symptom
AS – left ear
AU – both ears - Bruit – normal if with AV fistula, abnormal in
Ss – half other since it may signify arterial occlusion
ERROR: draw a straight line, signature, initials
- Auscultate the scrotum in inguinal hernia since
Types of Documentation it may have bowel sounds
 - Lordosis
- Compare each body part to the other - Scoliosis – lateral

POSITIONING Skin
- Sitting - Capillary refill test = 1-2 seconds
- High Fowlers (90%) - Icteric sclera
- Orthopneic position (leaning on a table, - Cyanosis – late sign of oxygen
hands extended) deprivation
- Supine, Back Lying, Dorsal, Horizontal - Vitiligo
Recumbent - Erythema
- Flat on Bed – no pillow - Pallor
- Dorsal Recumbent – legs flexed to relax
abdominal muscles, abdominal Nail Beds
palpation/ exam – followed by diagonal - Clubbing - Beyond 180 degree due to
draping dec. oxygen
- Standing/Errect – curvature of the spine - Koilonychia -Spoon shaped nail due to
- Prone/ Face – lying position iron deficiency anemia
- Sim’s Position, Left lateral, Side-lying - Onycholysis/Oncolysis – separation of
Rectal exam, suppository insertion, nail
enema administration - Paronychia – severe inflammation of
- Knee Chest position/ Geno-pectoral nail
position/ Jack Knife position - Unguis incartatus - ingrown toenail
Rectal exam, dysmenorrhea
- Kraaske – inverted V PALPATION
- Lithototomy – stirrups - Light (indentation half an inch)
- Trendelenburg – foot up; head down Fontanels, buldges, pulses, lymph
- Reverse trendelenburg – head up, foot nodes, thyroids, symmetry, neck veins,
down edema
- Modified trendelenburg – only 1 leg up - Deep
for shock: L - IE is a form of palpation
Chest expansion must be symmetrical
MCNAP – training to perform internal Tactile fremitus - sound that is palpable
examination - Increase in consolidation, pneumonia
- Decrease in pneumothorax
Chest Thrill – palpable murmur
- Pectus excavatum – funnel chest Edema – on dependent area and may occur in
(congenital); compression of heart and legs
breathing Pitting/Non-Pitting Anasarca – generalized
- Pectus carinatum – pigeon chest – edema
deformity for rickets (Vit D deficiency); Periorbital edema – about the eye
AP diameter decreased
PERCUSSION
Posture - Touch and healing
- Kyphosis
Tuning Fork - Crackles (rales) – Fine, short,
- Weber’s test/ Lateralization test – interrupted crackling sounds (rubbing
conduction hearing hair in small airways; retained
- Rhinne’s Test – bone-air conduction secretions;)
- Gurgles (rhonchi) – Continuous, low-
Indirect Palpation pitched, course, gurgling, harsh sounds
- Flexor – Hiitting with moaning / snoring quality (rubbing
- Pleximeter – Receiving hair in wide airway)
Sounds - Friction rub – Superficial grating or
- Dull – organ creaking sounds
- Flat – bones, muscles - Vocal (tactile) fremitus – Faintly
- Tympany – abdomen perceptible vibration felt through the
- Resonant – lungs chest wall when the client speaks
- Hyperresonance – abnormal - Stridor – noisy breathing Stridor –
(emphysema) laryngeal spasm Cardiac Sounds
- 5th ICS MCL at the PMI
Typanism – “kabag” - Llll left – Pulmonic valve
DTR - +2: NORMAL, above it hyper resonant, - Rrrrrr- Aortic valve NPH –
below it is hyperresonant Intermediate
- Humulin R- rapid Glargular – rapid
Parts of the Stethoscope Bowel Sounds
- Diaphragm – high pitched; lung sounds - Normoactive: 5-30 bowel sounds per minute
- Bell – low pitched; heart sounds - Wait 3-5 mins before concluding that bowel
sounds are absent
Adventitious breath sounds – no abnormal - Hyperactive – Borborygmus
sounds - Paralytic ileus – paralysis after surgery

Respiratory Sounds Voice Transmitted Sounds

Normal Breath Sounds - Egophony – say “E” but hears “A”
Vesicular – Soft intensity, low pitched - Whispered Pectoriloquy – whisper but we hear
- T5 onward it loudly, secondary to consolidation
- Peripheral lung, base of the lung - Vocal fremitus - Shifting dullness to check for
Bronchovesicular – Moderate intensity, ascites
moderate pitch
- T3-T5 LABORATORY EXAMS
- Between scapulae lateral to the sternum - Properly collect the specimen
Bronchial – High pitch, loud harsh sounds - Give instructions correctly
- T1-T3
- Anteriorly over the trachea Urinalysis
- Color: Amber, tea-colored (biliary d/o),
Adventitious Breath Sounds urobilinogen
- Wheeze – Continuous, high-pitched, - Odor: Aromatic/ Ammoniacal
squeaky musical sounds (narrowed (decomposed urine)
airway; asthma, bronchitis)
 - pH: Acidic – does not favor bacterial o +4 - Red
growth o Collected before meals
- Specific gravity: 1.050-1.025, if
elevated urine is concentrated, suspect - Heat and Acetic Acid Test – test of
dehydration albuminuria; divide into 3 parts then add
- Phosphates/Urates: Normal 2/3 urine, then 1/3 acetic acid
- Glycosuria – Diabetes (BS is more than o Turbid/Cloudy – positive
200mg) o Not reliable since no microscopic
- Hematuria – Stones, BPH, renal instruments were used
diseases, UTI o Done mostly in the community, NO
- Albuminemia – protein in urine, BOILING
eclampsia
- Pyuria – UTI Quantitative Urine Exam
- Cylindruria – cast in urine (stones) - 24-hour Urine Collection – HCG,
- First voided urine, mid-stream to clean urinary amylase, urinary
the urethra first catecholamines, urinary creatinine, urine
- Sterile specimen albumin, corticosteroids
- Indwelling catheter – wait in the end of o 6pm order, discard urine on 6pm, start
the catheter for 30 mins on 6:01pm
- Indwelling catheter – aspirate from 10ml o Whole amount of urine, need not be
syringe midstream
- Wee bag (*) o Preserve in ice – cold storage
o Leeway of 15-30mins; get urine after
Urine Culture & Sensitivity Test deadline as long as not too far
- Exact microbe - Fractional Urine Collection – shorter
- Result is final only after 5-7 days span; time determined by doctor
- Same collection process but less amount
- Ideal is catheterized cath Fecalysis
- Color of stool is influenced by
Chemical Tests for Urine stercobilin
- Clinitest – way to determine sugar in - Clay colored = acholic stool = biliary
urine (glycosuria) tract obstruction
- Hematochezia = red = lower GI
- Benedict’s test – used Benedict’s bleeding
solution then heat to check for potency: - Melena = blood = upper GI bleeding
must remain blue; if not blue, discard - Steatorrhea = fat = gallbladder problem
- Foul smelling – indole and skatole
- NO BOILING - Soft/formed
o Then add 3-10 drops of urine then - Dead bacteria, fibers, amorphous
heat phosphates – normal
o Negative results - Live bacteria – abnormal
o Negative: Blue - After 1 hour, the stool cannot be used
o +1 - Green for fecalysis
o +2 - Yellow - Collect abnormal looking feces, not the
o +3 – Orange one which is well formed
 - Needs chest x-ray
Stool Culture and Sensitivity - Positioned lying on unaffected side
- Determining exact microorganism
- Result also final after 5-7 days Thoracostomy
- Sterile container - to return to negative pressure

Guaiac Test Abdominal Paracentesis

- Occult blood test - Aspiration of peritoneal fluid in ascites
- No meat, highly colored food, iron - Semi-sitting/sitting position
preparation, Vit. C in diet - Void before procedure
- 3 days occult blood sample - May be therapeutic or diagnostic
Sputum Exam - Watch out for hypovolemia
- Done in early morning since secretions
already pooled Lumbar Puncture/ Tap
- Sputum C &S – may give oral hygiene - L3, L4, L5, subarachnoid space
to remove mouth bacteria - Paralysis risk low
- Acid Fast Bacilli – 3 consecutive days - Fetal position – widens the angle of the
- Sputum Cytology – cancer cells lumbar spine
- Eosinophil determination – to determine - 50-200mm – normal CSF pressure
allergic reaction - Prepare 4 test tubes since every test
- If unconscious, suction may be done: requires a different test tube
mucus trap - Label test tubes and seal with
appropriate cover; not with cotton
Blood Examinations - Xanthochromic – hemolyzed blood;
- FASTING yellowish discoloration
o Triglyceride (1-12 hours), BUN (6-8 - Flat on bed after procedure (6-8 hours)
hours), HDL, LDL, FBS, Total Protein, to prevent spinal headache
Albumin Globulin ratio, uric acid
Diagnostic Exams
- NON FASTING - Visualization procedures
o Crea, Na, K, Ca, CBG (but pre meals) - Endoscopy
o direct visualization; lighted instrument
CBG - X-Ray – graphy
- before meals o Contraindicated in pregnant women
- prick at the side since low blood vessels due to teratogenic effect
- Transformed
Thoracentesis o Ultrasound/ Sonogram
- aspiration of pleural fluid through a
needle Electroencephalography (EEG)
- orthopneic position - Shampoo hair before and after
- informed consent procedure
- Fluid - 7-8 or 8-9 in intercostal posterior - Sedative must be withheld
axillary line - Determining seizure disorders
- Air - 2-3, 3-4 in intercostals
Electrocardiography (ECG) - No need for written consent
- 3 y/o above – up & back
Electromyogram (EMG) - 3 y/o below – down & back
- Invasive
- Phase 2 – insertion of needle into Rhinoscopy
muscle - Rhinoscope
- Hyperextend the neck
CBC needs a heparinized syringe
Endoscope
Magnetic Resonance Imaging - Can be used for surgery, biopsy
- CI: steel implant and pacemaker - Pharyngoscopy
- Some ortho implants/prosthesis are - Bronchoscopy
allowed - Laryngoscopy
- Assess for claustrophobia - Esophagogastroduodenoscopy
- Needs consent since it’s expensive - Anoscopy
- With contrast in special procedures - Proctoscopy – rectum
- NPO – to avoid aspiration in case of - Sigmoidoscopy
untoward reaction - Colonoscopy – anus to ileum
o Cleansing enema until clear
Computed Tomography Scan - Remove dentures
- Lesion must be bigger - Remove gag reflex by local anesthetic
- Dye and NPO agent and check gag reflex
- Resume food only when gag reflex is
Positron Emission Tomography present
- Radioactive glucose (Fluorine) - Consent and NPO
- Cancer cells have strong affinity for - Urethroscopy
glucose; detect cancer sites of metastasis - Cystoscopy – bladder, written consent,
cystoclysis set up (continuous flow of
Nuclear Medicine Thyroid Scan sterile water which also exits)
- Nodule/tumor on thyroid - Colposcopy – vaginal examination,
For abdominal scans laxative, (castor oil/ needs vaginal speculum
Dulcolax) and NPO may be necessary o Shirodkar – tying the cervix so that
miscarriage is avoided; incompetent
Ophthalmoscopy cervix
- Ophthalmoscope - Roentgenography
- Used in determining cataract - Electromagnetic radiation photography -
- Dim the light and focus light of Xray but without contrast medium
ophthalmoscope in the eye - Chest X-Ray
- Fundoscopy may be determined o Not definitive of TB
- Mammography
Otoscopy o Examination of breast
- Otoscope - Scout Film of Abdomen
- A cannula is inserted in the external - KUB
auditory canal
Upper GI Series o Needs transducer
- Esophagus, stomach, duodenum - US Abdomen
- Barium swallow (dye) – outline the GI o Colon – laxative, NPO
system, flavored, has constipating effect o Kidney – KUB
– inc. fluid o Pelvic ultrasound – drink 6-8 glasses
- Uses laxative, NPO to have a full bladder; do not allow to
- Enema to evacuate barium to prevent void
fecal impaction o Gallbladder ultrasound
- Transvaginal Ultrasound
Lower GI Series o Will outline fallopian tube, uterus and
- Barium enema ovaries
- Outline of colon o Consent
- Laxative and cleansing enema until it is - Transrectal Ultrasound
clean o Consent
- Pink phosphosoda (oral cleansing o Empty the bladder for comfort and
enema) good visualization
- Evacuate barium through enema to o Visualization of uterus/ prostate
prevent fecal impaction
ADMITTING A CLIENT
Excretory Urography Types of Bed
- Intravenous Pyelography - Closed – in anticipation for an
o Hypaque- - made from iodine admission
substance; check for allergy for seafoods - Open
o Laxative + NPO - Post-Op/ Surgical/ Anesthetic/ Heater
o Given through IV port and the x ray bed
series is made - Occupied
o Assesses kidney’s ability to filter
o Assesses presence of stones Principle of Bed-making
o If reverse, retrograde pyelography - Body Mechanics: Bed from knees, wide
base of support
- Oral Cholecystography - Obtain help
o Iapanoic acid (Telepaque) – taken - Asepsis, do not let linen touch uniform
every 5-10 minute interval; 6 tablets - Do not let the linen fall into ground
o Low fat meal the day before the exam - Finish one side of bed first
o Laxative + NPO - Remove wrinkles to have aesthetic value
o Top sheet – excess linen in foot part
Ultrasound/ Sonogram o Bottom sheet – excess linen in head part
- US Brain
- US Heart (2D ECHO, CHANGING GOWN
Echocardiography) - Remove with free arm first in changing
o Regurgitation gown
o Stenosis - If both with contraption, any arms
- US Lungs
- US Breast/ Sonomammogram ORIENTING THE CLIENT
 o 2 mins under the tongue
ASSESSMENT HISTORY TAKING
PHYSICAL EXAM VITAL SIGNS - Rectal – contraindicated in imperforate
DOCUMENT anus, rectal polyps, hirschprung’s
- chief complaint only found on disease, diarrhea, increase ICP, cardiac
admission sheet disease (may cause vagal stimulation)
o Not safe since it can cause rectal
DISCHARGE OF PATIENT trauma
- may be against medical advice (DAMA) o 1 min
but it needs doctor’s order
- health instruction - Axillary – 3mins
- Illegal detention (false imprisonment) - Tympanic – external ear.
contraindicated in otitis, ear surgery;
VITAL SIGNS most accurate
Children – Respiratory Rate, Pulse Rate, - Temporal Scanner - done in temporal;
Temperature most convenient
* Blood Pressure can also be obtained in
children Temperature can be checked every 30 mins
since hypothalamus can only fluctuate the
TEMPERATURE temperature every 30 mins
Types of Temperature Spot Vital Signs – HR, RR, BP Thermopacifier
Core temp. – more important; can’t be affected – for crying babies Plastic strip Thermometer –
by the environment Amitemp
Surface temp. – more important in children since
hypothalamus not yet developed Alterations in body temperature Hyperpyrexia:
Poikilothermia – temp is same with 41˚ degrees + Pyrexia: 37.5˚ - 38˚ degrees +
environment; newborn • Onset / Chill phase: up HR, up RR, shivering,
Homeothermia – different with the environment cold skin, cessation of sweating
• Course / Plateau phase: absence of chills, feels
Factors that affect Body Temperature warm, up HR, RR, thirst
1. Age • Abatement phase: flushed skin, sweating,
2. Ovulation – temp is higher; reduced shivering
progesterone
3. Activity – inc. BMR Average: 36˚ - 38˚ degrees Hypothermia: 36˚
4. Environment Temperature conversion degrees below Death: 34˚ degrees
C-F multiply 1.8 + 32 F-C subtract 32/
1.8 Types of Fever
- Intermittent – fluctuates from febrile to
Methods of taking body temperature afebrile
- Oral – contraindicated in brain damage, - Remittent – febrile, temperature
mental illness, retarded, problem with fluctuation is minimal
nose and mouth, tooth extraction, - Relapsing – fluctuates in days
contraption in nose and mouth, altered - Constant / Continuous – febrile,
LOC, dyspnea, seizures, 7 y/o below temperature fluctuation is wide (+2)
 - Heat Stroke – depletion of fluid, Palpation
hypothalamus does not regulate Pattern of Beat (Rhythm)
- Hypothermia – induced (surgery), - Regular (60 – 100 bpm)
extreme temperature - Irregular (arrhythmia)
o Bigeminal pulse – 1, 2, disappear
Nursing interventions o Trigeminal pulse – 1, 2, 3, disappear
- Feels chilled – provide extra blankets
- Feels warm – remove excess blankets; Pulse Strength = pulse volume
loosen clothing Adequate nutrition and +1 – collapsible. thready
fluids +2 – normal
- Reduce physical activity +3 – full
- Oral hygiene +4 – full, bounding
- Tepid Sponge Bath – increase heat loss
(conduction, convection, evaporation) Corrigan pulse/ Waterhammer pulse – thready
and with full expansion followed
Unexpected Situation and Associated by sudden collapse.
Interventions. During rectal temperature
assessment Auscultation
- Patient reports feeling lightheaded or Apical (PMI)
passes out. • 3rd – 4th ICS MCL (below 7 years old)
- Remove the thermometer immediately. • 4th - 5th ICS MCL (7 years old and above)
- Quickly assess the patient’s BP and HR.
- Notify the physician. Unexpected Situations and Associated
- Do not attempt to take another rectal Interventions
temperature on this patient. The pulse is irregular. Monitor the pulse for a
full minute. If the pulse is difficult to assess,
PULSE validate pulse measurement by taking the apical
- Temporal pulse for 1 minute. If this is a change for the
- Carotid – cardiac arrest patient, notify the physician.
- Apical
- Brachial You cannot palpate a pulse Use a portable
- Radial – thumb site ultrasound Doppler to assess the pulse. If this is
- Femoral a change in assessment or if you cannot find the
- Popliteal pulse using an ultrasound Doppler, notify the
physician.
Affected by the following:
1. Age – the younger, the faster RESPIRATION Normal: 16-20 bpm
2. Activity
3. Stress Three processes
4. Drugs Ventilation – the breathing in and breathing out
Increase – anticholinergic, • Intact CNS
sympathomimetic • Clear airway
Decrease – cardiac glycoside • Intact thoracic cavity
• Compliance and recoil
Diffusion – movement of gasses from higher to - Phase 2 – swishing or whooshing sound
lower concentration - Phase 3 – thump softer than the tapping
• Adequate concentration of gasses in phase 1
• Normal lung tissue - Phase 4 – softer blowing muffled sound
Perfusion – circulation of the oxygenated blood that fades (end = diastolic)
to the different tissues of the body - Phase 5 – silence

Inhalation / Inspiration – 1 to 1.5 seconds Kinds

Exhalation / Expiration – 2 to 3 seconds - Direct – venous pressure, CVP, invasive,
cutdown (5- 12mmHg)
Alterations in Breathing Patterns - Indirect
Rate o Palpatory
Tachypnea – fast breathing Bradypnea – slowed o Auscultatory
breathing Apnea – absence of breathing Eupnea
– normal breathing Pulse pressure – 40 mmHg
Pulse deficit (systolic - diastolic)
Rhythm Mean Arterial Pressure ([2D+S]/D)
Biot’s – shallow breathing with periods of apnea
Cheyne-Strokes – deep breathing with apnea Classification SBP
Kussmaul’s – deep, rapid breathing (If with mmHg DBP
respiratory acidosis – to blow off excess carbon mmHg Lifestyle Modification
dioxides) - Optimal <120 And <80
Volume Encouraged
Hyperventilation – leads to respiratory alkalosis - Pre- hypertension 120-139
Hypoventilation – leads to respiratory acidosis Or 80-89 YES
- Stage 1 HPN 140-159 Or 90-
Ease of effort 99 YES
Dyspnea – difficulty of breathing - Stage 2 HPN >160 Or > 100
Orthopnea – difficulty of breathing within YES
supine position (best position for this is - Stage 3 HPN > 180 Or > 110
orthopneic position) YES
Kat Apnea - Difficulty of breathing while in
sitting position Choose the higher BP
Trepopnea - ease when in side-lying position Sources of error is BP Assessment
Hyperpnea – inc. rate and depth of respiration - High BP reading
- Bladder cuff too narrow
BLOOD PRESSURE - Arms unsupported
Factor’s Affecting Blood pressure - Insufficient rest before the assessment
- Age, Gender - Repeating reassessment too quickly
- Activity, exercise, stress - Deflating cuff too slowly
- Time of the day - Assessing immediately after a meal or
while client smokes or has pain
Korotkoff sounds - Low BP reading
- Phase 1 – sharp tapping (systolic) - Bladder cuff too wide
 - Deflating cuff too quickly • When = morning, at bedtime, 30 minutes – 1
- Arm above the level of the heart hour before or 1-2 hours after meal
- Failure to identify auscultatory gap • Each position = assumed for 10 – 15 minutes
• Entire treatment should last only for 30
OXYGENATION minutes
Respiratory Modalities
Abdominal (diaphragmatic) and pursed-lip Percussion
breathing • Rhythmical force provided by clapping the
• Semi / high fowler's position nurse’s cupped hands against the client’s thorax
• Slow deep breath, hold for a count of 3 then • Over affected segment for 1-2 minutes
slowly exhale through mouth and pursed lip
• 5 – 10 slow deep breaths every 2 hours on Vibration
waking hours • Perform by contracting all the muscles in the
nurse’s upper extremities to cause vibration
Coughing exercise while applying pressure to the client’s chest wall
• Upright position • One hand over the other
• Contraindicated: post brain, spinal or eye
surgery Suctioning
• Take two slow deep breaths; on the third Purposes
breath, hold for few seconds, cough twice • Maintain patent airway
without inhaling in between • Promote adequate exchange of O2 and CO2
• May splint surgical incisions • Substitute for effective coughing
• Every 2 hours while awake Size
• Adult: Fr 12-18
Incentive spirometry • Child: Fr 8-10
• A breathing device that provides visual • Infant: Fr 5-8
feedback that encourages patient to sustain deep Length
voluntary breathing and maximum inspiration. • From tip of nose to earlobe (5 in.)
• 10 times every 1 to 2 hours • Nasopharyngeal = 5-6 inches
• Oropharyngeal = 3-4 inches
Chest Physiotherapy • Nasotracheal = 8-9 inches
• Postural drainage • ET = length of ET + 1 inch
• Percussion • Tracheostomy = length of trachea + 1 cm
• Vibration
• Positioning > percussion > vibration > removal Suctioning
of secretions by coughing or suction • Duration of suction: 5-10 seconds
o Contraindications: • Intermittent suctioning upon withdrawal using
ICP more than 20mmHg, head and neck injury, rotating motion
active hemorrhage, recent spinal surgery, active • If to repeat: 1-2 mins interval
hemoptysis, pulmonary edema, confused or • Limit suctioning in a total of 5 minutes
anxious patients, rib fracture
Unexpected Situations and Associated
Postural Drainage Interventions
Patient vomits during suctioning If patient gags • 7-8L/min = 50%
or becomes nauseated, remove the catheter; it • 10L/min = 60%
has probably entered the esophagus
inadvertently. If the patient needs to be Priority nursing interventions:
suctioned again, suction catheter because it is o Monitor patient frequently to check the
probably contaminated. placement of the mask.
o Support patient if claustrophobia is a concern.
Secretion appears to be stomach content. Ask o Secure physician’s order to replace mask with
the patient to extend the neck slightly. This nasal cannula during meal time
helps to prevent the tube from passing into the
esophagus. Partial rebreather mask (approx. 60-80%)
• 6-10L/min = up to 80%
Epistaxis noted with continued suctioning Priority nursing interventions:
Notify the physician and anticipate the need for o Set flow rate so that mask remains two-thirds
a nasal trumpet. full during inspiration
o Keep the reservoir bag free of twists or kinks.
Oxygen Therapy
Special consideration: Nonrebeather mask
- Given with a doctor’s order • 10L/min = 80-100%
- Careful and continuous assessment to
evaluate the need for and its effect on Priority nursing interventions:
the patient o Maintain flow rate so the reservoir bag
collapses only slightly during inspiration.
Safety precautions: “NO SMOKING” and “O2 o Check that valved and rubber flaps are
IN USE” signs at the door functioning properly (open during expiration
Nasal Cannula (approx. 20-40% of oxygen) and closed during inhalation)
• 1L/min = 24% o Monitor SaO2 with pulse oximeter.
• 2L/min = 28%
• 3L/min = 32% Venturi mask (most accurate and precise oxygen
• 4L/min = 36% concentration delivery)
• 5L/min = 40% • 4L/min = 24%
• 6L/min = 40% • 4L/mins = 28%
• 6L/min = 31%
Priority nursing interventions: • 8L/min = 35%
o Check frequently that both prongs are in the • 8L/min = 40%
patient’s nares. • 10L/min = 50%
o Encourage the patient to breathe through the
nose, with mouth closed. Oxygen Tent
o May be limited to no more than 2-3L/min to Unexpected Situations and Associated
patients with chronic lung disease. Interventions
Child refuses to stay in the tent Parent may play
Face mask games in the tent with the child. Alternative
Simple face mask (approx. 40-60%) methods of O2 delivery may need to be
• 5-6L/min = 40% considered if child still refuses to stay in tent.
 o The tongue is sliding back into the posterior
It is difficult to maintain an O2 level above 40% pharynx, causing respiratory difficulties. Put on
in the tent. Ensure that the flap is closed and disposable gloves and remove the airway. Make
edges of the tent are tucked under the blanket. sure the airway is the most appropriate size for
Check the O2 delivery unit to ensure that rate the patient.
has not been changed. o Patient vomits as oropharyngeal airway is
inserted. Quickly position patient onto his side
Patient was confined on O2 delivered by nasal to prevent aspiration
cannula but now is cyanotic, and the pulse
oximeter reading is less than 0.5% Check to see Nasopharyngeal Airway / Nasal Trumpets
that O2 tubing is still connected to the flow • Indications Clenched teeth, enlarged tongue,
meter. need for frequent nasal suctioning
• Measurement: from the tragus of the ear to the
When dozing, patient begins to breathe through nostrils plus one inch
the mouth. Temporarily place the nasal cannula • Proper lubrication for easy insertion
near the mouth. If this does not raise the pulse
oximetry reading, you may need to obtain an Endotracheal
order to switch the patient to a mask while • Indications: route for mechanical ventilation,
sleeping. easy access for secretion removal, artificial
airway to relieve mechanical airway obstruction.
Inhalation Therapy • Care for patients with ET:
Moist inhalation – Steam inhalation = 12- 18 o Repositioned at least every 24-48 hours
inches; 15 – 20 mins. o Depth and length during insertion should be
Dry inhalation – Metered dose inhaler = use of maintained
spacer; hold breath for 10 seconds with 5 o Level of tube: gumline / biteline
minutes interval o Maintain cuff pressure of 20-25 mmHg
o Check lips for cracks and irritation
**Water
Child – has 70- 90 percent water Unexpected Situations and Associated
Adult – has 50-70 percent water Interventions
Males have more water than females since they o Patient is accidentally extubated during
have more adipose tissue suctioning. Remain with the patient. Instruct
assistant to notify physician. Assess the patient's
Artificial Airways vital signs, ability to breathe without assistance
Oropharyngeal airway and O2 saturation. Be ready to administer
• Prevents tongue from falling back against the assisted breaths with a bag-valve mask or
posterior pharynx administer O2. Anticipate need for reintubation.
• Measurement: from opening of the mouth to
the ear (back angle of the jaw) o Oxygen saturation decreases after suctioning.
• Check for loose teeth, food and dentures
Hyperoxygenate patient.
Unexpected Situations and Associated o Patient develops signs of intolerance to
Interventions suctioning; O2 saturation level decreases and
o The patient awakens Remove the oral airway remains low after hyperoxygenation, patient
becomes cyanotic or patient becomes • Purpose: measure arterial blood O2 by external
bradycardic. Stop suctioning. Auscultate lung sensor (non-invasive)
sounds. Consider hyperventilating a patient with • Placement
a manual resuscitation device. Remain with the o Adult: usually on the finger
patient. o Pedia: usually on the big toe
o Other sites: earlobes, nose, hand and feet
o Patient is accidentally extubated during tape
change. Remain with the patient. Instruct NUTRITION
assistant to notify physician. Assess the patient's
vital signs, ability to breathe without assistance Principles in the Promotion of Good Nutrition
and O2 saturation. Be ready to administer • The body requires food to:
assisted breaths with a bag-valve mask or o Provide energy for organ function, movement,
administer O2. Anticipate need for reintubation. and work.
o Provide raw materials for enzyme function,
o Patient is biting on ET Obtain a bite block. growth, replacement of cells and repair.
With the help of an assistant, place the bite • The process of digestion, absorption, and
block around the ET or in the patient's mouth. metabolism work together to provide all body
cells with energy and nutrients.
o Lung sounds are greater on one side Check • Man’s energy requirement varies and is
the depth of the ET. If the tube has been influenced by many factors: Age, body size,
advanced, the lung sounds will appear greater on activity, occupation, climate, sleep,
one side on which the tube is further down. physiological stress, pathological disorders,
Remove the tape and move the tube so that it is lifestyle, and gender.
placed properly.
Foods are described according to the density of
Tracheostomy their nutrients. Nutrient density – the proportion
• To maintain a patent airway and prevent of essential nutrients to the number of
infection of the respiratory tract. kilocalories.
• Care of patient with tracheostomy: Macronutrients – Give off calories for energy
o Sterile technique: acute phase • Fat soluble vitamins: Vit. A, D, E, and K
o Clean technique: home care Micronutrients – No calories, vitamins and
o 1st 24 hours: tracheostomy care every 4 hours nutrients
o Prevent aspiration • Water soluble vitamins: Vit. C, B1, B2, B3,
B6, B9, and B12 Calorie (kcal) – unit of energy
Unexpected Situations and Associated measurement; amount of heat required to raise
Interventions the temperature of 1kg of water to 1°C
o Patient coughs hard enough to dislodge
tracheostomy. Keep a spare tracheostomy and Sources:
obturator at the bedside. Insert obturator into CHO – 4 calories/gm; first to be burned
tracheostomy tube and insert tracheostomy into FATS – 9 calories/gm; stored as adipose tissue
stoma. Remove obturator. Secure ties and CHON – 4 calories/gm; meat
auscultate lung sounds. Alcohol – 7 calories/gm

Pulse Oximetry Vitamins

- Fat soluble - ADEK o Spinal deformity
- Water soluble – B complex , C o Stunted growth
Macrominerals – 100 mg or more You can store calcium up to 31 years
Microminerals – Less than 100 mg; Zinc, iron,
iodine Vit E (Tocopherol)
- Antioxidant: remove free radicals
**Potato – highest in potassium - Amount should not go to 400 units
**The tip of the banana has the highest amount because if it exceeds. It becomes
of potassium prooxidant
- Enhances RBC maturation
Iodine – prevent cretinism - Deficiency: anemia
Zinc – to improve appetite
Iron - correct anemia Vit K (Menadione)
Hypervitaminosis – increase in vitamins intake; - Anti-hemorrhagic
occurs commonly in fat soluble - Deficiency: hemorrhagic, bleeding

No hypervitaminosis in water soluble since it is **Kaesselbach’s plexus – prone to epistaxis

easily eliminated in urine
B Vitamins
Overweight – increase in macronutrients; may – Metabolism since these have enzymatic
progress to obese activity
Marasmus Vit B1 (Thiamin)
- calorie malnutrition - Deficiency: Beri-beri; Wernicke-Korsakoff
- Old man facie, intercostals and Syndrome
subcostal retractions - Edema in wet Beri-beri
Kwashiorkor
- moon face, Globular abdomen, edema Vit B2 (Riboflavin)
- protein malnutrition - Deficiencies: Ariboflavinosis, cheilosis
- Angular stomatitis - mouth fissures
VITAMIN DEFICIENCIES
Vit A (Retinol) Vit B3 (Niacin)
- Healthy eyes, skin, and gums -Deficiency: Pellagra - butterfly sign, cassel’s
- Deficiency: Xerophthalmia (night collar
blindness) – Bitot’s spot
- Severe: Keratomalacia (irreversible) Vit B5 (Pantothenic Acid)
Vit D (Calciferol) -Keeps integrity of hair
- Not coming from the sun; but sunlight -Deficiency: alopecia
activates it
- Enhances calcium and phosphorus absorption Vit B6 (Pyridoxin)
- Deficiency: Ricketts -Deficiency: Neuritis
- Severe: Osteomalacia
o Bow legged – genu varum Vit B12 (Cyanocobalamin)
o Knock knee – genu valgum -Definition: pernicious anemia, neuritis
o Pectus carinatum (Harrison’s groove)
Vit C (Ascorbic) –Obese
-Inc. absorption of iron
-Deficiency: scurvy – easy bruising, gums, Diabetic
perifollicular lesion, hemorrhage –Balance of protein, CHO and fat
–insulin-food imbalance
Types of Diet
High protein
Regular –Meat, fish, milk, cheese, poultry, eggs
–Has all essentials, no restrictions –Tissue repair and underweight
–No special diet needed
Low fat
Clear liquid –Little butter, cream, whole milk or eggs
–“see-through foods” like broth, tea, strained –Gallbladder, liver or heart disease
juices, gelatin
–Recovery from surgery or very ill Low cholesterol
–Little meat or cheese
Full liquid –Need to decrease fat intake
–Clear liquids plus milk products, eggs
–Transition from clear to regular diet Low sodium
–No salt added during cooking
Soft diet –Heart or renal disease
–Soft consistency and mild spice
–Difficulty swallowing Nutritional Problems
Mechanically soft
–Regular diet but chopped or ground 1. Anthropometric Measurement
–Difficulty chewing a. BMI – kg/m2
i. Underweight – below 18
Bland ii. Normal – 18-24
–Chemically and mechanically non stimulating, iii. Overweight – 24 above
no spicy food
–Ulcers or colitis 2. BiochemicalAssay- laboratory exams
3. Clinical signs – sx/s
Low residue 4. Dietary History
–No bulky foods, apples or nuts, fiber, foods a. Food habits
having skins and seeds
–Rectal disease Anorexia – no eating
Bulimia – binge-purge syndrome
High calorie
–High protein, vitamin and fat Management:
–Malnourished - Hygiene
- Small frequent feeding
Low calorie - Serve attractively
–Decreased fat, no whole milk, cream, eggs,
complex CHO Enteral and Parenteral Nutrition
 and that suction equipment is at bedside; Check
Parenteral Nutrition medication record to see if any antiemetics is
- Nonfunctional GIT ordered.
- Extended bowel rest
- Preoperative TPN • When attempting to aspirate contents, the nurse
notes that the tube is clogged. Try using warm
Enteral Nutrition water and gentle pressure to remove the clog;
- Cancer Never use a stylet to unclog the tubes; Tube may
- Neurological and Muscular disorder have to be replaced.
- Gastrointestinal disorder
- Respiratory failure with prolonged intubation Gastrostomy / Jejunostomy Feeding
• Long term nutritional support, more than 6 – 8
Nasogastric Tube Feeding/ Levine’s Tube weeks
• Position: sitting • Place in high fowler’s position
• Head: hyperextend and slightly flexed • Check the patency of the tube: Pour 15-30 cc
• Insertion: NEX (Tip of the nose – Earlobe – of water
Xiphoid Process) • Check the patency of the tube: Pour 15-30 cc
• pH gastric content: 4 – 6 of water
• Confirmation: By X-ray • Check for residual feeding
• Hold asepto-syringe 3-6 inches above ostomy
feeding
Gavage • Frequently assess for skin breakdown
• Position: sitting
• Gastric aspirate: >1000mL – withhold feeding; Unexpected Situations and Associated
put back the residue Interventions
• If with medication and is not gastric irritant:
20-30cc flushing > meds > feeding > 20-30cc • Gastrostomy tube is leaking large amounts of
flushing drainage Check tension of the tube; Apply
gentle pressure to tube while pressing the
Lavage external bumper closer to the skin; If the tube
• To irrigate the stomach in case of gastric has an internal balloon holding it in place, check
bleeding, food poisoning or ingestion; if to make sure that the balloon is inflated
corrosive substance: do not irrigate properly.
• Position: sitting
• Gastric aspirate: discard • Skin irritation around the insertion site Stop
• Amount of irrigating solution: 750mL – 1L the leakage, as prescribed previously and apply a
skin barrier.
Unexpected Situations and Associated
Interventions • Site appears erythematous and patient
Tube found not to be in the stomach or intestine complains of pain at the site Notify physician,
Replace the tube patient could be developing cellulitis at the site.

• Patient complains of nausea after tube feeding French is directly proportional to size Gauge is
Ensure that the head of the bed remains elevated inversely proportional to size
 • Male: Top of thigh or lower abdomen
**Intravenous Hyperalimentation/ TPN Unexpected Situations and Associated
- Kabiven Interventions
- Watch out for glycosuria and blood sugar
- May necessitate insulin • No urine flow is obtained and you note that the
- Large needle since it is central route catheter is in the vaginal office. Leave catheter
- Monitor for complications in place as a marker; Obtain new sterile gloves
and catheter set; Once new catheter is correctly
ELIMINATION in place, remove the catheter in vaginal orifice.
URINE ELIMINATION
1200 – 1500cc/day
Normal output: 30ml/hour Urge to urinate: 300- • Patient complains of extreme pain when you
500ml are inflating the balloon Stop inflation of
balloon; Withdraw solution from the balloon.

Poliacuria – frequent, scanty urine Bladder Irrigation

Urgency – urge but unproductive of urinate
Retention – stimulate urination, running water, Open system (intermittent)
warm water over perineum, warm compress, and - For installation of medications or irrigation of
straight catheterization catheter
Closed system (Intermittent or Continuous)
Catheterization - For those who had genitourinary surgery
- For instillation of medications, promoting
Indication: homeostasis, flushing of
- Decompression clots or debris
- Instillation
- Irrigation **NEVER INFLATE THE BALLOON
- Specimen collection UNLESS URINE FLOWS**
- Urine measurement: Residual urine; Hourly If inserted in vagina, keep it in place but insert
urine output another one.

Promotion of healing of GUT Catheter can be placed in one month as long as

Catheter size no signs of infection
• Children: Fr 8-10
• Female adult: Fr 14-16; Fr 12 for young girls Condom Catheter – must be secured through a
• Male adult: Fr 16-18 belt
Position
• Female: dorsal recumbent Fides’ Maneuver – application of pressure in the
• Male: supine with thighs slightly abducted bladder to stimulate urine
Length of insertion
• Female: 2-3 inches (5 – 7.5 cm) BOWEL ELIMINATION
• Male: 7-9 inches (17 – 22.5 cm)
Anchor Assessment
• Female: inner thigh
• Inspection – Auscultation – Percussion – Lubricant – Lubricates (Mineral Oil)
Palpation approach Saline / Osmotic – Draws water into intestine
• Bowel sound (4 quadrants) (Epsom salts, Milk of Magnesia)
• Active – every 5-20 seconds Enema
• Hypoactive – 1 per minute
• Hyperactive – every 3 seconds Types
• Absent – None heard in 3-5 minutes Cleansing Enema
• Fecalysis – an inch of formed stool, 15-30 mL • Prior to diagnostic test, surgery
of liquid stool • In cases of constipation and impaction
• Fecal occult blood testing / Guaiac test • Either be: High enema (12-18 in.) or Low
enema (12 in.)
Fecal Elimination Problems
Diarrhea – watery stools; ORESOL; banana rice Carminative Enema
apple • To expel flatus
Constipation – hard stools; laxative; Psyllium • 60 – 80 mL of fluid
(bulk-formers), Castor oil (GI irritant)
Tenesmus – urge to but unproductive of stool Retention Enema
• Solution retained for 1-3 hours
Fecal impaction • Oil enema, antibiotic enema, anthelmintic
- constipation and seepage of watery stools enema, nutritive enema
- No enema Return-flow Enema
- Digital/Manual extraction with doctor’s order • To expel flatus
- Monitor for vagal stimulation; stop if signs are • Alternating flow of 100-200 mL of fluid in and
noted out of the rectum

Eructation/ Belching Enema Administration

- Expulsion of gasses through mouth Appropriate Size
• Adult: Fr 22-30
Flatulence/Tympanism • Child: Fr 12-18
- Avoid gas forming foods: cauliflower, cola
- Carminative enema – expel flatus Correct Volume
- Rectal tube insertion – inserted in anus then • Adult: 750 – 1,000 mL
placed in water for 20 mins; if need be repeated, • Adolescent: 500 – 750 mL
wait for 2-3 mins. to prevent anal sphincter • School-aged: 300 – 500 mL
damage • Toddler: 250 – 350 mL
• Infant: 150 – 250 mL
Types of Laxatives
Bulk forming – Increases fluid, gaseous or solid Length of Insertion
bulk (Metamucil, Citrucel) • Adult: 3-4 inches
Emollient / Stool Softener – Softens and delays • Child: 2-3 inches
drying of feces (Colace) • Infant: 1 – 1 ½ inches

Stimulant / Irritant – Irritates / stimulates Commonly Used Enema Solutions

(Dulcolax, Senokot, Castor Oil)
Hypertonic – Draws water into colon (Sodium • Normal color of stoma, pinkish-red, moist.
phosphate solution) Hypotonic – Distended •Pale or bluish indicates cyanosis or
colon, stimulates, softens (Tap water) Isotonic – decreased circulation in the tissue
Distended colon, stimulates, softens (Normal • Note the side of the stoma
saline) • Keep skin around the peristomal area clean and
Soap suds – Irritates mucosa, distended colon dry
(3-5 mL soap to 1L of water) • Intake and output
Oil – Lubricates feces (Mineral, olive,
cottonseed) Unexpected Situations and Associated
Interventions
Unexpected Situations and Associated
Interventions • Peristomal skin is excoriated or irritated Make
sure appliance is not cut too large; Assess for
• Solution does not flow into the rectum presence of fungal skin infection; Thoroughly
Reposition rectal tube, if solution will still not cleanse skin and apply skin barrier; Allow to dry
flow, remove tube and check for any fecal completely; Reapply pouch
contents.
• Patient continues to notice odor Check system
• Patient cannot retain enema solution for for any leaks or poor adhesion; Thoroughly
adequate amount of time Patient needs to be empty pouch
placed on bedpan in the supine position
MEDICATIONS
• Patient cannot tolerate large amounts of enema Parenteral
solution Amount and length of administration Intradermal
may have to be modified if the patient begins to - Gauge 25 -25
complain of pain - Insert only the bevel; zero to 15 degree angle
- Epidermal
• Patients complain of severe cramping with the - Sensitivity test
introduction of enema solution. Lower solution Subcutaneous
containers and check temperature and flow rate; - Stretch if fat, pinch if thin
If the solution is too cold, or too fast, severe - Adipose layer of the buttocks, arms
cramping may occur. - Best site is the abdomen, below the umbilicus!
- Gauge 23-25, 5/8 inch inserted
Colostomy - If long needle, insert 5/8; if short 90 degree
- Size of stoma will be stabilized within 6-8 Intramuscular
weeks. - Must be strictly 90 percent
- Effluent; Foul-smelling and irritating to the - 1-1.5 inch
skin = ileostomy - Gauge 22-23

Guidelines for Ostomy Care Z-track technique

- Deep IM
• Keep patients as free of odors as possible. - Prevent leakage of solution to tissue
Empty ostomy appliances frequently.
• Inspect stoma frequently
**NO INSERTION IN GLUTEUS MAXIMUS, - Disposable hot packs
BUT ON MINIMUS AND MEDIUS - Floor lamp / gooseneck lamp / heat cradle
• Bulb = 25 watts
Intravenous • Distance = 12-24 inches
IV Push – check backflow, if none do not insert
Dry cold application
IV infusion pump – for more accurate drip - Ice cap
Soluset – chamber up to 100cc; microset - Compress
calibration - After 15 mins

Ophthalmic solution – lower conjunctival site; Tepid Sponge Bath

1-2 drops at maximum - Do anterior first
- Use 1 washcloths
Rectal Suppository – go beyond the anal
sphincter Sitz Bath
Inhaler – may use spacer - immersion of 110-115 degrees Fahrenheit
- do not remove rectal pack, remove rectal
DO NOT USE INHALER IN STEROIDS TO dressing
PREVENT MOUTH SORES! - may have cerebral hypoxia – put ice cap on
forehead
HEAT AND COLD APPLICATION
- Do not prolong more than 20 mins. because of WOUND MANAGEMENT
rebound
No gauze cause it can stick to skin Center to
Heat outer when cleaning
- Vasodilation
- Increase capillary permeability Jackson Pratt
- Increase cellular metabolism - keep in negative pressure; remove drainage
-Increase inflammation - in head injury, can have JP but not on negative
-Sedative effect pressure since it can interfere with ICP

Cold HYGIENIC MEASURES

- Vasoconstriction
- Decrease capillary permeability Perineal care
- Decrease cellular metabolism - Female: Dorsal recumbent; front to back
- Male: Supine; circular
- Decrease inflammation - one stroke, one direction
- Local anesthetic effect
Oral Care
Inflammation – first 24 hours = cold; then heat - Brushing – sulcular technique
Pain – cold; to block nerve - Lemon-glycerine swab, mineral oil

Dry heat Oral hygiene for unconscious

- Hot water bags temperature: 110-125 degrees F - supine, head turned to one side
- antiseptic solution - To absorb exudates
Bed Bath - Hydrocolloid
- Water temperature: 43-46C or 110-115F
- Arms: Long, firm strokes, distal to proximal SLEEP
-Breasts: Female – circular; Male – Longitudinal Rest – State of calmness; relaxation without
emotional stress or freedom from anxiety.
EXERCISE AND ACTIVITY Sleep – State of consciousness in which the
Active-assistive – one side help the affected side individual’s perception and reaction to the
Isotonic – jogging; change in length environment are decreased.
Isometric – muscle tension no change in length
Isokinetic – weights Physiology of Sleep
Reticular Activating System (RAS) –
Aerobic – exceed oxygen needs responsible in keeping you awake and alert
Anerobic – does not exceed oxygen needs Bulbar Synchronizing Region (BSR) – causes
sleep
Massages

Effleurage – smooth, long gliding stroke

Petrissage – large pinch of skin; “kneading”
Tapotement – side of each hand, sharp hacking
movement Types of Sleep

NREM (Non-Rapid Eye Movement/ deep,

Immobility restful sleep / slow-wave sleep)
- Thrombus formation Stage I: very light; drowsy; relaxed, eyes roll
- Edema from side-to-side; lasting a few mins.
- Constipation
- Urinary stasis – stones- calculi Stage II: light sleep; body processes slow further
- Atrophy (decrease PR/RR), eyes are still; lasts about 10-
- Disuse syndrome 20 mins.
- Trochanter roll to prevent external rotation of
femur Stage III: domination of the PNS; difficult to
arouse; not disturbed by sensory stimuli;
Pressure Ulcer snoring; muscles totally relaxed.
- Decubitus ulcer/ bed sore Stage IV: delta sleep; deep slow-wave sleep
- Prone in bony surfaces
1 – non blanchable erythema REM (Rapid Eye Movement)
2 – open lesion - Where most dreams take place.
3- with fat exposed - Brain is highly active, hence, paradoxical sleep
4 – exposed mucles and bones
Common Sleep Disorders
Dressing Insomnia – warm bath, massage, milk
- Transparent barrier (tryptophan), medication
- Gauze not used
Parasomnia – periods of waking up while asleep Bruxism – anxiety; grinding of teeth
Somnambulism – sleep walking; lock the door
Soliloquy – sleep talk Hypersomnia – excessive sleep; may have
hypothyroid, DKA
Nocturnal enuresis (night)/Diurnal enuresis
(morning) – Bed wet, place diaper Narcolepsy – uncontrolled desire to sleep;
amphetamine - taken after breakfast, anorexiant

DO NOT TOUCH
THIS PART

Sure, here are some key notes on the and interventions, implementation carries out the
fundamentals of nursing: plan, and evaluation assesses outcomes.

**1. Introduction to Nursing:** **3. Patient Assessment:**

- Nursing is the art and science of caring for - Assessment involves gathering information
individuals, families, and communities to about a patient's health status through physical
promote, maintain, and restore health. examination, interviews, and observations.
- Nurses play a crucial role in healthcare by - It includes collecting subjective data (patient's
providing holistic care, focusing on physical, feelings and perceptions) and objective data
emotional, social, and spiritual aspects of (measurable findings).
patients' well-being. - A thorough assessment forms the foundation
for developing an effective care plan.
**2. Nursing Process:**
- The nursing process is a systematic approach **4. Communication Skills:**
used by nurses to provide patient-centered care. - Effective communication is essential for
- It involves five steps: assessment, diagnosis, building trust and understanding between nurses
planning, implementation, and evaluation and patients.
(ADPIE). - Nurses must use active listening, empathy, and
- Assessment gathers patient data, diagnosis clear language to convey information and
identifies health issues, planning develops goals understand patients' needs.
 - Nurses adhere to a code of ethics that guides
**5. Vital Signs:** their practice and ensures patient rights,
- Vital signs (temperature, pulse, respiratory autonomy, and confidentiality.
rate, blood pressure) are basic measurements - They are also accountable for understanding
that reflect a patient's overall health status. and following legal regulations related to
- Nurses monitor vital signs to detect changes healthcare.
and deviations that might indicate underlying
health issues. **11. Cultural Competence:**
- Nurses provide culturally competent care by
**6. Infection Control:** recognizing and respecting patients' diverse
- Infection prevention and control practices are beliefs, values, and practices.
crucial to reduce the spread of infections within - They tailor care plans to accommodate cultural
healthcare settings. preferences and ensure effective communication.
- Nurses follow strict protocols, such as hand
hygiene, using personal protective equipment **12. Patient Education:**
(PPE), and following isolation precautions. - Nurses educate patients and their families
about health conditions, treatment plans, and
**7. Medication Administration:** self-care strategies.
- Nurses are responsible for administering - Patient education empowers individuals to
medications safely and accurately. actively participate in their healthcare and make
- They must understand medication indications, informed decisions.
dosages, routes, and potential side effects.
- Nurses also educate patients about their **13. Documentation:**
medications and monitor their responses. - Accurate and thorough documentation is
essential for maintaining a patient's health
**8. Hygiene and Comfort:** record.
- Nurses assist patients in maintaining personal - Nurses record assessments, interventions, and
hygiene and comfort, which contributes to patient responses, which supports continuity of
overall well-being. care and legal accountability.
- Proper hygiene practices prevent infections and
promote dignity and self-esteem. **14. Teamwork and Collaboration:**
- Nursing is a collaborative profession that
**9. Basic Nursing Skills:** involves working with various healthcare
- Basic nursing skills include wound care, professionals to provide comprehensive care.
dressing changes, urinary catheterization, and - Effective teamwork ensures a holistic approach
assisting with activities of daily living (ADLs). to patient care and improved patient outcomes.
- Nurses must be skilled in performing these
tasks while respecting patient privacy and Remember that these notes are just an overview
maintaining aseptic technique. of the fundamentals of nursing. Each of these
areas can be explored in much greater detail, and
**10. Ethical and Legal Responsibilities:** nursing as a field is continuously evolving with
advancements in healthcare practices and
technology.