GENERAL OBJECTIVES*At the end of the discussion, the learners shall be able to:◦Refresh their prior knowledge about concepts in

Fundamentals of Nursing ◦Discover certain topics which seem new to them

◦Develop techniques that would help them in inculcating the concepts by heart and mind

◦Evaluate the learning process they undergo by having simple quizzes and exercises

CONTENT PREVIEWFirst day

I. Historical and Contemporary Nursing Practice1. Nursing Leaders 2. Definitions of Nursing 3. Roles and Functions of a Nurse

II. Nursing Theories III. Paradigm: Definition of Terms

1. MAN: Levels of Clientele2. NURSING PROCESS 3. HEALTH

IV. Health Promotion 1. Levels of Prevention 2. Health Promotion and Health Protection

V. Man and His Basic Human Needs

VI. Health and Illness

VII. Asepsis and Infection Control

VIII. Stress, Adaptation, Homeostasis

IX. Physiologic Responses to Stress and Illness

X. Communication in Nursing

XI. The Nursing Process

XII. Assessing Health

Episodes of information overload

Student’s information processing

capacity

Information Load

Information Overload

Grassroots of Nursing:N-U-R-S-I-N-G- L-E-A-D-E-R-S

Florence Nightingale-first nursing scientist/ theorist for her work“Notes on Nursing: What It Is, and What It Is Not (1860/1969)”

Clara Barton -organized the American Red Cross

Lilian Wald-founder of Public Health Nursing. Henry Street Settlement and Visiting Nurse Service

Lavinia Dock-Nursing leader, protested for women’s rights

Margaret Sanger -Nurse activist, founder of Planned Parenthood

Common Themes in Definition of Nursing

Nursing is caring.Nursing is an art. (“SKILLS”)Nursing is a science. (“THEORIES”)Nursing is client-centered.Nursing is holistic. Nursing is adaptive. Nursing is a helping profession. Nursing is concerned with health promotion, disease

prevention, and health restoration.

NURSING as a science and an art.

1. Lewis introducing the topic “research” in class.2. Jumbo inserting IV catheter. 3. Gerald washed his hands first before he introduced the NGT because he wanted to maintain aseptic technique. 4. Noel could easily recall all the definitions of nursing. 5. Regina promptly performed CPR after assessing that the patient doesn’t have a pulse and is not breathing.

Nursing as a caring profession

Five Processes of Caring: 1.Knowing 2.Being with 3.Doing for 4.Enabling 5.Maintaining Belief

Caring includes the ffg. factors: Providing presence- “eye contact”’Comforting- “touch” Listening- “attention” Knowing the client- “uniqueness’ Spiritual caring- “transpersonally” Family Care- “participants”

Is Nursing a vocation or a profession?

Characteristics of a Profession

1.Education 2.Theory 3.Service4.Autonomy 5.Code of Ethics 6.Caring

-the most unique characteristic of nursing

“The Nurse is basically a good person”.

Four Virtues from the Practice of Charity1.Justice - being righteous2.Prudence- cautious 3.Fortitude- support 4.Temperance- sacrifice

Exercise: ____1. The nurse encourages the patient to verbalize. ____2. The nurse respects the autonomy of the patient. ____3. The nurse should stand even in unfavorable

conditions. ____4. Before giving the medication, the nurse verified

the dosage to the fellow nurse.

Attributes of Character

1. Thinking of other alternatives. 2. Your boss has put a lot of trust in you because of

this attribute.3. You’re protecting the name of the hospital you’re

working with. 4. You have to control your temper when undesirable

events happen. 5. Informing the client about the medication you’re

about to give. 6. Questioning an unclear doctor’s order. 7. Recognizing others because of a job well done. 8. Delaying your schedule of watching a movie

because of an exam.

Honesty Tolerance Reliability Resourcefulness Loyalty Judgment Motivation Moderation Honesty Tolerance Reliability Resourcefulness Loyalty Judgment Motivation Moderation

Roles and Functions of a Professional Nurse

Reporting abnormal VS to the doctor Continuing education to improve current practiceInforming the patient about his rightsProviding the client’s needsGives health teachingsPlans, gives directions, develops staff, monitors operationsInterpersonal influence to promote the health of the client Helps the patient to cope with stressful emotional problems Initiates changes and assists the client to have modifications in lifestyle to

promote health You meticulously wrote your SOAPIE method in the chart to inform others

about the care you delivered to the patient. Coordinates the activities you planned for CVA patients to a nutritionist,

physical therapist and speech therapist to properly manage the patient’s condition

Care Provider Leader Counselor Communicator Manager Collaborator Teacher Researcher Change Agent Client Advocate Case Manager

Care Provider Leader Counselor Communicator Manager Collaborator Teacher Researcher Change Agent Client Advocate Case Manager

Types of Nursing Interventions:

1. The nurse providing 2-3LPM of O2. 2. Steam Inhalation 3. Oral Inhaler 4. Chest Physiotherapy 5. Purse-lip breathing 6. Deep Breathing Exercises 7. Cough Excercises8. Health education9. Calories needed by the client10. For Chest X-ray

Independent Dependent Interdependent

Nursing Care Delivery Models

* to develop BEDSIDE NURSING and improve professional

relationships b/n staff. *RN is responsible for all

aspects of care to one or more clients.

*RN is the leader together with nursing assistants and

health aides. *Coordinates and links health

care services to clients and their families

*Division of tasks, one nurse assumes a responsibility

apart from others’ task

Total Patient Care

Functional Nursing

Team Nursing

Primary Nursing

Case Management

Total Patient Care

Functional Nursing

Team Nursing

Primary Nursing

Case Management

Nursing Theorists

Florence Nightingale -Environmental Theory

Virginia Henderson -Assist the client to gain

independence; 14 Basic

Needs

Faye Abdellah -21 Nursing Problems

Dorothy Johnson -Behavioral System Model

Imogene King -Goal Attainment Theory

Madeleine Leininger -Transcultural Nursing

Myra Levin -Four Conservational Theory

Betty Neuman -Health Care System Model

Cont…

Dorothea Orem -Self-Care Deficit Theory

Hildegard Peplau -Interpersonal Model

Martha Rogers -Science of Unitary Human Beings

Sister Callista Roy -Adaptation Model

Lydia Hall -Core, Care and Cure

Ida Jean Orlando -Dynamic Nurse-Patient Relationship

Jean Watson -Human Caring Model

Joyce Travelbee -Interpersonal Aspects of Nursing Model

Ernestine Weidenbach-Clinical Nursing- A Helping Art Model

Definition of Terms

MAN -is a biopsychosocial and spiritual being who is in constant contact with the environment. (Roy)

LEVELS OF CLIENTELE I. Individuals II. Families III. Social GroupIV. Communities

HEALTH- a complete state of physical, mental, emotional and social being of a person and not just merely the absence of disease or infirmity. (World Health Organization, 1947)

-From an Old English “heal” which means “whole”

A Simple Paradigm

MAN NURSING PROCESS HEALTH

Individuals ADPIE END GOAL Families Social GroupsCommunities

MAN’s Basic Needs:

Abraham Maslow’s Hierarchy of Needs Abraham Maslow’s Hierarchy of Needs

Self- Actualization

Self-Esteem Self-Esteem

Love and BelongingnessLove and Belongingness

Safety and Security Safety and Security

Physiologic Physiologic

Identify the following according to

Maslow’s Hierarchy of Needs:

1.Self-respect 2.The need to be fulfilled3.Rest and sleep 4.Elimination 5.The need for shelter 6.The need to care and be cared for7.Self-worth 8.Psychological safety 9.Oxygen 10.Spiritual fulfillment

CLINICAL/MEDICAL MODEL

ROLE PERFORMANCE MODEL

ADAPTIVE MODEL (Sister Callista Roy)

EUDOMONISTIC MODEL

AGENT-HOST-ENVIRONMENT MODEL (Leavell & Clark)

HEALTH-ILLNESS CONTINUUM (McCann/Flynn & Heffron, 1984)

DUNN’S HIGH- LEVEL WELLNESS GRID (1959)

Models of Health

Models of Health

A. Clinical Model hlt practitioners used this model if their focus is

on own relief of s/sx of dse & eliminate pain & malfunction.

If there is less or absence of s/sx & pain health is restored.

B. Role Performance Model People who can fulfil their roles are healthy

even if they appear clinically ill.Assumes in this model that “sickness” is the

inability to perform one’s work.

C. ADAPTIVE MODEL (Sister Callista Roy)

Adaptation – it is the focus of this modelBelief: health is a creative process. Therefore,

disease is a failure in adaptation. (maladaptation)Treatment of a person: aim is to restore person by

ability of a person to adapt, i.e. “to cope”

D. EUDOMONISTIC MODEL it views that in this model, the highest aspiration of

people is fulfilment & complete development which is “actualization”

Illness is viewed as a condition that prevents self-actualization

E. AGENT-HOST-ENVIRONMENT MODEL (Leavell & Clark)

also known as Ecologic Model; model was derived due to the community health work of authors

model is used in predicting illness rather than in promoting wellness

Env’t

Host

Agent

F. HEALTH-ILLNESS CONTINUUM (McCann/Flynn & Heffron, 1984)

Disability Symptoms Signs Awareness Education Growth

Treatment Model

Wellness Model

Premature Death

High-Level

Wellness

G. DUNN’S HIGH- LEVEL WELLNESS GRID (1959)

C. Protected Poor Hlt (in favourable

env’t) thru social & cultural institutions

A. High- Level Wellness (in favourable

environment)

D. Poor Health(unfavourable environment)

B. EmergentHigh-Level Wellness

(in unfavourable environment)

Very unfavorable environment

Peak WellnessDeath

Health Axis

Environmental Axis

Peak WellnessDeath Peak Wellness

Death

D. Poor Health(unfavourable environment)

Death

Very favorable environment

Classification of DiseasesAccording to Etiology

1.Hereditary 2.Congenital 3.Idiopathic 4.Metabolic 5.Deficiency 6.Neoplastic 7.Degenerative 8.Iatrogenic 9.Traumatic 10.Allergic

•DM •Alopecia after chemotherapy •Osteoarthritis •Uterine cancer

•Fracture•Skin Allergy

•Osteomalacia •Hyperthyroidism

•Cleft Palate •HPN

According to Duration or Onset

1.Acute Illness- short duration 2.Chronic Illness- longer than 6 mos.

*remission -asymptomatic but with dse.

*exacerbation -becomes active again with pronounced s/sx

Three Levels of Prevention 1. Primary- health promotion and protection 2. Secondary- early detection, diagnosis, screening 3. Tertiary- rehabilitation and adaptation

Identify the type of prevention:

1.Quit Smoking 2.Wear hazard devices 3.Physical Therapy after CVA 4.Attending Self-Management education for DM pts. 5.Have annual physical examination 6.Sputum Exam for TB 7.Weighing the children8.Taking adequate fluids9.Complete immunization 10.Speech therapy after laryngectomy

Activities to Promote Health and Prevent Illness

1. Have regular (yearly) PE-Papsmear and BSE

2. Men: regular testicular examination 3. Annual dental examination 4. Exercise regularly at least 3x per week for 30 mins. 5. Do not smoke.6. Avoid alcohol 7. Reduce fat and increase fiber in the diet.8. Sleep regularly 7 to 8 hours/ night9. Eat breakfast 10. Maintain an ideal body weight

Health and Illness

ASEPSIS and INFECTION CONTROL

Infection- invasion by MOsAsepsis- free from infection Medical Asepsis- clean techniqueSurgical Asepsis- sterile technique Sepsis- presence of infection Carrier- asymptomatic but with

infectionReservoir- habitat Resident flora- normally live on skinSterilization- all MOs are destroyed Disinfectant- remove pathogens on

inanimate objectsAntiseptic- remove pathogens on persons

but doesn’t necessarily destroyBactericidal- destroys bacteria

Cont…Communicable Dse.- infectious agent that can

be transmitted (direct, indirect, vehicle, airborne)

Pathogen- a disease-producing microorganisms

Pathogenicity- ability to cause a diseaseVirulence- the vigor of MOs in which they

can grow and multiply Nosocomial infection- hospital-acquired infection Isolation- separation of persons with

communicable diseaseEtiology- the study of the causes

Stages of Infectious Process

1.Incubation period time 2.Prodromal period non-specific to specific 3.Illness period s/sx4.Convalescent period recovery

Chain of infection

Agent Reservoir Portal of exit

HOST Portal of entry Mode of transmission

Mode of Transmission

1. Contact

a. direct body to body (bathing, feeding etc.)

b. indirect exposure (contaminated objects)

2. Droplet (<3ft.) secretions

3. Airborne (>3ft) fine particles suspended in

air

4. Vectorborne biologic and mechanical

5. Vehicle mediator (food, water, milk, blood etc)

Types of Immunization

Natural Natural

Artificial Artificial

ACTIVE PASSIVE

What type of immunity? 1.Recovery from mumps2.Colostrum 3.Tetanus Immuniglobulin 4.Tetanus Toxoid 5.OPV6.Recovery from Chickenpox

2 Types of Disinfection: a. Concurrent b. Terminal

Handwashing- is the single most important infection control practice.

Soap, water and alcohol are being used. Wash hands before and after every client care

contact. It would be effective with adequate friction. Medical asepsis is done b holding hands lower than

the elbows. Apply friction for 15 to 30 seconds on each hand. Clean under fingernails. Ideally, turn off the faucet with clean paper towel.

Health and Illness

Stress, Adaptation, Homeostasis

“Stress is always a part of the fabric of daily

life”. -hans selye

Adaptation- the adjustments that a person make in different

situations.

Types:1.General Adaptation Syndrome (GAS)

a. Stage of Alarm b. Stage of Resistancec. Stage of Exhaustion

2.Local Adaptation Syndrome (LAS)-man may respond to stress through a particular body part or organ. -examples: inflammation, backache, headache, diarrhea

Homeostasis -“homeodynamic”, because of constant change -a state of stability or equilibrium

Sympatho-Adreno-Medullary Responses (SAMR)

Stressors: Physical injury,

dehydration etc.

Hypothalamus

Adrenal Medullla (Norepinephrine and epinephrine)

Inflammatory Response • Rubor • Calor• Tumor• Dolor • Loss of Function

Exudates ◦Serous ◦Serosanguinous◦Sanguinous◦Purulent ◦Mucoid

Healing may be classified as: a. Primary/ First Intention

- clean cut wound b. Second Intention

- wound is extensive and there is a great amount of tissue loss.

c. Tertiary/Third Intention - delayed surgical closure of infected wound

Other responses to tissue injury: 1.Necrosis death of tissues2.Hypertrophy increase in cell size3.Hyperplasia increase in cell number 4.Metaplasia replacement of one mature cell type

with another mature cell type

Nursing Interventions for Clients with Inflammation

1. Promote rest2. Reduce swelling

Position: Elevate partCold and warm compress

3. Relieve pain 4. Increase hydration 5. Adequate nutrition: high calorie, CHON, Vit. C 6. Pharmacotherapy

Analgesic/ antipyretic: Acetaminophen, Paracetamol, Aspirin, Mefenamic acid NSAIDS, SteroidsAntimicrobials

Therapeutic Relationship -directed towards helping a patient heal,

physically and emotionally.

-a professional relationship between a nurse,

physician or therapist and a client.

-Focused on helping the client solve problems

and achieve health-related goals.

-a means for smoothly implementing the five

processes of the nursing process.

-TRUST is the foundation of a positive nurse-

client relationship.

I. Pre-interaction -review medical records-client’s history -speak with other HCP

II. Orientation -perform assessment -formulate patient outcomes-plan interventions-ESTABLISH RAPPORT AND TRUST

III. Working Phase -establish a contract -set limits-discuss the time frame of your relationship

IV. Termination -evaluate the pt.’s progress -review areas that need improvement -discuss any feelings (positive or negative) during termination

Phases of Therapeutic Nurse-Patient Relationship

Stress- is an essential aspect of existence and has always been of human experience; it is something that every one has to cope.

Stress Management

1. Supporting protective mechanism

-rest, massage, relief of pain

2. Exploration of feelings

3. Facilitating problem solving

4. Regular pattern of exercise

5. Relaxation techniques

Advanced Stress Management and Relaxation Techniques

Autogenic trainingVisualization and ImageryAffirmation Meditation Therapeutic touch Massage Yoga Music therapy Anti-anxiety medications

1.Use silence.2.Accepting. 3.Giving recognition.4.Offering self.5.Giving broad opening. 6.Offering general leads. 7.Making observations8.Encouraging comparison9.Restating 10.Focusing 11.Reflecting 12.Exploring13.Giving information 14.Seeking clarification 15.Presenting reality16.Asking direct questions

Communication Techniques Communication Techniques

What type of coping mechanism was used?

1.The adolescent decides to take up nursing because she greatly admires her mother who is a nurse.

2.The girl who is not as beautiful as her sisters, studies very hard and she achieves high grades.

3.The teacher who really wants to be the principal of the school states that she wouldn’t take the position if it were offered because it is a lot of work and no commensurate compensation.

4.The father shouts at his children as he arrives home because he was reprimanded by his boss at work.

5.The six year old child thumbsucks as he is confined in the hospital.

6.The nursing student vomits after a very difficult situation. 7.The client with cancer consults other physicians because he

refuses to accept his diagnosis. 8.The student who hates her teacher, frequently tells the teacher

that she admires her teaching.

Documenting- serves a permanent record. Reporting- when two or more people share

information about the client care, either face to face or by telephone.

Purposes: 1.Communication 2.Legal Documentation 3.Research 4.Statistics 5.Education 6.Audit and Quality Assurance 7.Planning Client Care8.Reimbursement

Documenting and Reporting

Types of RecordsA.Source-Oriented Medical Record

(Traditional)- Each department makes notes on the chart.

Five Basic Components 1.Admission Sheet 2.Physician’s Order Sheet3.Medical History 4.Nurses’ Notes 5.Special Records and Reports

(referrals, x-ray, VS, I&O)

B. Problem-Oriented Medical Record (POMR)

-integrates all data about the problem gathered by the HCP.

-records are recorded and arranged according to the source of information.

Four Basic Components 1.Database- all initial information 2.Problem List3.Plan of care4.Progress notes

(SOAPIE, Flow Sheets, Discharge notes)

Kardex-makes information readily accessible to all

members of the HCP. -series of flip cards-tool for change-of-shift-report (use a pencil

only)

Data included in KARDEX: • Personal data • Basic needs • Allergies • Diagnostic tests• Nursing procedures• Medications and IV therapy, BT • Treatments like oxygen supply, steam inhalation,

suctioning, change of dressing, mechanical ventilation

Characteristics of a Good Recording

1. Brevity (concise and complete)2. Use of ink/ permanence3. Accuracy (chart objective facts)

Incorrect: Ate with poor appetite. Correct: Ate 50% of the food served. Incorrect: DepressedCorrect: Seen crying

*Place quotation marks if it’s a client complain*Objective data (VS, I&O etc.)*Describe behaviors rather than feelings *Refusal of medications and treatments- documented

4. Appropriateness

Cont…

5. Completeness and chronology *Notes should appear on succeeding line.*Date and time are included.*Avoid time changes in the text of other nurses.*Avoid double charting.*Avoid squeezing an information into a space.

The following information should be charted:

1. Physician’s visits 2. Medication- immediately 3. Treatment- immediately

Cont…

6. Use of Standard Terminology (include grammar)7. Signed (Bernard M. Lapuz, SN/ Bernard M. Lapuz, RN)

8. In case of ERROR-draw a horizontal line, write “ERROR”, initials/ signature

9. Confidentiality 10. Legal Awareness11. Legible 12. Do not use the word “patient” or “pt.”; the chart belongs to

the patient. 13. A horizontal line drawn to fill up a partial line

-to prevent others from adding information e.g. Bernard M. Lapuz, RN

Types of Reporting1. Change-of-Shift Report

-endorsement (KARDEX)2. Telephone Reports

a. when the call was madeb. who made the reportc. who was calledd. to whom information was given e. what information was given f. what information was received

3. Telephone orders *ONLY RNs may receive telephone orders*The order must be verified; have a witness if possible*Should be countersigned by the physician within 24 hours

4. Transfer reports- when transferring a pt. to another unit.

Give the meaning of commonly used abbreviations…

a. Cognitive (Knowledge)

b. Affective (Emotions, Feelings and

Interests)

c. Psychomotor (Skills)

a.c OD ADL OU Ax. OSBID QIDBMR ADBP AUc.c. ASCap prnGtt s.s.h.S s.cIM statIV TIDMcgtt Od

a.c OD ADL OU Ax. OSBID QIDBMR ADBP AUc.c. ASCap prnGtt s.s.h.S s.cIM statIV TIDMcgtt Od

DOMAINS of LEARNING

THE NURSING PROCESS

a. Head-to-Toe Framework General: General Health State, VS, weight,

nutritional status Head, hair, scalp, eyes, ears, oral cavity, cranial

nerves Neck Chest Abdomen Extremities Genitals Rectum

Assessing Health Assessing Health

Body Systems FrameworkRespiratory Cardiovascular Musculoskeletal Gastrointestinal Integumentary Endocrine Genitourinary Reproductive NeurologiccSensory Psychosocial

1. Body Temperature-balance between heat produced and heat loss in the body.

Types: a.Core- deep tissues (oral and rectal)

b.Surface- skin and subQ (axilla)

Heat regulating center- HYPOTHALAMUS

Factors affecting body’s heat: a. Basal Metabolic rate

*younger-higher the BMR *older- lower the BMR

b. Muscle Activity- exercises increases BMRc. Thyroxine output- increases BMR d. Catecholamines- increases BMRe. Fever

Factors affecting temperature: 1. Age2. Diurnal variation- highest from 8-12MN

lowest from 4-6AM 3. Exercise4. Hormones 5. Stress- Sympathetic stimulation

PROCESSES in HEAT LOSS

1.Application of moist wash-cloth over the skin 2.Exposure of skin towards electric fan 3.Continuous vaporization of moisture from the skin,

oral mucous, respiratory tract4.It feels warm in a crowded area.

Radiation Convection Conduction Evaporation Radiation Convection Conduction Evaporation

Alterations in Body Temperature 1.Pyrexia/ Hyperthermia- above normal 2.Hyperpyrexia- very high, >41C 3.Hypothermia- low temp.

Types of Fever1.Intermittent Fever-fluctuates to normal and

abnormal within 24 hours2.Remittent Fever- fluctuates within 24 hours

of abnormal temperature 3.Relapsing Fever- fluctuates to normal and

abnormal few days in between 4.Constant Fever- remains very high

ORAL Most accessible and convenient to use

2-3 minutes

c/I: Oral Lesions, dyspnea, cough, seizure, chills, unconscious

AXILLA Safest and most non-invasive method

10 minutes

C/I: none

TYMPANIC Fastest

2-3 seconds

C/I: Mastoiditis and ear infection

RECTAL

Most accurate Assume lateral position

2 minutes

C/I: Hemmohoidectomy, diarrhea, anal fissures, quadriplegic clients

Pulse 1. Rate: Newborn 120-180bpm

Adult 60-100bpm *Tachycardia- above 100bpm *Bradycardia- below 60bpm

2. Rhythm- the pattern and intervals of beats. *Dysrhythmia- irregular rhythm

3. Volume- the strength of the pulse. *Normal pulse can be felt with moderate pressure*Full/ bounding- great pressure*Thready pulse- weak

4. Presence/ ansence of bilateral equality* radial, ulnar, femoral etc.

Pulse Sites

1.Temporal 2.Carotid 3.Apical 4.Brachial 5.Radial 6.Femoral 7.Posterior tibial 8.Popliteal 9.Pedal (Dorsalis Pedis)

Respiration -the act of breathing.

Three processes: 1.Ventilation – movement of gases in and out of lungs2.Diffusion – exchange of gases 3.Pefusion – movement of blood for transport

Two types:a.Costal (thoracic)- movement of chestb.Diaphragmatic (abdominal)- movement of

abdomen

Respiratory centersa.Medulla Oblongata- primary respiratory center b.Pons

*Pneumotaxic- rhythmic quality of breathing *Apneustic- deep prolonged breathing

Assessing Respiration Rate: 12-20 RR/minDepth- observe for movement of chestRhythm- observe for regularity of exhalation and inhalation Quality- respiratory effort and sound of breathing

Terminologies: Eupnea- normal respiration Tachypnea- >20RR/ min Bradypnea- <12RR/ min Hyperventilation- Deep, rapid respiration (alkalosis)Hypoventilation- slow, shallow respiration (acidosis)Dyspnea- DOB Orthopnea- ability to breath only in upright position Apnea- absence of respirations

Blood Pressure - The pressure exerted by blood against the walls of the

arteries

*Systolic Pressure- pressure of blood as a result of contraction of the ventricles

*Diastolic Pressure- pressure when ventricles are at rest.

*Pulse Pressure- difference between the systolic and diastolic pressures (30-40mmHg)

*Hypertension->140/90mmHg

*Hypotension- <90/60mmHg

Determinants of BP 1.Blood Volume 2.Peripheral Resistance (dialte and constrict)3.Elasticity or compliance of blood vessels4.Blood Viscosity

Assessing BP 1.Allow to rest. 2.Sitting or supine3.Left arm is preferred over the right. 4.Snugly fit5.Inflate6.Deflate- “Korotkoff sound’7.If Mercurial, read lower meniscus 8.Prevent “Error of Parallax”

Nursing Health History -gathered through interview

Components of Nursing Health History

1.Biographic Data 2.Chief Complaint 3.History of Present Illness 4.Past Health History 5.Family History of Illness 6.Review of Systems 7.Lifestyle 8.Social data9.Psychologic data10.Patterns of health care

Physical Health Examination -head to toes -determine the mental status and LOC -protect the client’s privacy during the examination -prepares the needed articles and equipment

Modes of Examination 1.Inspection -sight2.Palpation -touch3.Percussion -tapping4.Auscultation -stethoscope (hear)

Positions

1.Dorsal recumbent 2.Dorsal/ supine 3.Sitting4.Fowler’s- semi (45 degrees) and high (90 degrees)5.Lithotomy6.Lateral7.Sim’s/ Semi-prone position 8.Prone

Pointers: 1. Sequence of assessment in abdomen?

IAPERPAL2. Sequence of quadrants?

RLQ, RUQ, LUQ, LLQ3. Best position when examining the chest?

Sitting 4. Position when examining the back?

Standing 5. How do we check for neck lymphadenopathy?

Stand behind the client and palpate the neck 6. If you’ll use vaginal instrument, pour warm water

first to ensure comfort.

Supplemental Dataa.Urine b.Stool c.Sputum d.Blood e.Body secretions

Urine specimen 1.Clean-catch, mid-stream specimen for routine urinalysis, C&S

- Best time to collect is AM (concentrated)- Discard the first flow urine.- Sterile container. Wash first before getting the

specimen. - 30-50ml - Send to the laboratory immediately

2. 24-hour urine specimen -Discard first voided urine - Collect all specimen thereafter, until the same day the

ffg. day. - Soak the specimen in a container with ice.

3. Catheterized urine specimen -clamp the catheter for 30 mins. to 1hour. -cleanse the drainage port of the two-way FC-Use sterile needle and syringe to aspirate from the

drainage port. -don’t collect urine from the urinary drainage bag.

Stool a.Routine fecalysis –determine ova/ parasitesb.Stool Culture- etiologic agents c.Guaiac Stool Exam/ Occult Blood- bleeding

Test of Glucose in the urine *Benedict’s Test -collect specimen before meals-Heat 5ml of Benedict’s solution in a test tube-Add 8-10 drops of urine Interpretation:

Blue - (-)Green - +Yellow - ++Orange - +++Red - ++++

Test for Albumin in the urine *Heat and Acetic Acid Test-collect urine specimen before meals -imaginary divide the test tube into three parts-fill the 2/3 part with urine, heat the test tube -add 1/3 acetic acid or just few drops, don’t boil -CLOUDINESS indicates albuminuria

Sputum Specimen: 1. Sputum Culture and Sensitivity Test 2. Acid-fast bacilli (AFB) staining (3 consecutive

mornings)

THANK YOU!