FUNDAMENTALS OF NURSING

OVERVIEW
I

THEORETICAL FRAMEWORK of NURSING PRACTICE

A
B
C
D
E
F
G

Nursing
Concepts of Health and Illness
Concepts of Stress
Homeostasis
Adaptation
Adaptation to Stress Physiological Response (Hans Selye)
Physiologic Indicators of Stress

II

COPING STRATGIES (COPING MECHANISMS)

A 2 Types of Coping Strategies
B Relaxation Techniques

III

PSYCHOLOGICAL RESPONSE
A Task Oriented Behaviors
B Defense Mechanisms
C Common Defense Mechanisms

IV

TYPES of NURSING DIAGNOSES

A Formulating the Nursing Diagnosis
B Collaborative Problems

METHODS USED for ASSESSMENT

A Collection of Data: Objective and Subjective

VI

DOCUMENTING and REPORTING

A Guidelines for Good Documentation and Reporting
B Documentation
C Documentation Systems
D Nursing Care Plan (NCP)
E KARDEX
F Nursing Discharge / Referral Summaries

VII

PHYSICAL EXAMINATION
A Purposes
B Preparation of Examination
C Order of Examination
D Skills in Physical Assessment
E Examples of Adventitious Breath Sounds

VIII

THE COMMUNICATION PROCESS

A Modes of Communication
B Verbal Communication
C Nonverbal Communication
D Factors Influencing the Communication Process
E Therapeutic Communication Technique
F Barriers to Communication
G Phases of the Helping Relationship
PRINCIPLES and PRACTICE of NURSING CARE

IX

PRINCIPLES of ASEPSIS and INFECTION CONTROL

A
B
C
D
E
F
G
H

Chain of Infection
Modes of Transmission
Course of Infection
Inflammation
Immune Response
Nosocomial Infection
Factors Increasing Susceptibility to Infection
Diagnostic Tests Used to Screen for Infection

THEORIES OF PAIN
A Specific Theory
B Pattern Theory
C Gate Control Theory
D Current Developments in Pain Theory

XI

TYPES OF PAIN
A
B

XII

Acute Pain
Chronic Pain

PAIN ASSESSMENT
A TOOLS/INSTRUMENTS USED
B A B C D E method of pain assessment
C P Q R S T assessment for pain perception
D Pain History
ADMINISTRATION OF MEDICATIONS

XIII

DRUG NOMENCLATURE and FORMS

A Names
B Classification
C Forms
D Types of Drug Actions
E Principles in Administering Medications

XIV

BASIC HUMAN NEEDS

A Abraham Maslow
B Maslows Characteristics of a SelfActualized Person

XV

MEETING OXYGENATION NEEDS

A Oxygenation
B Cardiovascular Physiology
C Structure and Function
D Steps in the Process of Oxygenation
E
MEETING NUTRITIONAL NEEDS
A Principles of Nutrition
B Nutrients

XVI

XVII

MEETING URINARY ELIMINATION NEEDS

A Normal Urinary Function
B Common Assessment Findings

XVIII

URINARY CATHETERIZATION
A Purposes
B Necessary Equipment for Catheterization
C Preparation of the Patient
D Retention or Indwelling Catheter (Foley)
E Procedure for Insertion
F Caring for the Patient with an Indwelling Catheter
G Removing the Indwelling Catheter and Aftercare of the Patient

XIX

MEETING BOWEL ELIMINATION NEEDS

A Factors that Influence Bowel Elimination
B Characteristics of Normal Stool
C Common Bowel Elimination Problems

XX

TYPES of ENEMAS
A Cleansing
B Oil-Retention
C Carminative
D Astringent

XXI

NASOGASTRIC and INTESTINAL TUBES

A Nasogastric Tubes
B Intestinal Tubes

XXII

LOSS AND GRIEF

A Loss
B Grieving Process (Theories of Grief, Dying, and Mourning)
C Anticipatory Grief
D Complications of Bereavement
E Symptoms of Normal Grief
F Nursing Health Promotion (to facilitate mourning)

1
A

THEORETICAL FRAMEWORK of NURSING PRACTICE

Nursing
As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia Henderson: The
unique function of the nurse is to assist the individual, sick or well, in the performance of those
activities contributing to health. Its recovery, or to a peaceful death that the client would perform
unaided if he had the necessary strength, will or knowledge.
Help the client gain independence as rapidly as possible.

CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE

Theorist

Description

FLORENCE
NIGHTINGALE

Developed the first theory of nursing.

Focused on changing and manipulating the environment in order to put the patient in the
best possible conditions for nature to act.

HILDEGARD PEPLAU

Introduced the Interpersonal Model.

She defined nursing as a therapeutic, interpersonal process which strives to develop a
nurse-patient relationship in which the nurse serves as a resource person, counselor
and surrogate.

FAYE ABDELLAH

Defined nursing as having a problem-solving approach, with key nursing problems

related to health needs of people; developed list 21 nursing problem areas

IDA JEAN ORLANDO

Developed the three elements client behavior, nurse reaction and nurse action
compose the nursing situation. She observed that the nurse provide direct assistance to
meet an immediate need for help in order to avoid or to alleviate distress or helplessness.

MYRA LEVINE

Described the Four Conservation Principles.

1 conservation of energy
2 conservation of structured integrity
3 conservation of personal integrity
4 conservation of social integrity

DOROTHY JOHNSON

Developed the Behavioral System Model.

1 Patients behavior as a system that is a whole with interacting parts
2 how the client adapts to illness
3 goal of nursing is to reduce so that the client can move more easily through
recovery.

MARTHA ROGERS

Conceptualized the Science of Unitary Human Beings. She asserted that human beings
are more than different from the sum of their parts; the distinctive properties of the whole
are significantly different from those of its parts.

DOROTHEA OREM

Emphasizes the clients self care needs; nursing care becomes necessary when client is
unable to fulfill biological, psychological, developmental or social needs.

IMOGENE KING

Nursing process is defined as dynamic interpersonal process between nurse, client and
health care system.

BETTY NEUMAN

Stress reduction is a goal of system model of nursing practice. Nursing actions are in
primary, secondary or tertiary level of prevention

SISTER CALLISTA ROY

Presented the Adaptation Model. She viewed each person as a unified bio-psychosocial
system in constant interaction with a changing environment. The goal of nursing is to
help the person adapt to changes in physiological needs, self-concept, role function and
interdependent relations during health and illness.

LYDIA HALL

Introduced the notion that nursing centers around three components: person(core),
pathologic state and treatment(cure) and body(care).

JEAN WATSON

Conceptualized the Human Caring Model. She emphasized that nursing is the
application of the art and human science through transpersonal caring transactions to help
persons achieve mind-body-soul harmony, which generates self-knowledge, self-control,
self-care and self-healing.

ROSEMARIE RIZZO
PARSE

Introduced the Theory of Human Becoming. She emphasized free choice of personal
meaning in relating to value priorities, co-creating of rhythmical patterns, in exchange
with the environment and contranscending in many dimensions as possibilities unfold.

MADELEINE LENINGER

Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic
and scientific mode of helping a client through specific cultural caring processes (cultural
values, beliefs and practices) to improve or maintain a health condition

ROLES AND FUNCTION OF A NURSE

a
b

f
g

h
i

Caregiver the caregiver role has traditionally included those activities that assist the
client physically and psychologically while preserving the clients dignity. Caregiving
encompasses the physical, psychosocial, developmental, cultural and spiritual levels.
Communicator communication is an integral to all nursing roles. Nurses communicate
with the client, support persons, other health professionals, and people in the community.
In the role of communicator, nurses identify client problems and then communicate these
verbally or in writing to other members of the health team. The quality of a nurses
communication is an important factor in nursing care.
Teacher as a teacher, the nurse helps clients learn about their health and the health
care procedures they need to perform to restore or maintain their health. The nurse
assesses the clients learning needs and readiness to learn, sets specific learning goals in
conjunction with the client, enacts teaching strategies and measures learning.
Client advocate a client advocate acts to protect the client. In this role the nurse may
represent the clients needs and wishes to other health professionals, such as relaying the
clients wishes for information to the physician. They also assist clients in exercising their
rights and help them speak up for themselves.
Counselor counseling is a process of helping a client to recognize and cope with
stressful psychologic or social problems, to developed improved interpersonal
relationships, and to promote personal growth. It involves providing emotional, intellectual,
and psychologic support.
Change agent the nurse acts as a change agent when assisting others, that is, clients,
to make modifications in their own behavior. Nurses also often act to make changes in a
system such as clinical care, if it is not helping a client return to health.
Leader a leader influences others to work together to accomplish a specific goal. The
leader role can be employed at different levels; individual client, family, groups of clients,
colleagues, or the community. Effective leadership is a learned process requiring an
understanding of the needs and goals that motivate people, the knowledge to apply the
leadership skills, and the interpersonal skills to influence others.
Manager the nurse manages the nursing care of individuals, families, and communities.
The nurse-manager also delegates nursing activities to ancillary workers and other nurses,
and supervises and evaluates their performance.
Case manager nurse case managers work with the multidisciplinary health care team to
measure the effectiveness of the case management plan and to monitor outcomes.

Research consumer nurses often use research to improve client care. In a clinical area
nurses need to:
Have some awareness of the process and language of research
Be sensitive to issues related to protecting the rights of human subjects
Participate in identification of significant researchable problems
Be a discriminating consumer of research findings

Concepts of Health and Illness

I

Health As defined by the World Health Organization (WHO): state of complete physical,
mental and social well-being, not merely the absence of disease or infirmity.
a Characteristics
i
A concern for the individual as a total system
ii
A view of health that identifies internal and external environment
iii
An acknowledgment of the importance of an individuals role in life
A dynamic state in which the individual adapts to
changes in internal and external environment to maintain a state of well being
b

Models of Health and Illness

i
ii
iii

iv

II

Four Components
individual is perception of susceptibility to an illness
individuals perception of the seriousness of the illness
perceived threat of a disease
perceived benefits of taking the necessary preventive
measures

The
The
The
The

Evolutionary Based Model Illness and death serves as a evolutionary function.

Evolutionary viability reflects the extent to which individuals function to promote
survival and well-being. The model interrelates the following elements:
Life events
Life style determinants
Evolutionary viability within the social context
Control perceptions
Viability emotions
Health outcomes

vi

Health-Illness Continuum (Neuman) Degree of client wellness that exist at any point
in time, ranging from an optimal wellness condition, with available energy at its
maximum, to death which represents total energy depletion.
High Level Wellness Model (Halbert Dunn) It is oriented toward maximizing the
health potential of an individual. This model requires the individual to maintain a
continuum of balance and purposeful direction within the environment.
Agent Host environment Model (Leavell) The level of health of an individual or
group depends on the dynamic relationship of the agent, host and environment
Agent any internal or external factor that disease or illness.
Host the person or persons who may be susceptible to a
particular illness or disease
Environment consists of all factors outside of the host
Health Belief Model Addresses the relationship between a persons belief and
behaviors. It provides a way of understanding and predicting how clients will behave in
relation to their health and how they will comply with health care therapies.

Health Promotion Model A complimentary counterpart models of health protection.

Directed at increasing a clients level of well being. Explain the reason for clients
participation health-promotion behaviors. The model focuses on three functions:
It identifies factors (demographic and socially) enhance or decrease the
participation in health promotion
It organizes cues into pattern to explain likelihood of a clients
participation health-promotion behaviors
It explains the reasons that individuals engage in health activities
Illness State in which a persons physical, emotional, intellectual, social developmental or
spiritual functioning is diminished or impaired. It is a condition characterized by a deviation
from a normal, healthy state.

3 Stages of Illness
i
Stage of Denial Refusal to acknowledge illness; anxiety, fear, irritability and
aggressiveness.
ii
Stage of Acceptance Turns to professional help for assistance
iii
Stage of Recovery (Rehabilitation or Convalescence) The patient goes
through of resolving loss or impairment of function

Rehabilitation
i
A dynamic, health oriented process that assists individual who is ill or disabled
to achieve his greatest possible level of physical, mental, spiritual, social and
economical functioning.
ii
Abilities not disabilities, are emphasized.
iii
Begins during initial contact with the patient
iv
Emphasis is on restoring the patient to independence or regain his preillness/predisability level of function as short a time as possible
v
Patient must be an active participant in the rehabilitation goal setting an din
rehabilitation process.

Focuses of Rehabilitation
i
Coping pattern
ii
Functional ability focuses on self-care: activities of daily living (ADL); feeding,
bathing/hygiene, dressing/grooming, toileting and mobility
iii
Mobility
iv
Integrity of skin
v
Control of bowel and bladder function

Concepts of Stress
I
Stress
(Theory by Hans Selye)
a Non specific response of the body to nay demand made upon it
b Any situation in which a non specific demand requires an individual to respond or take
action
II
a

Characteristics of Stress
Stress is not nervous energy. Emotional reactions are common stressors

Stress is not always the result of damage to the body

Stress does not always result in feelings of distress (harmful or unpleasant stress)

Stress is a necessary part of life and is essential for normal growth and development

Stress involves the entire body acting as a whole and is an integrated manner

Stress response is natural, productive and adaptive

III

Stressors Factor or agent producing stress, maybe: physiological, psychological, social,

environmental, developmental, spiritual or cultural and represent an unmet needs
a

Classification of Stressors
i
Internal Stressors originate from within the body. E.g. fever, pregnancy,
menopause, emotion such as guilt
ii

External Stressors originate outside a person. E.g. change in family or

social role, peer pressure, marked change in environmental temperature

Factors influencing response to stressors

i
Physiological functioning
ii
Personality
iii
Behavioral characteristics
iv
Nature of the stressor: integrity, scope, duration, number, and nature of
other stressors

Homeostasis Process of maintaining uniformity, stability and constancy with in the living organisms.
(from Greek word homotos like, and stasis position)

Adaptation Bodys adjustment to different circumstances and conditions. Process by the

physiological or psychological dimensions change in response to stress; attempt to maintain optimal
functioning

Adaptation to Stress-Physiological Response (Hans Selye)

I
Local Adaptation Syndrome (LAS) Response of a body tissue, organ or part to the stress of
trauma, illness or other physiological change
a Characteristics
i
The response is localized, it does not involve entire body systems
ii
The response is adaptive, meaning that a stressor is necessary to stimulate it
iii
The response is short term. It does not persist indefinitely
iv
The response is restorative, meaning that the LAS assists in restoring homeostasis to
the body region or part
b

Two Localized Responses

Reflex Pain Response is a localized response of the central
nervous system to pain. It is an adaptive response and protects tissue from further
damage. The response involves a sensory receptor, a sensory nerve from the spinal
cord, and an effector muscle. An example would be the unconscious, reflex removal of
the hand from a hot surface.

ii

Inflammatory Response is stimulated by trauma or infection. This response localizes

the inflammation, thus revenging its spread and promotes healing. The inflammatory
response may produce localized pain, swelling, heat, redness and changes in
functioning.
c Three Phases of Inflammatory Response
First Phase Narrowing of blood vessels occurs at the injury to control bleeding. Then
histamine is released at the injury, increasing the number of white blood cells to combat
infection.

ii

Second Phase It is characterized by release of exudates from the wound

iii

Third Phase The last phase is repair of tissue by regeneration or scar formation.
Regeneration replaces damaged cells with identical or similar cells.

II

General Adaptation Syndrome (GAS) or Stress Syndrome characterized by a chain or

pattern of physiologic events.
a 3 Stages

ii

The three stages of adaptation to stress: the alarm reaction, the stage of resistance and the stage of exhaustion.

iii

Alarm Reaction initial reaction of the body which alerts the bodys
defenses. SELYE divided this stage into 2 parts:
The SHOCK PHASE
The COUNTERSHOCK PHASE
Stage of Resistance occurs when the bodys adaptation takes place; the
body attempts to adjust with the stressor and to limit the stressor to the
smallest area of the body that can deal with it.
Stage of Exhaustion the adaptation that the body made during the
second stage cannot be maintained; the ways used to cope with the
stressors have been exhausted

Stressor

Shock Phase

Epinephrine
Tachycardia
Myocardial contractility

Blood clotting
Metabolism

Norepinephrine
Blood to kidney
Renin

Cotisone
Protein catablism
Gluconeogenesis

Stage of Resistance

b
c
d
e
f
g
h
i
j

Adaptation

Stage of Exhaustion

Rest

Death

STRESSORS stimulate the sympathetic nervous system, which in turn stimulates the
hypothalamus. The HYPOTHALAMUS releases corticotrophin releasing hormone (CRH).
During times of stress, the ADRENAL MEDULLA secretes EPINEPHRINE &
NOREPINEPHRINE in response to sympathetic stimulation. Significant body responses
to epinephrine include the following:
i
Increased myocardial contractility, which increases cardiac output & blood
flow to active muscles
ii
Bronchial dilation, which allows increased oxygen intake
iii
Increased blood clotting
iv
Increased cellular metabolism
v
Increased fat mobilization to make energy available & to synthesize other
compounds needed by the body.

Physiologic Indicators of Stress

a Pupils dilate to increase visual perception when serious threats to the body arise.
b

Sweat production (diaphoresis) increases to control elevated body heat due to increased
metabolism.

The heart rate & cardiac output increase to transport nutrients and by-products of metabolism
more efficiently.

Skin is pallid because of constriction of peripheral vessels, an effect of norepinephrine.

Sodium & water retention increase due to release of mineralocorticoids, which results in
increased blood volume.

The rate & depth of respirations increase because of dilation of the bronchioles, promoting
hyperventilation.

Urinary output may increase or decreases.

The mouth may be dry.

Peristalsis of the intestines decreases, resulting in possible constipation and flatus.

For serious threats, mental alertness improves.

Muscle tension increases to prepare for rapid motor activity or defense.

Blood sugar increases because of release of glucocorticoids & gluconeogenesis.

H
a
b
c
d

Psychologic Indicators psychologic manifestations of stress include anxiety, fear, anger,

depression & unconscious ego defense mechanisms.

Anxiety a common reaction to stress. It is a state of mental uneasiness, apprehension, dread, or foreboding or a
feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. It
can be experienced, subcutaneous or unconscious level. Can be manifested on 4 LEVELS:
Fear an emotion or feeling of apprehension aroused by impending or seeming danger, or other perceived threat. The
object of fear may or may not be based in reality.
Anger an emotional state consisting of a subjective feeling of animosity or strong displeasure. People may feel guilty
when they feel anger because they have been taught that to feel angry is wrong.
Depression common reaction to events that seem overwhelming or negative. It is an extreme feeling of sadness,
despair, dejection, lack of worth or emptiness.
Emotional symptoms can include: Feelings of tiredness, sadness, emptiness, or numbness
Behavioral signs include: Irritability, inability to concentrate, difficulty making decisions, loss of
sexual desire, crying, sleep disturbance and social withdrawal.
Physical signs include: Loss of appetite, weight loss, constipation, headache and dizziness
I

Cognitive Indicators are thinking responses that include problem-solving, structuring,

self-control or self-discipline, suppression and fantasy

Problem solving involves thinking through the threatening situation, using a specific steps to arrive at a solution

Structuring arrangement or manipulation of a situation so that threatening events do not occur.

Self-Control (discipline) assuming a manner of facial expression that convey a sense of being in control or in change.

Suppression consciously and willfully putting a thought or feeling out of mind

Fantasy (daydreaming) likened to make believe. Unfulfilled wishes & desires are imagined as fulfilled, or a
threatening experience is reworked or replayed so that it ends differently from reality.
2

COPING STRATEGIES (COPING MECHANISMS)

Coping dealing with problems & situations or contending with them successfully.
Coping Strategy innate or acquired way of responding to a changing environment or specific problem or
situation.
According to Folkman and Lazarus, coping is the cognitive & behavioral effort to manage specific external
and/ or internal demands that are appraised as taxing or exceeding the resources of the person.
A

Coping Strategies: 2 Types

I
Problem-focused coping efforts to improve a situation by making changes or taking some
action
II Emotion-focused coping does not improve the situation, but the person often feels better.
Coping strategies are also viewed as:
a Long-term coping strategies can be constructive & realistic
b Short-term coping strategies can reduce stress to a tolerable limit temporarily but are
in the end od ineffective ways to deal with reality.
Coping can be adaptive or maladaptive:
B Adaptive Coping helps the person to deal effectively with stressful events &
minimizes distress associated with them.
C Maladaptive Coping can result in unnecessary distress for the person & others
associated with the person or stressful event.
*Effective coping results in adaptation; ineffective coping results in maladaptation. The
effectiveness of an
individuals coping is influenced by a number of factors:

The number, duration & intensity of the stressors

Past experiences of the individual

Support systems available to the individual

Personal qualities of the person

*If the duration of the stressors is extended beyond the coping powers of the individual,
that person becomes exhausted and may develop increased susceptibility to health
problems.
*Reaction to long term stress is seen in family members who undertake the care of a
person in the home for a long period. This stress is called caregiver burden & produces
responses such as chronic fatigue, sleeping difficulties & high BP.
*Prolonged stress can also result in mental illness.

Relaxation Techniques used to quiet the mind, release tension & counteract the fight or flight
responses of General Adaptation Syndrome (GAS).
I
Breathing Exercises
II Massage
III Progressive Relaxation
IV Imagery
V Biofeedback
VI Yoga

VII
VIII
IX
X

Meditation
Therapeutic Touch
Music Therapy
Humor & Laughter
3

PSYCHOLOGICAL RESPONSE

Exposure to a stressor results in psychological and physiological and physiological adaptive responses. As
people are exposed a stressors, their ability to meet their basic needs is threatened. This threat whether
actual or perceived, produces frustration, anxiety and tension. Psychological adaptive behaviors assist the
persons ability to cope with stressors. These behaviors are directed at stress management and are
acquired through learning and experience as a person identifies acceptable and successful behaviors.
Psychological adaptive behaviors are also related to as COPING MECHANISMS. It involves:
A

Task Oriented Behaviors Involve using cognitive abilities to reduce stress, solve problems,
resolve conflicts and gratify needs. It enables a person to cope realistically with the demands of a
stressor.
Three General Types
I
Attack Behavior Is acting to remove or overcome a stressor or to satisfy a need
II Withdrawal Behavior Is removing the self physically or emotionally from the stressor
III Compromise Behavior Is changing the usual method of operating, substituting goals or
omitting the satisfaction of needs to meet other needs or to avoid stress.

Defense Mechanisms Unconscious behaviors that offer psychological protection from a stressful
event. They are used by everyone and help protect against feelings of worthlessness and anxiety.
Frequently activated by short-term stressors and usually do not result in psychiatric disorders.
4

TYPES OF NURSING DIAGNOSES

Formulating the Nursing Diagnosis

I
Actual
a Clients demonstrates defining characteristics of a problem
b Nurse intervenes to resolve or help client cope with the problem
II

High-risk
a A problem is likely to develop based on assessment of risk factors
b Nurse intervenes to reduce risk factors or increase protective factors
c Example: encourage smoking cessation

III

Wellness
a Client is presently healthy but wishes to achieve a higher level of function
b Nurse intervenes to promote growth or maintenance of the healthy response

Collaborative Problems
I
Definition: a potential problem the nurse manages using both independent and
interdependent interventions
II

Example: potential complication of head injury: loss of consciousness, epidural or subdural

hematoma, seizures

III

Usually occurs when a disease is present or a treatment is prescribed

IV

Clients with similar disease or treatment will have the same potential for complications,
which must be managed collaboratively; however, their responses to the condition will vary,
so a broad range of nursing diagnoses will apply.
a Example: a client with asthma will always be at risk for lowered oxygen saturation;
however, the clients response to this condition will be unique based on his/her
developmental level, past experiences and family configuration

b
Example:
Disease/Situation
Potential
complication of
childbirth

Refer to Table for examples of collaborative problems

Complication
Hemorrhage

Related to
Related to

Dysrhythmia

Related to

Etiology
1.Uterine atony
2. Retained placental
fragment
3. Bladder distention
Low serum potassium

Potential
complication of
diuretic therapy

5
A

METHODS USED for ASSESSMENT

Collaboration of Data: Objective & Subjective

I

Review of clinical record

a Client records contain information collected by many members of the healthcare team,
such as demographics, past medical history, diagnostic test results and consultations

II

Reviewing the clients record before beginning an assessment prevents the nurse from
repeating questions that the client has already been asked and identifies information
that needs clarification.

Interview
a The purpose of an interview is to gather and provide information, identify problems of
concerns, and provide teaching and support.
b The goals of an interview are to develop a rapport with the client and to collect data
c An interview has 3 major stages
i
Opening: purpose is to establish rapport by creating goodwill and trust; this
is often achieved through a self introduction, nonverbal gestures (a
handshake), and small talk about the weather, local sports team, or recent
current event; the purpose of the interview is also explained to the client at
this time.
ii
Body: during this phase, the client responds to open and closed-ended
questions asked by the nurse.
iii
Closing: either the client or the nurse may terminate the interview, it is
important fro the nurse to try to maintain the rapport and trust that was
developed thus far during the interview process.
d

Types of questions
i
Closed questions used in directive interview
Re____ short factual answers; e.g. Do you have pain?
Answers usually reveal limited amounts of information
Useful with clients who are highly stressed and/or have difficulty
communicating
ii

Open-ended questions used in nondirective interview

Encourage clients to express and clarify their thoughts and feelings;
e.g. How have you been sleeping lately?
Specify the broad area to be discussed and invite longer answers
Useful at the start of an interview or to change the subject

iii

Leading questions
Direct the clients answer; e.g. You dont have any questions about
your medications, do you?
Suggests what answer is expected
Can result in client giving inaccurate data to please the nurse
Can limit client choice of topic for discussion

III Nursing History

a Collection of information about the effect of the clients illness on daily functioning and
ability to cope with the stressor (the human response)
b

Subjective
i
ii
iii
iv

data
May be called covert data
Not measurable or observable
Obtained from client (primary source), significant others, or health
professionals (secondary sources).
For example, the client states, I have a headache

Objective data
i
May be called overt data
ii
Can be detected by someone other than the client
iii
Includes measurable and observable client behavior
iv
For example, a blood pressure reading of 190/110 mmHg.

IV Physical assessment
a Systematic collection of information about the body systems through the use of
observation, inspection, auscultation, palpation and percussion
b A body system format for physical assessment is found below:

General assessement
Integumentary system
Head, ears, eyes, nose, throat
Breast and axillae
Thorax and lungs
Cardiovascular system
Nervous system
Abdomen and gastrointestinal system
Anus and rectum
Genitourinary system
Reproductive system

Musculoskeletal system
Psychosocial assessment
a Helpful framework for organizing data
b A suggested format for psychosocial assessment is found below:

Vocation/education/financial
Home and Family
Social, leisure, spiritual and cultural
Sexual
Activities of daily living
Health Habits

Psychological

The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be
helpful for guiding data collection

VI Consultation
a The nurse collects data from multiple sources: primary (client) and secondary (family
members, support persons, healthcare professionals and records)
b Consultation with individuals who can contribute to the clients database is helpful in
achieving the most complete and accurate information about a client
c Supplemental information from secondary sources (any source other then the client)
can help verify information, provide information for a client who cannot do so, and
convey information about the clients status prior to admission
VII Review of literature
a A professional nurse engages in continued education to maintain knowledge of current
information related to health care
b Reviewing professional journals and textbooks can help provide additional data to
support or help analyze the client database

6
I
II
III
IV

V
VI

DOCUMENTING and REPORTING

A Guidelines for Good Documentation and Reporting

Fact information about clients and their care must be factual. A record should contain descriptive, objective
information about what a nurse sees, hears, feels and smells
Accuracy information must be accurate so that health team members have confidence in it
Completeness the information within a record or a report should be complete, containing concise and thorough
information about a clients care. Concise data are easy to understand
Currentness ongoing decisions about care must be based on currently reported information. At the time of
occurrence include the following:
a Vital signs
b Administration of medications and treatments
c Preparation of diagnostic tests or surgery
d Change in status
e Admission, transfer, discharge or death of a client
f
Treatment fro a sudden change in status
Organization the nurse communicate in a logical format or order
Confidentiality a confidential communication is information given by one person to another with trust and confidence
that such information will not be disclosed
B

Documentation anything written or printed that is relied on as a record of proof fro authorized
persons.
Purposes of Records:
I
Communication
II Planning Client Care
III Auditing Health Agencies
IV Research
V Education
VI Reimbursement
VII Legal Documentation
VIII Health Care Analysis

Documentation Systems
I
Source Oriented Record
a The traditional client record
b Each person or department makes notations in a separate section or sections of the
clients chart
c It is convenient because care providers from each discipline can easily locate the forms
on which to record data and it is easy to trace the information
d Example: the admissions department has an admission sheet; the physician has a
physicians order sheet, a physicians history sheet & progress notes
e NARRATIVE CHARTING is a traditional part of the source-oriented record
II

Problem Oriented Medical Record (POMR)

a Established by Lawrence Weed
b The data are arranged according to the problems the client has rather than the source
of the information.
The four (4) basic components:
i
Database consists of all information known about the client when the
client first enters the health care agency. It includes the nursing
assessment, the physicians history, social & family data
ii
Problem List derived from the database. Usually kept at the front of the
chart & serves as an index to the numbered entries in the progress notes.
Problems are listed in the order in which they are identified & the list is
continually updated as new problems are identified & others resolved
iii
Plan of Care care plans are generated by the person who lists the
problems. Physicians write physicians orders or medical care plans;
nurses write nursing orders or nursing care plans
iv
Progress Notes chart entry made by all health professionals involved in a
clients care; they all use the same type of sheet fro notes. Numbered to
correspond to the problems on the problem list and may be lettered for the
type of data

10

Example: SOAP Format Or SOAPIE and SOAPIER

S Subjective data
O Objective data
A Assessment
P Plan
I Intervention
E Evaluation
R- Revision
Advantages of POMR:

It encourages collaboration

Problem list in the front of the chart alerts caregivers to the clients
needs & makes it easier to track the status of each problem.

Disadvantages of POMR:

Caregivers differ in their ability to use the required charting format

Takes constant vigilance to maintain an up-to-date problem list

Somewhat inefficient because assessments & interventions that apply

to more than one problem must be repeated.
III

PIE (Problems, Interventions, and Evaluation)

a Groups information in to three (3) categories
b This system consists of a client care assessment floe sheet & progress notes
c FLOW SHEET uses specific assessment criteria in a particular format, such as human
needs or functional health patterns
d Eliminate the traditional care plan & incorporate an ongoing care plan into the progress
notes

IV

Focus Charting
a Intended to make the client & client concerns & strengths the focus of care
b Three (3) columns fro recording are usually used: date & time, focus & progress notes

Charting by Exception
a Documentation system in which only abnormal or significant findings or exceptions to
norms are recorded
b Incorporates three (3) key elements:
i
Flow sheets
ii
Standards of nursing care
iii
Bedside access to chart forms

VI

Computerized Documentation
a Developed as a way to manage the huge volume of information required in
contemporary health care
b Nurses use computers to store the clients database, add new data, create & revise
care plans & document client progress.

VII Case Management

a Emphasizes quality, cost-effective care delivered within an established length of stay
b Uses a multidisciplinary approach to planning & documenting client care, using critical
pathways.
D

Nursing Care Plan (NCP)

Two Types:
I
Traditional Care Plan written fro each client; it has 3 columns: nursing diagnoses, expected
outcomes & nursing interventions.
II Standardized Care Plan based on an institutions standards of practice; thereby helping to
provide a high quality of nursing care

KARDEX widely used, concise method of organizing & recording data about a client, making
information quickly accessible to all health professionals. Consists of a series of cards kept in a
portable index file or on computer generated forms. Information may be organized into sections:
I
Pertinent information about the client
II List of medications
III List of IVF
IV List of daily treatments & procedures
V List of Diagnostic procedures
VI Allergies
VII Specific data on how the clients physical needs are to be met
VIII A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge / Referral Summaries completed when the client is being discharged &
transferred to another institution or to a home setting where a visit by a community health nurse is
required. Regardless of format, it include some or all of the following:
I
Description of clients physical, mental & emotional state
II Resolved health problems
III Unresolved continuing health problems
IV Treatments that can be continued (e.g. wound care, oxygen therapy)
V Current medications
VI Restrictions that relate to activity, diet & bathing
VII Functional/self-care abilities
VIII Comfort level
IX Support networks
X Client education provided in relation to disease process
XI Discharge destination

11

XII Referral Services (e.g. social worker, home health nurse)

7
A

PHYSICAL EXAMINATION

Purposes
The nurse uses physical assessment for the following reasons:
I
To gather baseline data about the clients health
II To supplement, confirm or refute data obtained in the nursing history
III To confirm and identify nursing diagnoses
IV To make clinical judgments about a clients changing health status and management

Preparation of Examination
I
Environment A physical examination requires privacy. An examination room that is well
equipped for all necessary procedures is preferable
II Equipment Hand washing is done before equipment preparation and the examination. Hand
washing reduces the transmission of microorganisms
III Client
a Psychological Preparation clients are easily embarrassed when forced to answer
sensitive questions about bodily functions or when body parts are exposed and
examined. The possibility that the examination will find something abnormal also
creates anxiety so reduction of this anxiety may be the nurses highest priority before
the examination
b Physical Preparation the clients physical comfort is vital to the success of the
examination. Before starting, the nurse asks if the client needs to use the toilet.
c Positioning during the examination, the nurse asks the clients to assume proper
positions so that body parts are accessible and clients stay comfortable. Clients
abilities to assume positions will depend on their physical strength and degree of
wellness.

Order of Examination
I
General Survey includes observation of general appearance and behavior, vital signs,
height and weight measurement
II Review of systems
III Head to toe examination

Skills in Physical Examination

I
Inspection to detect normal characteristics or significant physical signs. To inspect body
parts accurately the nurse observes the following principles:
a Make sure good lighting is available
b Position and expose body parts so that all surface can be viewed
c Inspect each areas fro size, shape, color, symmetry, position and abnormalities
d If possible, compare each area inspected with the same area of the opposite side of
the body
e Use additional light (for example, a penlight) to inspect body cavities
II

Palpation the hands can make delicate and sensitive measurements of specific physical
signs, so palpation is used to examine all accessible parts of the body. The nurse uses
different parts of the hand to detect characteristics such as texture, temperature and the
perception of movement.

III

Percussion examination by striking the bodys surface with a finger, vibration and sound
are produced. This vibration is transmitted through the body tissues and the character of the
sound depends on the density of the underlying tissue

IV

Auscultation is listening to sound created in body organs to detect variations from normal.
Some sounds can be heard with the unassisted ear, although most sounds can be heard only
through a stethoscope.
a Bowel sounds
b Breath sounds
i
Vesicular
ii
Bronchovesicular
iii
Bronchial
Examples of Adventitious Breath Sounds
I
Crackles (previously called rales)
II Rhonchi
III Wheeze
IV Friction rub
Therapeutic Communication Techniques
1 Using silence
2 Providing general leads
3 Being specific & tentative
4 Using open-ended questions
5 Using touch
6 Restating to paraphrasing
7 Seeking clarification
8 Perception checking or seeking consensual validation
9 Offering self
10 Giving information
11 Acknowledging
12 Clarifying time or sequence
13 Presenting reality
14 Focusing
15 Reflecting
16 Summarizing & planning
B Barriers to Communication
1 Stereotyping

12

2
3
4
5
6
7
8
9
10
11

Agreeing & disagreeing

Being defensive
Challenging
Probing
Testing
Rejecting
Changing topics & subjects
Unwarranted reassurance
Passing judgment
Giving common advice

Phases of the Helping Relationship

12 Pre-interaction Phase
13 Introductory Phase
a. Opening the relationship
b. Clarifying the problem
c. Structuring & formulating the contract
14 Working Phase
a. Exploring & understanding thoughts or feelings
b. Facilitating & taking action
15 Termination Phase
8
A

PRINCIPLES of ASEPSIS and INFECTION CONTROL

Chain of Infection
I
The chain of infection refers to those elements that must be present to cause an infection
from a microorganism
II

Basic to the principle of infection is to interrupt this chain so that an infection from a
microorganism does not occur in clients

III

Infectious agent; microorganisms capable of causing infections are referred to as an

infectious agent or pathogen.

IV

Modes of transmission: the microorganism must have a means of transmission to get

from one location to another, called direct and indirect

Susceptible host describes a host (human or animal) not possessing enough resistance
against a particular pathogen to prevent disease or infection from occurring when exposed to
the pathogen; in humans this may occur if the persons resistance is low because of poor
nutrition, lack of exercise of a coexisting illness that weakens the host.

VI

Portal of entry: the means of a pathogen entering a host: the means of entry can be the
same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary tract).

VII Reservoir: the environment in which the microorganism lives to ensure survival; it can be a
person, animal, arthropod, plant, oil or a combination of these things; reservoirs that support
organism that are pathogenic to humans are inanimate objects food and water, and other
humans.
VIII Portal of exit: the means in which the pathogen escapes from the reservoir and can cause
disease; there is usually a common escape route for each type of microorganism; on
humans, common escape routes are the gastrointestinal, respiratory and the genitourinary
tract.
Modes of Transmission
1 Direct contact: describes the way in which microorganisms are transferred from
person to person through biting, touching, kissing, or sexual intercourse; droplet
spread is also a form of direct contact but can occur only if the source and the host
are within 3 feet from each other; transmission by droplet can occur when a person
coughs, sneezes, spits, or talks.
2 Indirect contact: can occur through fomites (inanimate objects or materials) or
through vectors (animal or insect, flying or crawling); the fomites or vectors act as
vehicle for transmission
3 Air: airborne transmission involves droplets or dust; droplet nuclei can remain in
the air for long periods and dust particles containing infectious agents can become
airborne infecting a susceptible host generally through the respiratory tract
B

Course of Infection
I

Incubation: the time between initial contact with an infectious agent until the first
signs of symptoms - - > the incubation period varies from different
pathogens; microorganisms are growing and multiplying during this stage

II

Prodromal Stage: the time period from the onset of nonspecific symptoms to the
appearance of specific symptoms related to the causative pathogen
- - > symptoms range from being fatigued to having a low-grade fever with
malaise; during this phase it is still possible to transmit the pathogen to
another host

III

Full Stage: manifestations of specific signs & symptoms of infectious agent; referred to
as the acute stage; during this stage, it may be possible to transmit the infectious
agent to another, depending on the virulence of the infectious agent

13

IV

Convalescence: time period that the host takes to return to the pre-illness stage; also
called the recovery period; - - >the host defense mechanisms have responded to the
infectious agent and the signs and symptoms of the disease disappear; the host, however, is
more vulnerable to other pathogens at this time; an appropriate nursing diagnostic label
related to this process would be Risk for Infection

Inflammation The protective response of the tissues of the body to injury or infection; the
physiological reaction to injury or infection is the inflammatory response; it may be acute or chronic
Bodys response
I
The inflammatory response begins with vasoconstriction that is followed by a brief increase
in vascular permeability; the blood vessels dilate allowing plasma to escape into the injured
tissue
II
III

WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and attack
and ingest the invaders (phagocytosis); this process is responsible for the signs of
inflammation
Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as a result
of the heat from the increased blood in the area, swelling occurs from fluid accumulation; the
pain occurs from pressure or injury to the local nerves.

Immune Response
I
The immune response involves specific reactions in the body to antigens or foreign material
II

This specific response is the bodys attempt to protect itself, the body protects itself by
activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes

III

Cell mediated immunity: T-lymphocytes are responsible for cellular immunity

a When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they enter
the circulation from lymph tissue and seek out the antigen
b Once theantigen is found they produce proteins (lymphokines) that increase the
migration of phagocytes to the area and keep them there to kill the antigen
c After the antigen is gone, the lymphokines disappear
d Some T-lymphocytes remain and keep a memory of the antigen and are reactivated if
the antigen appears again.

IV

Humoral response: the ability of the body to develop a specific antibody to a specific antigen
(antigen-antibody response)
a B-lymphocytes provide humoral immunity by producing antibodies that convey specific
resistance to many bacterial and viral infections
b

Active immunity is produced when the immune system is activated either naturally or
artificially.
i
Natural immunity involves acquisition of immunity through developing the
disease
ii
Active immunity can also be produced through vaccination by introducing
into the body a weakened or killed antigen (artificially acquired immunity)
iii
Passive immunity does not require a host to develop antibodies, rather it is
transferred to the individual, passive immunity occurs when a mother
passes antibodies to a newborn or when a person is given antibodies from
an animal or person who has had the disease in the form of immune
globulins; this type of immunity only offers temporary protection from the
antigen.

Nosocomial Infection
I
Nosocomial Infections: are those that are acquired as a result of a healthcare delivery system
II

Iatrogenic infection: these nosocomial infections are directly related to the clients treatment
or diagnostic procedures; an example of an iatrogenic infection would be a bacterial infection
that results from an intravascular line or Pseudomonas aeruginosa pneumonia as a result of
respiratory suctioning

III

Exogenous Infection: are a result of the healthcare facility environment or personnel; an

example would be an upper respiratory infection resulting from contact with a caregiver who
has an upper respiratory infection

IV

Endogenous Infection: can occur from clients themselves or as a reactivation of a previous

dormant organism such as tuberculosis; an example of endogenous infection would be a
yeast infection arising in a woman receiving antibiotic therapy; the yeast organisms are
always present in the vagina, but with the elimination of the normal bacterial flora, the yeast
flourish.

Factors Increasing Susceptibility to Infection

I
Age: young infants & older adults are at greater risk of infection because of reduced defense
mechanisms
a Young infants have reduced defenses related to immature immune systems
b In elderly people, physiological changes occur in the body that make them more
susceptible to infectious disease; some of these changes are:
i
Altered immune function (specifically, decreased phagocytosis by the
neutrophils and by the macrophages)
ii
Decreased bladder muscle tone resulting in urinary retention
iii
Diminished cough reflex, loss of elastic recoil by the lungs leading to
inability to evacuate normal secretions
iv
Gastrointestinal changes resulting in decreased swallowing ability and
delayed gastric emptying.

14

II

Heredity: some people have a genetic predisposition or susceptibility to some infectious

diseases

III

Cultural practices: healthcare beliefs and practices, as well as nutritional and hygiene
practices, can influence a persons susceptibility to infectious diseases

IV

Nutrition: inadequate nutrition can make a person more susceptible to infectious diseases;
nutritional practices that do not supply the body with the basic components necessary to
synthesized proteins affect the way the bodys immune system can respond to pathogens

Stress: stressors, both physical and emotional, affect the bodys ability to protect against
invading pathogens; stressors affect the body by elevating blood cortisone levels; if elevation
of serum cortisone is prolonged, it decreases the anti-inflammatory response and depletes
energy stores, thus increasing the risk of infection

VI

Rest, exercise and personal health habits: altered rest and exercise patterns decrease the
bodys protective, mechanisms and may cause physical stress to the body resulting in an
increased risk of infection; personal health habits such as poor nutrition and unhealthy
lifestyle habits increase the risk of infectious over time by altering the bodys response to
pathogens

VII Inadequate defenses: any physiological abnormality or lifestyle habit can influence normal
defense mechanisms in the body, making the client more susceptible to infection; the
immune system functions throughout the body and depends on the following:
a Intact skin and mucous membranes
b Adequate blood cell production and differentiation
c A functional lymphatic system and spleen
d An ability to differentiate foreign tissue and pathogens from normal body tissue and
flora; in autoimmune disease, the body has a problem with recognizing its own tissue
and cells; people with autoimmune disease are at increased risk of infection related to
their immune system deficiencies.
VIII Environmental: an environment that exposes individuals to an increased number of toxins or
pathogens also increases the risk of infection; pathogens grow well in warm moist areas with
oxygen (aerobic) or without oxygen (anaerobic) depending on the microorganism, an
environment that increases exposure to toxic substances also increases risk

IX

Immunization history: inadequately immunized people have an increased risk of infection

specifically for those diseases for which vaccines have been developed.

Medications and medical therapies: examples of therapies and medications that increase
clients risk for infection includes radiation treatment, anti-neo-plastic drugs, anti
inflammatory drugs and surgery

Diagnostic Tests Used to Screen for Infection

I
Signs and symptoms related to infections are associated with the area infected; for instance,
symptoms of a local infection on the skin or mucous membranes are localized swelling,
redness, pain and warmth
II

Symptoms related to systemic infections include fever, increased pulse & respirations,
lethargy, anorexia, and enlarged lymph nodes

III

Certain diagnostic tests are ordered to confirm the presence of an infection.

9 THEORIES OF PAIN
Specific Theory
I
Proposes that bodys neurons & pathways for pain transmission are specific, similar to other
senses like taste
II

Free nerve endings in the skin act as pain receptors, accept input & transmit impulses along
highly specific nerve fibers

III

Does not account for differences in pain perception or psychologic variables among
individuals.

Pattern Theory
I
Identifies 2 major types of pain fibers; rapidly & slowly conducting
II

Stimulation of these fibers forms a pattern; impulses ascend to the brain to be interpreted as
painful

III

Does not account for differences in pain perception or psychologic variables among
individuals.

Gate Control Theory

I
Pain impulses can be modulated by a transmission blocking action within the CNS.
II Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or scratching an area)
and may inhibit smaller diameter fibers to prevent transmission of the impulse (close the
gate).

Current Developments in Pain Theory Indicate that pain mechanisms & responses are far more
complex than believed to be in the past.
I
Pain may modulated at different points in the nervous system.
a First-order neurons at the tissue level
b Second-order neurons in the spinal cord that process nociceptor information

15

c
II

Third-order tracts & pathways in the spinal cord & brain that relay/process this
information

The role of the pain experience in the development of new nociceptors and/or reducing the
threshold of current nociceptor is also being investigate

10 TYPES OF PAIN
Acute Pain
I
Usually temporary, sudden in onset, localized, lasts for 6 months; results from tissue injury
associated with trauma, surgery, or inflammation.
Types of Acute Pain
a Somatic: arises from nerve receptors in the skin or close to bodys surface; may be
sharp & well-localized or dull & diffuse; often accompanied by nausea & vomiting

II

Visceral: arises from bodys organs; dull & poorly localized because of minimal
noriceptors; accompanied by nausea & vomiting, hypotension & restlessness

Referred pain: pain that is perceived in an area distant from the site of stimuli (e.g.
pain in a shoulder following abdominal laparoscopic procedure).

Acute pain initiates the fight-or-flight response of the Autonomic Nervous System and is
characterized by the following symptoms:
a Tachycardia
b Rapid, shallow respirations
c Increased BP
d Sweating
e Pallor
f
Dilated pupils
g Fear & Anxiety

Chronic Pain
I
Prolonged, lasting longer than 6 months, often not attributed to a definite cause, often
unresponsive to medical treatment.
Types of Chronic Pain
a Neuropathic: painfuil condition that results from damage to peripheral nerves caused
by infection or disease; post-therapeutic neuralgia (shingles) is an example

II

Phantom: pain syndrome that occurs following surgical or traumatic amputation of a

limb.
i
The client is aware that the body part is missing
ii
Pain may result of stimulation of severed nerves at the site of amputation
iii
Sensation may be experienced as an itching, pressure, or as stabbing or
burning in nature
iv
It can be triggered by stressors (fatigue, illness, emotions, weather)
v
This experience is limited for most clients because the brain adapts to
amputated limb; however, some clients experience abnormal sensation or
pain over longer periods
vi
This type of pain requires treatment just as any other type of pain does.

Psychogenic: pain that is experienced in the absence of a diagnosed physiologic cause

or event; the clients emotional needs may prompt pain sensation.

Depression is a common associated symptom for the client experiencing chronic pain;
feelings of despair & hopelessness along with fatigue are expected findings.
11 PAIN ASSESSMENT

TOOLS/INTRUMENTS USED
I
A VERBAL REPORT using an intensity scale is a fast, easy & reliable method allowing the
client to state pain intensity & in turn, promotes consisted communication among the nurse,
client & other healthcare professionals about the clients pain status; the 2 most common
scales used are 0 to 5 or 0 to 10. With 0 specifying no pain & the highest number
specifying the worst pain
II

A VISUAL ANALOG SCALE is a horizontal pain-intensity scale with word modifiers at both ends
of the scale, such as no pain at one end and worst pain at the other, clients are asked to
point or mark along the line to convey the degree of pain being experienced

III

A GRAPHIC RATING SCALE is similar to the visual analog scale but adds a numerical scale
with the word modifiers, usually the numbers 0 to 10 are added to the scale.

IV

FACES PAIN SCALE children, clients who do not speak English & clients with communication
impairments may have difficulty using a numerical pain intensity scale; the FACES pain scale
may be used for children as young as 3 years old; this scale provides facial expressions
(happy face reflects no pain, crying face represents worst pain)

PHYSIOLOGIC INDICATORS OF PAIN may be the only means a nurse can use to assess pain
for a non-communicating client, facial & vocal expression may be the initial manifestations of
pain; expressions may include rapid eye blinking, biting of the lip, moaning, crying,
screaming, either closed or clenched eyes, or stiff unmoving body position

A B C D E method of pain assessment

I
This acronym was developed for cancer pain; however, it is very appropriate for clients with
any type of pain, regardless of the underlying disease.

16

II
III
IV
V
VI
C

A = Ask about pain

B = Believe the client & family reports pain
C = Choose pain control options appropriate for the client
D = Deliver interventions in a timely, logical &coordinated fashion
E = Empower clients & families

P Q R S T assessment for pain reception

I
This method is especially helpful when approaching a new pain problem
II P = What precipitated the pain?
III Q = What are the quality & quantity of the pain?
IV R = What is the region of the pain?
V S = What is the severity of the pain?
VI T = What is the timing of the pain?
Pain History
I
Location when clients report pain all over, this generally refers to total pain or existential
distress (unless there is an underlying physiologic reason for pain all over the body, such as
myalgias); assess the clients emotional state for depression, fear, anxiety or hopelessness.
II

Intensity It is important to quantify pain using a standard pain intensity scale. When clients
cannot conceptualize pain using a number, simple word categorizes can be useful (e.g. no
pain, mild, moderate, severe).

III

Quality
a Nociceptive pain are usually related to damage to bones, soft tissues, or internal
organs; nociceptive pain includes somatic & visceral pains.
i
Somatic pain is aching, throbbing pain; example arthritis
ii
Visceral pain is squeezing, cramping pain; example: pain associated with
ulcerative colitis

IV

Pattern pain may be always present for a client; this is often termed baseline pain.
Additional pain may occur intermittently that is of rapid onset & greater intensity than the
baseline pain; known as breakthrough pain. People at end-of-life often have both types of
pain. Cultural beliefs regarding the meaning of pain should be examined
ADMINISTRATION OF MEDICATIONS
12 DRUG NOMENCLATURE and FORMS

Names
I

Chemical Name provides an exact description of the drugs composition. An example of

chemical name acetylsalicylic known common as Aspirin

II

Generic Name is given by the manufacturer who first develops the drug before it receives
official approval. Protected by law, the generic name is given before a drug receives official
publications.

III

Official Name is the name under which drug is listed in official publication

IV

Trade, Brand or Propriety Name is the name under which a manufacturer markets.

Classification Nurses categorized medications with similar characteristics by their class. Drug
classification indicates the effects on a body system, the symptoms relieved or the desired effect. Each
class contains drugs prescribed for similar types of health problems. The physical and chemical
composition of drugs within a class is not necessarily the same. A drug may also belong to more than
one class. For example, aspirin is an analgesic and antipyretic and an anti-inflammatory drug.

Forms Drugs are available in a variety of forms preparations. The form of the drug determines its
route o administration. For example, a capsule is taken orally and a solution may be given
intravenously. The composition drug is designed to enhance its absorption and metabolism within the
body. Many drugs are available in several forms such as tablets, capsules, elixirs and suppositories.
When administering a medication, the nurse must be certain to give the metabolism in the proper
form.

Principles in Administering Medications

I
Observe the 7 RIGHTS of Drug Administration:
a Right Drug
b Right Dose
c Right Time
d Right Route
e Right Patient
f
Right Recording
g Right Approach
II

Practice asepsis

III

Nurses who administer medications are responsible for their own actions. Question any order
that you can consider incorrect.

IV

Be knowledgeable about medications that you administer

Keep narcotics & barbiturates in locked place

VI

Use only medications that are in clearly labeled containers

VII Return liquid that are cloudy or have changed in color to the pharmacy
VIII Before administering a medication, identify the client correctly

17

IX

Do not leave the medication at the bedside

If the client vomits after taking an oral medication, report this to the nurse in charge and/or
physician

XI

Preoperative medications are usually discontinued during the post operative period unless
ordered to be continued

XII

When a medication is omitted for any reason, record the fact together with the reason

XIII When a medication error is made, report immediately to the nurse in charge and/or
physician
A

13 BASIC HUMAN NEEDS

Abraham Maslow developed the five (5) levels of human needs:
I
II
III
IV
V

Physiologic Needs needs such as air, food, water, shelter, rest, sleep, activity and
temperature maintenance are crucial for survival
Safety and Security Needs the need for safety has both physical and physiologic aspects
Love and Belonging Needs the third level of needs includes giving and receiving affection,
attaining a place in a group and maintaining the feeling of belonging
Self-Esteem Needs the individual needs both self-esteem and esteem from others
Self-Actualization when the need for self-esteem is satisfied, the individual strives for selfactualization, the innate need to develop ones maximum potential and realize ones abilities
and qualities

Maslows Characteristics of a Self-Actualized Person

I
Is realistic, sees life clearly and is objective about his or her observations
II Judges people correctly
III Has superior perception, is more decisive
IV Has a clear notion of right or wrong
V Is usually accurate in predicting future events
VI Understands art, music, politics and philosophy
VII Possesses humility, listens to others carefully
VIII Is dedicated to some work, task, duty or vocation
IX Is highly creative, flexible, spontaneous, courageous,
and willing to make mistakes
X Is open to new ideas
XI
Is self-confident and has self-respect
XII
Has low degree of self-conflict; personality is integrated
XIII
Respect self, does not need fame, possesses a feeling of self-control
XIV Is highly independent, desires privacy
XV
Can appear remote or detached
XVI is friendly, loving and governed more by inner directives than by society
XVIICan make decisions contrary to popular opinion
XVIII
Is problem centered rather than self-centered
XIX Accepts the world for what it is
14 MEETING OXYGENATION NEEDS
Oxygenation a basic human need & is required to sustain life.

Cardiovascular Physiology the function of the cardiac system is to

deliver oxygen, nutrients, & other substances to the tissues and to remove the waste products of
cellular metabolism

Structure and Function the heart pumps blood through the pulmonary circulation by way of the
right ventricle and to the systemic circulation by way of the left ventricle
I
Myocardial Pump the pumping action of the heart is essential to maintain oxygen delivery
II Myocardial Blood Flow to maintain adequate blood flow to the pulmonary and systemic
circulations, myocardial blood flow must sufficiently supply oxygen and nutrients to the
myocardium itself
III Coronary Artery Circulation blood flow to the atria and ventricles does not supply oxygen
and nutrients to the myocardium itself. It is the branch of the systemic circulation that
supplies oxygen and nutrients and removal of waste from the myocardium
IV Systemic Circulation the arteries and veins of the systemic circulation deliver nutrients and
oxygen and remove wastes from the tissues. Oxygenated blood flows from the left ventricle
by way of of the aorta and into the large systemic arteries
V Regulation of Blood Flow the amount of blood ejected from the left ventricle each minute is
the cardiac output. The circulating volume of blood changes according to the oxygen and
metabolic needs of the body. For example, during exercise, pregnancy and fever, the cardiac
output increases but during sleep, the cardiac output decreases.

Steps in the Process of Oxygenation

I
Ventilation process by which gases are moved into and out of the lungs. Adequate
ventilation requires coordination of the muscular and elastic properties of the lung and
thorax and intact innervation. The major inspiratory muscle is the diaphragm which is
innervated by the phrenic nerve.

18

II

Perfusion the primary function of pulmonary circulation is to move blood to and from the
alveolar-capillary membrane so that gas exchange can occur

III

Exchange of Respiratory Gases respiratory gases are exchanged in the alveoli of the lungs
and the capillaries of the body tissues
a Diffusion movement of molecules from an area of higher concentration to an area of
lower concentration
b Oxygen Transport delivery depends on the amount of oxygen entering the lungs
(ventilation), blood flow to the lungs & tissues (perfusion), adequacy of diffusion &
capacity of the blood to carry oxygen.
c Carbon Dioxide Transport carbon dioxide diffuses into RBCs and I rapidly hydrated
into carbonic acid because of the presence of carbonic hydrase

15 MEETING NUTRITIONAL NEEDS

Principles of Nutrition
I
Digestion process by which food substances are changed into forms that can be absorbed
through cell membranes
II

Absorption the taking in of substance by cells or membranes

III

Metabolism sum of all physical and chemical processes by which a living organism is
formed and maintained and by which energy is made available

IV

Storage some nutrients are stored when not used to provide energy; e.g. carbohydrates are
stored either as glycogen or as fat
Elimination process of discarding unnecessary substances through evaporation, excretion

V
B

Nutrients
I
Carbohydrates the primary sources are plant foods
Types of Carbohydrates
a Simple (sugars) such as glucose, galactose, and fructose
b Complex such as starches (which are polysaccharides) and fibers (supplies bulk or
roughage to the diet)
Proteins organic substances made up of amino acids

III

Lipids organic substances that are insoluble in water but soluble in alcohol and ether.
a Fatty acids the basic structural units of all lipids and are either saturated (all the
carbon atoms are filled with hydrogen) or unsaturated (could accommodate more
hydrogen than it presently contains)
b Food sources of lipids are animal products (milk, egg yolks and meat) and plants and
plant products (seeds, nuts, oils)

IV

Vitamins organic compounds not manufactured in the body and needed in small quantities
to catalyze metabolic processes
a Water-soluble vitamins include C and B-complex vitamins
b Fat-soluble vitamins include A, D, E, and K and these can be stored in limited amounts
in the body

Minerals compounds that work with other nutrients in maintaining structure and function of
the body
a Macronutrients calcium, phosphate, sodium, potassium, chloride, magnesium and
sulfur
b Micronutrients (trace elements) iron, iodine, copper, zinc, manganese and fluoride
The best sources are vegetables, legumes, milk and some meats

VI

Water the bodys most basic nutrient need; it serves as a medium for metabolic reactions
within cells and a transporter fro nutrients, waste products and other substances

16 MEETING URINARY ELIMINATION NEEDS

Normal Urinary Function
I
Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr to ensure continued
normal kidney function
II Urine normally consists of 96% water
III Solutes found in urine include:
a Organic solutes: urea, ammonia, uric acid and creatinine
b Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium & phosphorus
Common Assessment Findings
I
Urgency strong desire to void my be caused by inflammations or infections in the bladder
or urethra
II Dysuria painful or difficult voiding
III Frequency voiding that occurs more than usual when compared with the persons regular
pattern or the generally accepted norm of voiding once every 3 to 6 hours
IV Hesitancy undue delay and difficulty in initiating voiding
V Polyuria a large volume of urine or output voided at any given time
VI Oliguria a small volume of urine or output between 100 to 500 mL/24 hr
VII Nocturia excessive urination at night interrupting sleep
VIII Hematuria RBCs in the urine

II

17 URINARY CATHETERIZATION
Is the introduction of a catheter through the urethra into the bladder for the purpose of
withdrawing urine.

Purposes
I
To relieve urinary retention

19

II To obtain a sterile urine specimen from a woman

III To measure the amount of residual urine in the bladder
IV To obtain a urine specimen when a specimen cannot secure satisfactory by other means
V To empty bladder before and during surgery and before certain diagnostic examinations
***Several BASIC FACTS about the lower urinary tract system should be borne in mind when considering
catheterization.
B

Necessary Equipment for Catheterization

Catheters are graded on the French scale according to the size of the lumen. For the female
adult, No. 14 and No. 16 French catheters are usually used. Small catheters are generally not
necessary and the size of the lumen is also so small that it increases the length of time
necessary for emptying the bladder. Larger catheter distends the urethra and tends to increase
the discomfort of the procedure. For male adult, No.18 and No. 20 French catheters usually
used, but if this appears to be too large, smaller catheter should be used. No. 8 and No. 10
French catheters are commonly used for children.

Preparation of the Patient

I
Adequate exploration
II Position dorsal recumbent for the female and supine for the male using a firm mattress or
treatment table, Sims or lateral position can be an alternate for the female patient
III Provision for privacy

Retention or Indwelling Catheter (Foley) A catheter to remain in place for the following
purposes:
I
The gradual decompression of an over distended bladder
II For intermittent bladder drainage
III For continuous bladder drainage
An indwelling catheter has a balloon which is inflated after the catheter is inserted into the
bladder. Because the inflated balloon is larger than the opening to the urethra, the catheter is retained
in the bladder.

Procedure for Insertion

I
Inflate the balloon with the prefilled syringe before inserting the catheter to check for balloon
patency. Aspirate the fluid back into the syringe when it is determined that the balloon is
patent.
II Hold the catheter with one hand and inflate the balloon according to the manufacturers
instructions, as soon as the catheter is in the bladder and urine has begun to drain from the
bladder. Usually 5 ml to 10 ml of sterile water is used
III If the patient complains of pain after the balloon is inflated, allow it to empty and replace the
catheter with another one. The balloon is probably located in the urethra and is causing
discomfort owing to distention of the urethra
IV Exert slight tension on the catheter after the balloon is inflated to assure its proper
placement in the bladder
V Connect the catheter to the drainage tubing and drainage bag if not already connected
VI Tape the catheter along the interior aspect of the thigh fro a female patient. Be sure there is
no tension on the catheter when it is taped to the patient
VII Hang the drainage bag on the frame of the bed below the level of the bladder

Caring for the Patient with an Indwelling Catheter

I
Be sure to wash hands before and after caring for a patient with an indwelling catheter
II Clean the perineal area thoroughly, especially around the meatus, twice a day and after each
bowel movement. This helps prevent organisms for entering the bladder
III Use soap or detergent and water to clean the perineal area and rinse the area well
IV Make sure that the patient maintains a generous fluid intake. This helps prevent infection
and irrigates the catheter naturally by increasing urinary output
V Encourage the patient to be up and about as ordered
VI Record the patients intake and output
VII Note the volume and character of urine and record observations carefully
VIII Teach the patient the importance of personal hygiene, especially the importance of careful
cleaning after having bowel movement and thorough washing of hands frequently
IX Report any signs of infection promptly. These include a burning sensation and irritation at the
meatus, cloudy urine, a strong odor to the urine, an elevated temperature and chills
X Plan to change indwelling catheters only as necessary. The usual length of time between
catheter changes varies and can be anywhere from 5 days to 2 weeks. The less often a
catheter is changed, the less the likelihood than an infection will develop

Removing the Indwelling Catheter and Aftercare of the Patient

I
Be sure the balloon is deflated before attempting to remove the catheter. This may be done
by inserting a syringe into the balloon valve or by cutting the balloon valve
II Have the patient take several deep breaths to help him relax while gently removing the
catheter. Wrap the catheter in a towel or disposable, waterproof drape
III Clean the area at the meatus thoroughly with antiseptic swabs after the catheter is removed
IV See to it that the patients fluid intake is generous and record the patients intake and
output. Instruct the patient to void into the bedpan or urinal
V Observe the urine carefully for any signs of abnormality
VI Record and report any usual signs such as discomfort, a burning sensation when voiding,
bleeding and changes in vital signs, especially the patients temperature. Be alert to any
signs of infection and report them promptly

Factors
I
II
III
IV

18 MEETING BOWEL ELIMINATION NEEDS

that influence Bowel Elimination
Age
Diet
Position
Pregnancy

20

V
VI
VII
VIII
IX
X
XI

Fluid Intake
Activity
Psychological
Personal Habits
Pain
Medications
Surgery/Anesthesia

Characteristics of Normal Stool

I
Color varies from light to dark brown foods & medications may affect color
II Odor aromatic, affected by ingested food and persons bacterial flora
III Consistency formed, soft, semi-solid; moist
IV Frequency varies with diet (about 100 to 400 g/day)
V Constituents small amount of undigested roughage, sloughed dead bacteria and epithelial
cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter
(calcium, phosphates)

Common Bowel Elimination Problems

I
Constipation abnormal frequency of defecation and abnormal hardening of stools
II Impaction accumulated mass of dry feces that cannot be expelled
III Diarrhea increased frequency of bowel movements (more than 3 times a day) as well as
liquid consistency and increased amount; accompanied by urgency, discomfort and possibly
incontinence
IV Incontinence involuntary elimination of feces
V Flatulence expulsion of gas from the rectum
VI Hemorrhoids dilated portions of veins in the anal canal causing itching and pain and bright
red bleeding upon defecation.

19 TYPES OF ENEMAS
Cleansing Enemas: Stimulate peristalsis through irrigation of colon and rectum and by distention
I
Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile
soap in 1000 ml of water
II Tap water: Give caution o infants or to adults with altered cardiac and renal reserve
III Saline: For normal saline enemas, use smaller volume of solution
IV Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does
not require further preparation

Oil-Retention Enemas: Lubricates the rectum and colon; the feces absorb the oil and become softer
and easier to pass

Carminative Enema: Provides relief from gaseous distention

Astringent Enema: Contracts tissue to control bleeding

Key Points: Administering Enema
I
Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for children,
250 cc or less fro an infant), 99 degrees F to 102 degrees F. Solutions that are too hot or too
cold, or solutions that are instilled too quickly, can cause cramping and damage to rectal
tissues
II Allow solution to run through the tubing so that air is removed
III Place client on left side in Sims position
IV Lubricate the tip of the tubing with water-soluble lubricant
V Gently insert tubing into clients rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3
inches for children), past the external and internal sphincters
VI Raise the water container no more than 12 to 18 inches above the client
VII Allow solution to flow slowly. If the flow is slow, the client will experience fewer cramps. The
client will also be able to tolerate and retain a greater volume of solution
VIII After you have instilled the solution, instruct client to hold solution for about 10 to 15
minutes
IX Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10
to 15 minutes.
20 NASOGASTRIC and INTESTINAL TUBES

Nasogastric Tubes
I

Levin Tube single lumen

a Suctioning gastric contents
b Administering tube feedings

II

Salem Sump Tube double lumen (smaller blue lumen vents the tube & prevents suction on the
gastric mucosa, maintains intermittent suction regardless of suction source)
Suctioning gastric contents
Maintaining gastric decompression

a
b

Key Points:
a Prior to insertion, position the client in High-Fowlers position if possible.
b Use a water-soluble lubricant to facilitate insertion
c Measure the tube from the tip of the clients nose to the earlobe and from the nose
to the xiphoid process to determine the approximate amount of tube to insert to
reach the stomach
d Flex the clients head slightly forward; this will decrease the chance of entry into
the trachea
e Insert the tube through the nose into the nasopharyngel area; ask the client to
swallow, and as the swallow occurs, progress the tube past the area of the trachea
and into the esophagus and stomach. Withdraw tube immediately if client
experiences respiratory distress

21

f
g

Secure the tube to the nose; do not allow the tube to exert pressure on the upper
inner portion of the nares
Validating placement of tube.

Aspirate gastric contents via a syringe to the end of the tube

Measure ph of aspirate fluid

Place the stethoscope over the gastric area and inject a small amount of air
through the NGT. A characteristic sound of air entering the stomach from the
tube should be heard
Characteristics of nasogastric drainage:

Normally is greenish-yellowish, with strands of mucous

Coffee-ground drainage old blood that has been broken down in the
stomach

Bright red blood bleeding from the esophagus, the stomach or

swallowed from the lungs

Foul-smelling (fecal odor) occurs with reverse peristalsis in bowel

obstruction; increase in amount of drainage with obstruction

Intestinal Tubes provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease

intestinal distention. Placement of a tube containing a mercury weight and allowing normal peristalsis
to propel tube through the stomach into the intestine to the point of obstruction where decompression
will occur
I

Types of Intestinal Tubes

a Cantor and Harris Tubes
i
Approximately 6-10 feet long
ii
Single lumen
iii
Mercury placed in rubber bag prior to tube insertion
b

II

Miller-Abbot Tubes
i
Approximately 10 feet long
ii
Double lumen
iii
One lumen utilized for aspiration of intestinal contents
iv
Second lumen utilized to instill mercury into the rubber bag after the tube
has been inserted into the stomach

Nursing Implications
a Maintain client on strict NPO
b Initial insertion usually done by physician and progression of the tube may be
monitored via an X-ray
c After the tube has been placed in the stomach, position client on the right side to
facilitae passage through the pyloric valve
d Advance the tube 2 to 4 inches at regular intervals as indicated by the physician
e Encourage activity, to facilitate movement of the tube through the intestine
f
Evaluate the type of gastric secretions being aspirated
g Do not tape or secure the tube until it has reached the desired position
h Tubes may attached to suction and left in place for several days
i
Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce
thirst
j
Removal of the tube depends on the relief of the intestinal obstruction
i
May be removed by gradual pulling back (4-6 inches per hour) and
eventual removal via the nose or mouth
ii
May be allowed to progress through the intestines and expelled via the
rectum.
21 LOSS AND GRIEF

Loss absence of an object, person, body part, emotion, idea

or function that was valued
I
Actual loss is identified and verified by others
II Perceived Loss cannot be verified by others
III Maturational Loss occurs in normal development
IV Situational Loss occurs without expectations
V Ultimate Loss (Death) results in a lost for a dying person
as well as for those left behind, can be viewed as a time of growth for all who
experienced it

Grieving Process (Theories of Grief, Dying and Mourning)

I

3 Phases of Grief
a Protest: lack of acceptance, concerning the loss, characterized by anger, ambivalence
and crying
b Despair: denial and acceptance occurs simultaneously causing disorganized behavior,
characterized by crying and sadness
c Detachment: loss is realized; characterized by hopelessness, accurately defining the
relationship with the lost individual and energy to move forward in life.

II

Kubler-5 Stages of Grieving

a Denial characterized by shock and disbelief, serves as a buffer to mobilize defense
mechanism
b Anger: resistance of the loss occurs, anger is typically directed toward others
c Bargaining = deals are sought with God or other higher power in an effort to postpone
the loss
d Depression: loss is realized; may talk openly or withdraw.

22

Acceptance: recognition of the loss occurs, disinterest may occur; future thinking may
occur.

III Wordens 4 Tasks of Mourning

a Accept the reality of the loss, the loss is accepted
b Experience the pain of grief, healthy behaviors are accomplished to assist in the
grieving process.
c Adjust to the environment without the deceased, task are accomplished to reorient the
environment, i.e. removing the clothes of the deceased from the closet.
d Emotionally relocate the deceased and move forward with life, correctly align the past,
the present & look towards the future
C

Anticipatory Grief expression of the symptoms of grief prior to the actual loss, grief period
following the lost may be shortened and the intensity lessened because of the previous of grief; for
example, a child told that a family move is expected may grieve about losing friends prior to actually
living

Complications of Bereavement
I
Chronic Grief symptoms of grief occur beyond the expected time frame and the severity of
symptoms is greater; depression may result.
II

Delayed Grief when symptoms of grief are not expressed and are suppressed, a delayed
reaction of grief occurs, the nurse should discuss the normal process of grieving with the
client and give permission to express these symptoms

Symptoms of Normal Grief

I
Feelings include sadness, exhaustion, numbness, helplessness, loneliness, and
disorganization, preoccupation with the lost object or person, anxiety, depression.
II Thought patterns include fear, guilt, denial, ambivalence, anger
III Physical sensations include nausea, vomiting, anorexia, weight loss or gain, constipation or
diarrhea, Diminished hearing or sight, chest pain, shortness of breath, tachycardia
IV Behaviors include crying, difficulty carrying out activities of daily living and insomia

Nursing Health Promotion (to facilitate mourning)

1

Help client accept that the loss is real by providing sensitive, factual information concerning the
loss

Encourage the expression of feelings to support people; this build relationships and enhances the
grief process

Support efforts to live without the diseased person or in the face of disability; this promotes a
clients sense of control as well as a healthy vision of the future

Encourage establishment with new relationships to facilitate healing.

Allow time to grief, the work of grief may take longer for some; observe for a healthy progression
of symptoms.

Interpret normal behavior by teaching thoughts, feelings, and behaviors that can be expected in
the grief process

Provide continuing support in the form of the presence for therapeutic communication and
resource information.

Be alert for signs of ineffective coping such as inability to carry out activities of daily living, signs of
depression, or lack of expression of grief.

23