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GENERAL OBJECTIVES

*At the end of the discussion, the learners shall


be able to:
◦ Refresh their prior knowledge about concepts in
Fundamentals of Nursing

◦ Discover certain topics which seem new to them

◦ Develop techniques that would help them in


inculcating the concepts by heart and mind

◦ Evaluate the learning process they undergo by having


simple quizzes and exercises
CONTENT PREVIEW
First day
I. Historical and Contemporary Nursing Practice
1. Nursing Leaders
2. Definitions of Nursing
3. Roles and Functions of a Nurse
II. Nursing Theories
III. Paradigm: Definition of Terms
1. MAN: Levels of Clientele
2. NURSING PROCESS
3. HEALTH
IV. Health Promotion
1. Levels of Prevention
2. Health Promotion and Health Protection
V. Man and His Basic Human Needs
VI. Health and Illness
VII. Asepsis and Infection Control
VIII. Stress, Adaptation, Homeostasis
IX. Physiologic Responses to Stress and
Illness
X. Communication in Nursing
XI. The Nursing Process
XII. Assessing Health
Information Overload
Episodes of
information
overload

Student’s
information
processing
capacity

Information Load
Grassroots of Nursing:
N-U-R-S-I-N-G- L-E-A-D-E-R-S
Florence Nightingale
-first nursing scientist/ theorist for her work
“Notes on Nursing: What It Is, and What It Is Not (1860/1969)”

Clara Barton
-organized the American Red Cross

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

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

Margaret Sanger
-Nurse activist, founder of Planned Parenthood
Common Themes in Definition of
Nursing

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

1. Lewis introducing the topic “research” in class.


2. Jumbo inserting IV catheter.
3. Gerald washed his hands first before he
introduced the NGT because he wanted to maintain
aseptic technique.
4. Noel could easily recall all the definitions of
nursing.
5. Regina promptly performed CPR after assessing
that the patient doesn’t have a pulse and is not
breathing.
Nursing as a caring
profession
Five Processes of Caring:
1.Knowing
2.Being with
3.Doing for
4.Enabling
5.Maintaining Belief

Caring includes the ffg. factors:


Providing presence- “eye contact”’
Comforting- “touch”
Listening- “attention”
Knowing the client- “uniqueness’
Spiritual caring- “transpersonally”
Family Care- “participants”
Is Nursing a vocation or a
profession?

Characteristics of a Profession

1.Education
2.Theory
3.Service
4.Autonomy
5.Code of Ethics
6.Caring
-the most unique characteristic of nursing
“The Nurse is basically a good person”.

Four Virtues from the Practice of Charity


1.Justice - being righteous
2.Prudence- cautious
3.Fortitude- support
4.Temperance- sacrifice

Exercise:
____1. The nurse encourages the patient to verbalize.
____2. The nurse respects the autonomy of the patient.
____3. The nurse should stand even in unfavorable
conditions.
____4. Before giving the medication, the nurse verified the
dosage to the fellow nurse.
Attributes of Character
Honesty Tolerance Reliability Resourcefulness
Loyalty Judgment Motivation Moderation

1. Thinking of other alternatives.


2. Your boss has put a lot of trust in you because of this
attribute.
3. You’re protecting the name of the hospital you’re
working with.
4. You have to control your temper when undesirable
events happen.
5. Informing the client about the medication you’re
about to give.
6. Questioning an unclear doctor’s order.
7. Recognizing others because of a job well done.
8. Delaying your schedule of watching a movie because of
an exam.
Roles and Functions of a Professional Nurse

Care Provider Leader Counselor


Communicator Manager Collaborator
Teacher Researcher Change Agent
Client Advocate
Reporting Case Manager
abnormal VS to the doctor
Continuing education to improve current practice
Informing the patient about his rights
Providing the client’s needs
Gives health teachings
Plans, gives directions, develops staff, monitors operations
Interpersonal influence to promote the health of the client
Helps the patient to cope with stressful emotional problems
Initiates changes and assists the client to have modifications in lifestyle to promote health
You meticulously wrote your SOAPIE method in the chart to inform others about the care you
delivered to the patient.
Coordinates the activities you planned for CVA patients to a nutritionist, physical therapist and
speech therapist to properly manage the patient’s condition
Types of Nursing Interventions:
Independent Dependent Interdependent

1. The nurse providing 2-3LPM of O2.


2. Steam Inhalation
3. Oral Inhaler
4. Chest Physiotherapy
5. Purse-lip breathing
6. Deep Breathing Exercises
7. Cough Excercises
8. Health education
9. Calories needed by the client
10. For Chest X-ray
Nursing Care Delivery Models
* to develop BEDSIDE NURSING
and Total
improve professional
Patient Care relationships b/n staff.
*RN is responsible for all aspects of care to one or more
clients.
*RNFunctional
is the leader together with nursing assistants and health
Nursing
aides.
*Coordinates and links health care services to clients and their
familiesTeam Nursing
*Division of tasks, one nurse assumes a responsibility apart
from others’ task
Primary Nursing

Case Management
Nursing Theorists
Florence Nightingale -Environmental Theory
Virginia Henderson -Assist the client to gain
independence; 14 Basic Needs
Faye Abdellah -21 Nursing Problems
Dorothy Johnson -Behavioral System Model
Imogene King -Goal Attainment Theory
Madeleine Leininger -Transcultural Nursing
Myra Levin -Four Conservational Theory
Betty Neuman -Health Care System Model
Cont…

Dorothea Orem -Self-Care Deficit Theory


Hildegard Peplau -Interpersonal Model
Martha Rogers -Science of Unitary Human Beings
Sister Callista Roy -Adaptation Model
Lydia Hall -Core, Care and Cure
Ida Jean Orlando -Dynamic Nurse-Patient Relationship

Jean Watson -Human Caring Model


Joyce Travelbee -Interpersonal Aspects of Nursing Model
Ernestine Weidenbach-Clinical Nursing- A Helping Art Model
Definition of Terms

MAN -is a biopsychosocial and spiritual being who is


in constant contact with the environment. (Roy)

LEVELS OF CLIENTELE
I. Individuals
II. Families
III. Social Group
IV. Communities

HEALTH- a complete state of physical, mental,


emotional and social being of a person and not just
merely the absence of disease or infirmity. (World
Health Organization, 1947)
-From an Old English “heal” which means “whole”
A Simple Paradigm

MAN NURSING PROCESS HEALTH

Individuals ADPIE END GOAL


Families
Social Groups
Communities
MAN’s Basic Needs:

Self-
Actualization

Self-Esteem

Love and Belongingness

Safety and Security

Physiologic

Abraham Maslow’s Hierarchy of Needs


Identify the following according to
Maslow’s Hierarchy of Needs:

1.Self-respect
2.The need to be fulfilled
3.Rest and sleep
4.Elimination
5.The need for shelter
6.The need to care and be cared for
7.Self-worth
8.Psychological safety
9.Oxygen
10.Spiritual fulfillment
Models of
Health MODEL
CLINICAL/MEDICAL

ROLE PERFORMANCE MODEL

ADAPTIVE MODEL (Sister Callista Roy)

EUDOMONISTIC MODEL

AGENT-HOST-ENVIRONMENT MODEL
(Leavell & Clark)

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

DUNN’S HIGH- LEVEL WELLNESS GRID


(1959)
A. Clinical Model
hlt practitioners used this model if their focus is on
own relief of s/sx of dse & eliminate pain &
malfunction.
If there is less or absence of s/sx & pain  health is
restored.

B. Role Performance Model


People who can fulfil their roles are healthy even if
they appear clinically ill.
Assumes in this model that “sickness” is the inability
to perform one’s work.
C. ADAPTIVE MODEL
(Sister Callista Roy)
Adaptation – it is the focus of this model
Belief: health is a creative process. Therefore,
disease is a failure in adaptation. (maladaptation)
Treatment of a person: aim is to restore person by
ability of a person to adapt, i.e. “to cope”

D. EUDOMONISTIC MODEL
it views that in this model, the highest aspiration of
people is fulfilment & complete development which
is “actualization”
Illness is viewed as a condition that prevents self-
actualization
E. AGENT-HOST-ENVIRONMENT MODEL
(Leavell & Clark)
also known as Ecologic Model; model was
derived due to the community health work of
authors
model is used in predicting illness rather than in
promoting wellness

Env’t

Host

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

Wellness Model
  
Premat High-
ure
  
Level
Death Disability Symptoms Signs
Awareness Education Growth Wellnes
s
Treatment Model
G. DUNN’S HIGH- LEVEL WELLNESS
GRID (1959)
Very favorable
environment

C. Protected Poor A. High- Level


Hlt (in favourable Wellness (in
env’t) thru social & favourable
cultural institutions environment)
Death
Death
Death
Peak
Peak
Peak Wellness
Wellness
D. D.
Poor
Poor Health
Health B. Emergent
(unfavourable environment) Wellness
(unfavourable High-Level Wellness
environment) (in unfavourable
environment)

Very
unfavorable Health
environment
Axis

Environmental
Axis
Classification of Diseases
According to Etiology

1.Hereditary •DM
2.Congenital •Alopecia after
3.Idiopathic
chemotherapy
4.Metabolic
•Osteoarthritis
5.Deficiency
•Uterine cancer
6.Neoplastic
•Fracture
7.Degenerative
•Skin Allergy
8.Iatrogenic
•Osteomalacia
9.Traumatic
•Hyperthyroidism
10.Allergic
•Cleft Palate
•HPN
According to Duration or Onset

1.Acute Illness- short duration


2.Chronic Illness- longer than 6 mos.
*remission -asymptomatic but with dse.
*exacerbation -becomes active again with
pronounced s/sx

Three Levels of Prevention


1. Primary- health promotion and protection
2. Secondary- early detection, diagnosis, screening
3. Tertiary- rehabilitation and adaptation
Identify the type of prevention:

1.Quit Smoking
2.Wear hazard devices
3.Physical Therapy after CVA
4.Attending Self-Management education for DM pts.
5.Have annual physical examination
6.Sputum Exam for TB
7.Weighing the children
8.Taking adequate fluids
9.Complete immunization
10.Speech therapy after laryngectomy
Activities to Promote Health
and Prevent Illness

1. Have regular (yearly) PE


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

ASEPSIS and
INFECTION CONTROL
Infection- invasion by MOs
Asepsis- free from infection
Medical Asepsis- clean technique
Surgical Asepsis- sterile technique
Sepsis- presence of infection
Carrier- asymptomatic but with infection
Reservoir- habitat
Resident flora- normally live on skin
Sterilization- all MOs are destroyed
Disinfectant- remove pathogens on
inanimate objects
Antiseptic- remove pathogens on persons
but doesn’t necessarily destroy
Bactericidal- destroys bacteria
Cont…
Communicable Dse.-infectious agent that can be
transmitted (direct, indirect, vehicle, airborne)
Pathogen- a disease-producing microorganisms
Pathogenicity-ability to cause a disease
Virulence- the vigor of MOs in which they can grow
and multiply
Nosocomial infection- hospital-acquired infection
Isolation- separation of persons with communicable
disease
Etiology- the study of the causes
Stages of Infectious Process

1.Incubation period time


2.Prodromal period non-specific to specific
3.Illness period s/sx
4.Convalescent period recovery

Chain of infection

Agent Reservoir Portal of exit

HOST Portal of entry Mode of


transmission
Mode of Transmission
1. Contact
a. direct body to body (bathing, feeding etc.)
b. indirect exposure (contaminated objects)
2. Droplet (<3ft.) secretions
3. Airborne (>3ft) fine particles suspended in air
4. Vectorborne biologic and mechanical
5. Vehicle mediator (food, water, milk, blood etc)
Types of Immunization

ACTIVE PASSIVE

Natural Natural

Artificial Artificial
What type of immunity?
1.Recovery from mumps
2.Colostrum
3.Tetanus Immuniglobulin
4.Tetanus Toxoid
5.OPV
6.Recovery from Chickenpox

2 Types of Disinfection:
a. Concurrent
b. Terminal
Handwashing- is the single most
important infection control practice.

Soap, water and alcohol are being used.


Wash hands before and after every client care
contact.
It would be effective with adequate friction.
Medical asepsis is done b holding hands lower than
the elbows.
Apply friction for 15 to 30 seconds on each hand.
Clean under fingernails.
Ideally, turn off the faucet with clean paper towel.
Health and Illness

Stress, Adaptation,
Homeostasis

“Stress is always a part of the fabric of

daily life”.
-hans selye
Adaptation
- the adjustments that a person make in different
situations.

Types:
1.General Adaptation Syndrome (GAS)
a. Stage of Alarm
b. Stage of Resistance
c. Stage of Exhaustion
1.Local Adaptation Syndrome (LAS)
-man may respond to stress through a particular
body part or organ.
-examples: inflammation, backache, headache,
diarrhea
Homeostasis -“homeodynamic”,
because of constant
change
-a state of stability or equilibrium

Sympatho-Adreno-Medullary
Stressors: Responses
Physical injury,
(SAMR) dehydration etc.

Hypothalamus

Adrenal Medullla
(Norepinephrine and epinephrine)
Inflammatory Response
• Rubor
• Calor
• Tumor
• Dolor
• Loss of Function

Exudates
◦ Serous
◦ Serosanguinous
◦ Sanguinous
◦ Purulent
◦ Mucoid
Healing may be classified as:
a. Primary/ First Intention
- clean cut wound
b. Second Intention
- wound is extensive and there is a great
amount of tissue loss.
c. Tertiary/Third Intention
- delayed surgical closure of infected wound

Other responses to tissue injury:


1.Necrosis death of tissues
2.Hypertrophy increase in cell size
3.Hyperplasia increase in cell number
4.Metaplasia replacement of one mature cell type
with another mature cell type
Nursing Interventions for
Clients with Inflammation
1. Promote rest
2. Reduce swelling
Position: Elevate part
Cold and warm compress
3. Relieve pain
4. Increase hydration
5. Adequate nutrition: high calorie, CHON, Vit. C
6. Pharmacotherapy
Analgesic/ antipyretic: Acetaminophen,
Paracetamol, Aspirin, Mefenamic acid
NSAIDS, Steroids
Antimicrobials
Therapeutic Relationship
 -directed towards helping a patient heal, physically
and emotionally.
 -a professional relationship between a nurse,
physician or therapist and a client.
 -Focused on helping the client solve problems and
achieve health-related goals.
 -a means for smoothly implementing the five
processes of the nursing process.
 -TRUST is the foundation of a positive nurse-client
relationship.
Phases of Therapeutic Nurse-Patient Relationship
I. Pre-interaction
-review medical records
-client’s history
-speak with other HCP
II. Orientation
-perform assessment
-formulate patient outcomes
-plan interventions
-ESTABLISH RAPPORT AND TRUST
III. Working Phase
-establish a contract
-set limits
-discuss the time frame of your relationship
IV. Termination
-evaluate the pt.’s progress
-review areas that need improvement
-discuss any feelings (positive or negative) during
termination
Stress- is an essential aspect of existence and has
always been of human experience; it is something
that every one has to cope.

Stress Management
1. Supporting protective mechanism
-rest, massage, relief of pain
2. Exploration of feelings
3. Facilitating problem solving
4. Regular pattern of exercise
5. Relaxation techniques
Advanced Stress Management
and Relaxation Techniques
Autogenic training
Visualization and Imagery
Affirmation
Meditation
Therapeutic touch
Massage
Yoga
Music therapy
Anti-anxiety medications
Communication Techniques
1.Use silence.
2.Accepting.
3.Giving recognition.
4.Offering self.
5.Giving broad opening.
6.Offering general leads.
7.Making observations
8.Encouraging comparison
9.Restating
10.Focusing
11.Reflecting
12.Exploring
13.Giving information
14.Seeking clarification
15.Presenting reality
16.Asking direct questions
What type of coping mechanism was
used?
1.The adolescent decides to take up nursing because she greatly
admires her mother who is a nurse.
2.The girl who is not as beautiful as her sisters, studies very hard
and she achieves high grades.
3.The teacher who really wants to be the principal of the school
states that she wouldn’t take the position if it were offered
because it is a lot of work and no commensurate compensation.
4.The father shouts at his children as he arrives home because he
was reprimanded by his boss at work.
5.The six year old child thumbsucks as he is confined in the
hospital.
6.The nursing student vomits after a very difficult situation.
7.The client with cancer consults other physicians because he
refuses to accept his diagnosis.
8.The student who hates her teacher, frequently tells the teacher
that she admires her teaching.
Documenting and
Reporting
Documenting- serves a permanent record.
Reporting- when two or more people share
information about the client care,
either face to face or by telephone.
Purposes:
1.Communication
2.Legal Documentation
3.Research
4.Statistics
5.Education
6.Audit and Quality Assurance
7.Planning Client Care
8.Reimbursement
Types of Records
A.Source-Oriented Medical Record
(Traditional)
- Each department makes notes on the chart.

Five Basic Components


1.Admission Sheet
2.Physician’s Order Sheet
3.Medical History
4.Nurses’ Notes
5.Special Records and Reports
(referrals, x-ray, VS, I&O)
B. Problem-Oriented Medical Record
(POMR)
-integrates all data about the problem gathered
by the HCP.
-records are recorded and arranged according
to the source of information.

Four Basic Components


1.Database- all initial information
2.Problem List
3.Plan of care
4.Progress notes
(SOAPIE, Flow Sheets, Discharge notes)
Kardex
-makes information readily accessible to all
members of the HCP.
-series of flip cards
-tool for change-of-shift-report (use a pencil only)

Data included in KARDEX:


• Personal data
• Basic needs
• Allergies
• Diagnostic tests
• Nursing procedures
• Medications and IV therapy, BT
• Treatments like oxygen supply, steam inhalation,
suctioning, change of dressing, mechanical ventilation
Characteristics of a Good Recording
1. Brevity (concise and complete)
2. Use of ink/ permanence
3. Accuracy (chart objective facts)
Incorrect: Ate with poor appetite.
Correct: Ate 50% of the food served.
Incorrect: Depressed
Correct: Seen crying
*Place quotation marks if it’s a client complain
*Objective data (VS, I&O etc.)
*Describe behaviors rather than feelings
*Refusal of medications and treatments- documented
4. Appropriateness
Cont…

5. Completeness and chronology


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

The following information should be charted:


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

6. Use of Standard Terminology (include


grammar)
7. Signed (Bernard M. Lapuz, SN/ Bernard M. Lapuz, RN)
8. In case of ERROR
-draw a horizontal line, write “ERROR”, initials/ signature
9. Confidentiality
10. Legal Awareness
11. Legible
12. Do not use the word “patient” or “pt.”; the chart belongs to
the patient.
13. A horizontal line drawn to fill up a partial line
-to prevent others from adding information
e.g. Bernard M. Lapuz, RN
Types of Reporting
1. Change-of-Shift Report
-endorsement (KARDEX)
2. Telephone Reports
a. when the call was made
b. who made the report
c. who was called
d. to whom information was given
e. what information was given
f. what information was received
3. Telephone orders
*ONLY RNs may receive telephone orders
*The order must be verified; have a witness if possible
*Should be countersigned by the physician within 24 hours
4. Transfer reports- when transferring a pt. to another unit.
Give the meaning of commonly used abbreviations…
a.c OD DOMAINS of LEARNING
ADL OU
a. Cognitive
Ax. OS
(Knowledge)
BID QID
BMR AD
b. Affective AU
BP
(Emotions, Feelings and Interests)
c.c. AS
Cap
c. Psychomotor prn
Gtt
(Skills)
s.s.
h.S s.c
IM stat
IV TID
Mcgtt Od
THE NURSING PROCESS
Assessing Health

a. Head-to-Toe Framework
 General: General Health State, VS, weight, nutritional
status
 Head, hair, scalp, eyes, ears, oral cavity, cranial nerves
 Neck
 Chest
 Abdomen
 Extremities
 Genitals
 Rectum
Body Systems Framework
Respiratory
Cardiovascular
Musculoskeletal
Gastrointestinal
Integumentary
Endocrine
Genitourinary
Reproductive
Neurologicc
Sensory
Psychosocial
1. Body Temperature
-balance between heat produced and heat
loss in the body.

Types:
a.Core- deep tissues (oral and rectal)
b.Surface- skin and subQ (axilla)

Heat regulating center- HYPOTHALAMUS


Factors affecting body’s heat:
a. Basal Metabolic rate
*younger-higher the BMR
*older- lower the BMR
b. Muscle Activity- exercises increases BMR
c. Thyroxine output- increases BMR
d. Catecholamines- increases BMR
e. Fever

Factors affecting temperature:


1. Age
2. Diurnal variation- highest from 8-12MN
lowest from 4-6AM
3. Exercise
4. Hormones
5. Stress- Sympathetic stimulation
PROCESSES in HEAT LOSS
Radiation Convection
Conduction Evaporation

1.Application of moist wash-cloth over the skin


2.Exposure of skin towards electric fan
3.Continuous vaporization of moisture from the skin,
oral mucous, respiratory tract
4.It feels warm in a crowded area.
Alterations in Body Temperature
1.Pyrexia/ Hyperthermia- above normal
2.Hyperpyrexia- very high, >41C
3.Hypothermia- low temp.

Types of Fever
1.Intermittent Fever- fluctuates to normal and
abnormal within 24 hours
2.Remittent Fever- fluctuates within 24 hours
of abnormal temperature
3.Relapsing Fever- fluctuates to normal and
abnormal few days in between
4.Constant Fever- remains very high
Most accessible and c/I: Oral Lesions,

ORAL convenient to use dyspnea, cough, seizure,


chills, unconscious
2-3 minutes

Safest and most non- C/I: none

AXILLA invasive method

10 minutes

Fastest C/I: Mastoiditis and ear

TYMPANIC 2-3 seconds


infection

Most accurate C/I: Hemmohoidectomy,


Assume lateral position diarrhea, anal fissures,

RECTAL quadriplegic clients

2 minutes
Pulse
1. Rate: Newborn 120-180bpm
Adult 60-100bpm
*Tachycardia- above 100bpm
*Bradycardia- below 60bpm
2. Rhythm- the pattern and intervals of beats.
*Dysrhythmia- irregular rhythm
3. Volume- the strength of the pulse.
*Normal pulse can be felt with moderate pressure
*Full/ bounding- great pressure
*Thready pulse- weak
4. Presence/ ansence of bilateral equality
* radial, ulnar, femoral etc.
Pulse Sites
1.Temporal
2.Carotid
3.Apical
4.Brachial
5.Radial
6.Femoral
7.Posterior tibial
8.Popliteal
9.Pedal (Dorsalis Pedis)
Respiration
-the act of breathing.

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

Two types:
a.Costal (thoracic)- movement of chest
b.Diaphragmatic (abdominal)- movement of abdomen

Respiratory centers
a.Medulla Oblongata- primary respiratory center
b.Pons
*Pneumotaxic- rhythmic quality of breathing
*Apneustic- deep prolonged breathing
Assessing Respiration
Rate: 12-20 RR/min
Depth- observe for movement of chest
Rhythm- observe for regularity of exhalation and inhalation
Quality- respiratory effort and sound of breathing

Terminologies:
Eupnea- normal respiration
Tachypnea- >20RR/ min
Bradypnea- <12RR/ min
Hyperventilation- Deep, rapid respiration (alkalosis)
Hypoventilation- slow, shallow respiration (acidosis)
Dyspnea- DOB
Orthopnea- ability to breath only in upright position
Apnea- absence of respirations
Blood Pressure
- The pressure exerted by blood against the walls of the
arteries

*Systolic Pressure- pressure of blood as a


result of contraction of the ventricles
*Diastolic Pressure- pressure when
ventricles are at rest.
*Pulse Pressure- difference between the
systolic and diastolic pressures (30-40mmHg)
*Hypertension->140/90mmHg
*Hypotension- <90/60mmHg
Determinants of BP
1.Blood Volume
2.Peripheral Resistance (dialte and constrict)
3.Elasticity or compliance of blood vessels
4.Blood Viscosity

Assessing BP
1.Allow to rest.
2.Sitting or supine
3.Left arm is preferred over the right.
4.Snugly fit
5.Inflate
6.Deflate- “Korotkoff sound’
7.If Mercurial, read lower meniscus
8.Prevent “Error of Parallax”
Nursing Health History
-gathered through interview

Components of Nursing Health History

1.Biographic Data
2.Chief Complaint
3.History of Present Illness
4.Past Health History
5.Family History of Illness
6.Review of Systems
7.Lifestyle
8.Social data
9.Psychologic data
10.Patterns of health care
Physical Health Examination
-head to toes
-determine the mental status and LOC
-protect the client’s privacy during the examination
-prepares the needed articles and equipment

Modes of Examination
1.Inspection -sight
2.Palpation -touch
3.Percussion -tapping
4.Auscultation -stethoscope (hear)
Positions

1.Dorsal recumbent
2.Dorsal/ supine
3.Sitting
4.Fowler’s- semi (45 degrees) and high (90 degrees)
5.Lithotomy
6.Lateral
7.Sim’s/ Semi-prone position
8.Prone
Pointers:
1. Sequence of assessment in abdomen?
IAPERPAL
2. Sequence of quadrants?
RLQ, RUQ, LUQ, LLQ
3. Best position when examining the chest?
Sitting
4. Position when examining the back?
Standing
5. How do we check for neck lymphadenopathy?
Stand behind the client and palpate the neck
6. If you’ll use vaginal instrument, pour warm water
first to ensure comfort.
Supplemental Data
a.Urine
b.Stool
c.Sputum
d.Blood
e.Body secretions

Urine specimen
1.Clean-catch, mid-stream specimen for
routine urinalysis, C&S
- Best time to collect is AM (concentrated)
- Discard the first flow urine.
- Sterile container. Wash first before getting the specimen.
- 30-50ml
- Send to the laboratory immediately
2. 24-hour urine specimen
-Discard first voided urine
- Collect all specimen thereafter, until the same day the ffg.
day.
- Soak the specimen in a container with ice.

3. Catheterized urine specimen


-clamp the catheter for 30 mins. to 1hour.
-cleanse the drainage port of the two-way FC
-Use sterile needle and syringe to aspirate from
the drainage port.
-don’t collect urine from the urinary drainage bag.
Stool
a.Routine fecalysis –determine ova/ parasites
b.Stool Culture- etiologic agents
c.Guaiac Stool Exam/ Occult Blood- bleeding

Test of Glucose in the urine


*Benedict’s Test
-collect specimen before meals
-Heat 5ml of Benedict’s solution in a test tube
-Add 8-10 drops of urine
Interpretation:
Blue - (-)
Green - +
Yellow - ++
Orange - +++
Red - ++++
Test for Albumin in the urine
*Heat and Acetic Acid Test
-collect urine specimen before meals
-imaginary divide the test tube into three parts
-fill the 2/3 part with urine, heat the test tube
-add 1/3 acetic acid or just few drops, don’t boil
-CLOUDINESS indicates albuminuria

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

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