Fundamentals of Nursing Ho

7/28/2019 Fundamentals of Nursing Ho

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FUNDAMENTALS OF NURSING

Nursing Theories and Theorists

Florence Nightingale (Environmental Theory) a persons health was the direct result of theenvironmental influences specially cleanliness, light, pure air, pure water and efficient drainage.

Through manipulating the environment, nursing aims to discover the laws of nature that would assist

in putting the patient in the best possible condition so that nature can effect a cure.

Hildegard Peplau (Theory of Interpersonal Relations) defined the concepts and stages involved in thedevelopment of the nurse-client relationship. She identified the roles of the nurse as stranger, resource

person, teacher, leader, surrogate and counselor.

Virginia Henderson (14 basic needs) defined nursing as, The unique function of the nurse is to assistthe individual, sick or well, in the performance of those activities contributing to health or its recovery

(or to a peaceful death) that he would perform unaided if he has the necessary strength, will, or

knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

Henderson attempted to identify the basic human needs as the basis of nursing care. The 14 basic

needs are as follows:

breathing normally eating and drinking adequately eliminating body waste moving and maintaining a desirable position sleeping and resting selecting suitable clothes maintaining normal body temperature by adjusting clothing and modifying the environment keeping the body clean and well groomed to promote integument avoiding dangers in the environment and avoiding injuring others communicating w/others in expressing emotions ,needs,fears or opinions worshipping accdg. to one's faith working in such a way that one feels a sense of accomplishment playing or participating in various forms of recreation learning , discovering or satisfying the curiosity that leads to normal development and health, and

using available health facilities

Faye Abdellah (21 nursing problems)"Nursing is based on an art and science that mould the attitudes, intellectual competencies, and

technical skills of the individual nurse into the desire and ability to help people , sick or well, cope with

their health needs."

o To promote good hygiene and physical comforto To promote optimal activity, exercise, rest, and sleepo To promote safety through prevention of accidents, injury, or other trauma and through the

prevention of the spread of infection

o To maintain good body mechanics and prevent and correct deformitieso To facilitate the maintenance of a supply of oxygen to all body cellso To facilitate the maintenance of nutrition of all body cellso To facilitate the maintenance of eliminationo To facilitate the maintenance of fluid and electrolyte balanceo To recognize the physiologic responses of the body to disease conditionso To facilitate the maintenance of regulatory mechanisms and functionso To facilitate the maintenance of sensory functiono To identify and accept positive and negative expressions, feelings, and reactions


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o To identify and accept the interrelatedness of emotions and organic illnesso To facilitate the maintenance of effective verbal and nonverbal communicationo To promote the development of productive interpersonal relationshipso To facilitate progress toward achievement of personal spiritual goalso To create and maintain a therapeutic environmento To facilitate awareness of self as an individual with varying physical, emotional, and

developmental needs

o To accept the optimum possible goals in light of physical and emotional limitationso To use community resources as an aid in resolving problems arising from illnesso To understand the role of social problems as influencing factors in the cause of illness

Joyce Travelbee (Existentialism/ Human-to-human relationship model) a theory that is centered onindividual existence in an incomprehensible world and the role that free will plays in it, and searched ti

find meaningin lifes experiences.

Jospehine Paterson and Loreta Zderad ((Humanistic NUrsing Theory) a humanistic nurse has adifferent frame of reference that places her relationship with the patient at the center of her focus,

with the patient's health benefiting from that relationship rather than solely from medical or

educational experience.

Myra Estrine Levine(4 Conservation Principles) Levine believed in the wholeness of the human beingand the primary focus of conservation is to maintain that wholeness.

o Conservation of Energy the individual requires a balance of energy and a constant renewal ofenergy to maintain life activities.

o Conservation of Structural Integrity structural integrity is concerned with the process ofhealing to restore wholeness and continuity after injury or illness.

o Conservation of Personal Integrity everyone seeks to defend his or her identity as a self, inboth that hidden, intensely private person that dwells within and in the public faces assumed as

individuals move through their relationship with others.

o Conservation of Social Integrity No diagnosis should be made that does not include the otherpersons intertwined with that of the individual.

Dorothea Orem (Self-care /Self-care deficit theory ) self-care is a learned behavior and a deliberateaction in response to a need. Self-care deficit purports that nursing care is needed when people areaffected by limitations that do not allow them to meet their self-care needs. These theories define

three types of nursing systems:

o Wholly Compensatory Nursing System the nurse supports and cares for the client,compensates for the clients inability to care for self, and attempts to provide care for the

client.

o Partly Compensatory Nursing System both the nurse and the client perform care measures.o Supportive-Educative Nursing Systemthe nurses actions are to help the clients develop their

own self care activities.

Sister Callista Roy (Adaptation Theory) the person has coping mechanisms that are broadlycategorized in either the regulator of cognator subsystem. The regulator subsystem functions through

the autonomic nervous system, which responds automatically through neural,chemical, and

endocrine coping processes. The cognator subsystem enables the person to respond to stimuli

through processing stimuli, learning, judgment, and emotion. All input into the system (the person) is

channeled through the regulator and cognator subsystems. If the regulator or cognator subsystem

fails, there is ineffective adaptation.

Jean Watson (Theory of Human Caring) focuses on the art and science of human caring. Watsonstheory is composed on 10 carative factors which are defined as nursing actions or caring processes.

These carative factors are:


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o Formation of a humanistic-altruistic system of valueso Nurturing of faith-hopeo Cultivation of sensitivity to ones self and to otherso Developing a helping-trusting, human caring

relationship

o Promotion and acceptance of the expression ofpositive and negative feelings

o Use of creative problem-solving method processeso Promotion of transpersonal teaching and learningo Provision for a supportive, protective, or corrective

mental, physical, sociocultural, and spiritual environment

o Assistance with gratification of human needso Allowance for existential-phenomenological forces

Martha Rogers (Science of Unitary Human Beings) the person is a unified whole and seen as greaterthan and different from the sum of the parts. The whole person cannot be known by examining any

particular aspect or dimension of the person because all aspects together combine to form an entity

different from the collection of parts. It is the characterization of the person as a human energy field

that unites all aspects of the person into a unified whole. The whole ofthe persons energy field

interacts with the whole of the environmental energy field, which results in the process of life. Rosemarie Rizzo Parse (Theory of Human Becoming)

o The first theme, MEANING, is expressed in the first principle of humanbecoming, which statesthat "Structuring meaning is the imaging and valuing of languaging. This principle means that

people coparticipate in creating what is real for them through self-expression in living their

values in a chosen way.

o The second theme, RHYTHMICITY, is expressed in the second principle of humanbecoming,which states that "Configuring rhythmical patterns of relating is the revealing-concealing and

enabling-limiting of connecting-separating". This principle means that the unity of life

encompasses apparent opposites in rhythmic patterns of relating. It means that in livingmoment-to-moment one shows and does not show self as opportunities and limitations

emerge in moving with and apart from others.

o The third theme, TRANSCENDENCE, is expressed in the third principle of humanbecoming,which states that "Cotranscending with possibles is the powering and originating of

transforming". This principle means that moving beyond the "now" moment is forging a unique

personal path for oneself in the midst of ambiguity and continuous change.

Imogene King (Goal Attainment Theory) Madeleine Leninger (Transcultural Nursing) Margaret Newman (Health as an expanding Consciousness) Patricia Benner Betty Neumann (Healthcare Systems Model) Lydia Hall (The Nursing Process)

Types of Healthcare Services

Basically, health care services can be categorized into three levels: Primary, Secondary and Tertiary.

The complexity of care caries according to the individuals need, providers expertise, and delivery set ting


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PRIMARY: HEALTH PROMOTION AND ILLNESS PREVENTION

Goal: To decrease the risk to a client (individual or community) for disease or dysfunction)

Examples: Teaching, Lifestyle modifications for health, referrals, immunizations, promotion of a safe

environment

SECONDARY: DIAGNOSIS AND TREATMENT

Goal: Early intervention to alleviate disease and prevent further disability

Examples: Screenings/Diagnosis, Acute Care, Surgery

TERTIARY: REHABILITATION

Goal: to minimize effects and permanent disability of chronic or irreversible condition

Examples: Education and retraining, provision of direct care, environmental modifications

THE NURSING PROCESS

The nursing process is a framework for providing professional, quality nursing care. It directs nursing

activities for health promotion, health protection and disease prevention and is used by nurses in every

practice, setting and specialty.

OVERVIEW OF THE NURSING PROCESS

Assessment

Assessment is the first step in the nursing process and includes collection, verification, organization,

interpretation and documentation of data. The completeness and correctness of the information obtained

during the assessment are directly related to the accuracy of the steps that follow.

Primary Source of Data the major provider of information. As much information as possible should be

gathered from the client, using both interview techniques and physical examination

Secondary Source of Data - sources of data other than the client. and may include family members, other

health care providers and medical records.

Subjective Datasubjective data are data from the clients point of view and include feelings, perceptions,

and concerns. The method of collecting the data is primarily the interview.

Objective Data objective data are observable and measurable data that can be obtained through both

standard assessment techniques performed during the physical examination and diagnostic tests.

Diagnosis

The second step in the nursing process involves further analysis and synthesis of the data that have

been collected. Formulation of the list of nursing diagnoses is the outcome of this process. According to

NANDA, nursing diagnosis is a clinical judgment about the individual, family or community responses to actual,

or potential health problems/life processes. Below is a table of comparison between Medical and Nursing

Diagnoses.


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Medical Diagnosis Nursing Diagnosis

Focuses on the illness, injury or disease process Focuses on the responses to actual or potential health

problems or life processes

Remains constant until a cure is effected Changes as the clients response and/or the health

problem changes

Identifies conditions the health care practitioner is

licensed and qualified to treat

Identifies situations in which the nurse is licensed and

qualified to intervene

Types of Nursing Diagnoses

Actual Nursing Diagnosis indicates that a problem exists and is composed of a diagnostic label,related factors and signs and symptoms

Risk Nursing Diagnosis indicates that a problem does not yet exist, but special risk factors arepresent. A risk diagnosis is a diagnostic label preceded by the phrase risk for with the specific risk

factor listed.

Possible Nursing Diagnosis indicates a situation in which a problem could arise unless preventiveaction is taken. In addition, a possible diagnosis may state a hunch or intuition by the nurse that

cannot be confirmed or eliminated until more data have been collected

Wellness Nursing Diagnosisindicates that the clients expression of a desire to attain a higher level ofwellness in some area of function. It is composed of the diagnostic label preceded by the phrase

potential for enhanced

Collaborative problems are defined as physiologic complications monitored by nurses to assesschanges in the client status. Collaborative problems are managed through the use of interventions

prescribed by other health care practitioners and/or nurses

Planning

Planning is the third step of the nursing process and includes the formulation of guidelines that

establish the proposed course of nursing action in the resolution of nursing diagnoses. Client-centered goals

are established in collaboration with the client whenever possible.A Goal is an aim, intent or end. Goals are broad statements that describe the intended or desired

change in the clients behavior

Expected Outcomes are specific objectives related to the goals that are used to evaluate the nursing

intervention. Outcomes have to be SMART

A Nursing Intervention is the activity that the nurse will execute for and with the client to enable

accomplishment of the goals.

Implementation

The fourth step of the nursing process is implementation. It involves the execution of the nursing plan

of care derived during the planning phase. It consists of performing nursing activities that have been planned

to meet the goals set with the client.

Evaluation

The fifth step in the Nursing Process, involves determining whether the client goals have been met,

partially met and not met. Evaluation is an ongoing process. Nurses continually evaluate data in order to

make informed decisions during other phases of the nursing process.


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ASSESSMENT

Purpose: to establish a database concerning a clients physical, psychosocial and emotional health in

order to identify health promoting behaviors as well as actual and/or potential problems

Review of Systems

Review of systems is a brief account from the client of any recent signs or symptoms associated with

any of the body systems. This allows the client to communicate any deviations from normal that have been

otherwise identified. Relevant data in the review of systems shall include:

Location: the area of the body in which the symptom (such as pain) can either be pointed ordescribed in detail

Character: the quality of the feeling or sensation (e.g., sharp, dull, stabbing) Intensity: the severity or quantity of the feeling or sensation and its interference with functional

abilities. The sensation can be rated on a scale of 1 to 10

Timing: the onset, duration, frequency and precipitating factors of the system Aggravating/alleviating factors: the activities or actions that make the symptom worse or better

PHYSICAL EXAMINATION

Inspection

- Involves careful visual observation. The client is observed first from a general point of view and

then with specific attention to detail

Palpation

- uses the sense of touch to assess texture, temperature, moisture, organ location and size,

vibrations and pulsations, swelling, masses and tenderness.

- Palpation uses a calm, gentle approach and is used systematically with light palpation preceding

deep palpation and palpation of tender areas performed last

Percussion- Uses short, tapping strokes on the surfaces of he skin to create vibrations of underlying organs. It is

used for assessing the density of structures or determining the location and size of organs in the

body

Auscultation

- Involves listening to sounds in the body that are created by movement of air or fluid.

MEASURING VITAL SIGNS

MEASUREMENT OF HEIGHT AND WEIGHT

Height

Measurement of height is expressed in inches (in), feet, (ft), or meters (m)

CONVERSION EQUIVALENTS

FOR HEIGHT MEASUREMENT

1 in. = 2.5 cm 1 cm = 0.4 in. 1 in. = 2.5 cm 1 cm = 0.4 in.

1 ft = 30.5 cm or 0.3 m 1 m = 39.4 in. or 3.28 1 ft = 30.5 cm or 0.3 m 1 m = 39.4 in. or 3.28


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Guidelines in taking the height:

- When measuring an infants length, the nurse should place the child in a firm surface. Extend the

knees with the feet at right angles to the table. Measure the distance form the vertex (top) of the

head to the soles of the feet with a measuring tape.

- Height increases gradually from birth to the prepubertal growth spurt

- Girls usually reach their adult height between the ages of 16 and 17whereas boys continue to grow

until the ages 18 to 20 years

Weight

` Measurement in weight is usually expressed in ounces (oz), pounds (lbs) and kilograms (kg)

CONVERSION EQUIVALENTS FOR

WEIGHT MEASUREMENT

1 lb = 0.45 kg 1 kg = 2.2 lb 1 lb = 0.45 kg 1 kg = 2.2 lb

1 oz = 28.4 g 1 g = 0.35 oz 1 oz = 28.4 g 1 g = 0.35 oz

Guidelines in taking the weight:

- When the client has an order for daily weights, the weight should be obtained at the same time

of the day on the same scale, with the client wearing the same type of clothing.

- Standing scales are used for clients who can carry their own weight.

- Accurate reading of weights are imperative because they are used in drug dosage calculations and

to evaluate the effectiveness of drug, fluid and nutritional therapy.

BODY TEMPERATURE

Frequent monitoring is required for clients who have or are at risk for infection

CENTIGRADE AND FAHRENHEIT

CONVERSION FORMULAS

Centigrade to Fahrenheit conversion: multiplythe centigrade reading by 9/5 and add 32: F =

(C 9/5) + 32

Fahrenheit to centigrade conversion: deduct 32

from the Fahrenheit reading and multiply by 5/9:

C = (F32) 5/9

Sites for Body Temperature taking

Traditional sites for measuring the bodys internal (core) temperatures are Oral, Rectal and Axillary

using either glass (obsolete) or electronic thermometers. Advances in clinical thermometry provide other

devices and sites, such as thermistors for pulmonary artery temperature and infrared thermometers for Ear

Canal Temperature. Oral and rectal measurements are higher than the axillary because the measuring device

is in contact with a mucous membrane. The axilla is a commonly used site for infants and children with

disabilities because it is the safest, even though least accurate method. Axillary or rectal sites are used for

clients who are uncooperative, comatose or who have a nasogastric tube in place.

*Rectal temperature measurements is contraindicated in clients with cardiovascular alterations because the

thermometer may stimulate the vagus nerve and cause an irregular cardiac rhythm. It is also contraindicated

in leukemia and rectal surgery clients because the insertion of the thermometer may traumatize the mucosa

or the incision line, causing bleeding. *


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Alterations in thermoregulation

Alteration Definition Characteristics

Heat exhaustion An increase in body temperature

(3840C; 100.4104.0F) in

response to environmental

conditions that, in turn, causes

diaphoresis (profuse perspiration)

Loss of excessive amounts of water

and sodium from perspiring leads

to thirst, nausea, vomiting,

weakness, and disorientation.

Heat stroke A critical increase in body

temperature, (41-44 C) resulting

from exposure to high

environmental temperatures

Dry, hot skin is the most important

sign. The person becomes

confused, or delirious and

experiences thirst, abdominal

distress, muscle cramps and visual

disturbances. Loss of

consciousness occurs if untreated

Hypothermia A body temperature of 35 C or

lower resulting from cold weather

exposure or artificial induction

Decrease in metabolism leads to

impaired mental functioning and

depressed pulse, respirations andblood pressure; can result in

cardiac arrest if untreated

Frostbite Freezing of the bodys surface

areas (earlobes, fingers and toes)

in extremely low temperatures

Circulatory impairment may be

followed by gangrene

PULSE

Pulse assessment is the measurement of a pressure pulsation created when the heart contracts and

ejects blood into the aorta. There are multiple pulse points. The most accessible are the radial and carotid

sites.

Pulse Characteristics

A normal pulse has defined characteristics, quality, rate, rhythm and volume. Pulse Quality refers to

the feel of the pulse, its rhythm and forcefulness. Pulse Rate is an indirect measurement of cardiac output

by counting the number of apical or peripheral pulse wave over a pulse point. A normal pulse rate for for

adults is between 60 to 100 beats per minute. Bradycardia is a heart rate less than 60 beats per minute in an

adult. Tachycardia is a heart rate in excess of 100 beats per minute in an adult

Electrocardiogram (ECG) provides an electrical representation of the hearts activity. The primarypacemaker of the heart is the Sinoatral (SA) node. If another site within the heart initiates the

electrical activity, the ECG tracing will identify the area serving as the pacemaker. Cardiac Telemetry transmits the hearts electrical activity to a site for continuous monitoring A Holter monitor is a portabledevice worn for a 24 hour interval to identify the dysrhythmia pattern.

RESPIRATIONS

Respirations is the measurement of the breathing pattern.

Characteristics of Normal and Abnormal Breath Sounds

Different Respiratory patterns are characterized by their rate, rhythm and depth.

Eupnea refers to easy respirations with a normal rate of breaths per minute that are age-specific


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Nursing Considerations

Before checking a blood pressure, review the clients chart for brachial artery contraindications and

make sure that the client has not exercised or eaten for the past 30 minutes. Clients who have recently eaten,

ambulated, or experienced an emotional upset will have a falsely high blood pressure reading. When

the vital signs are taken correctly in sequence (T-P-R and BP), the client should be calm from sitting or lying

quietly.

Faulty techniques that constrict blood flow will produce

a false high pressure reading:

A cuff too narrow for the extremity

A cuff that does not fit snugly around the extremity

A cuff that is deflated too slowly

Other false high readings occur when the mercury column in the manometer is not positioned flat on a

firm surface or is read above eye level or the extremity is below the hearts apex level. False low readings

occur when the extremity is above the hearts apex level, the cuff is too wide for the extremity, or the mercury

column in the manometer is read below eye level. If the nurse fails to recognize the auscultatory gap, the

temporary disappearance of sounds at the end of Korotkoff phase I and beginning of phase II, the systolicpressure is read at a false low pressure.

Fundamentals of Nursing Ho

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