Escolar Documentos
Profissional Documentos
Cultura Documentos
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.
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”.
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
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…
LEVELS OF CLIENTELE
I. Individuals
II. Families
III. Social Group
IV. Communities
Self-
Actualization
Self-Esteem
Physiologic
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
EUDOMONISTIC MODEL
AGENT-HOST-ENVIRONMENT MODEL
(Leavell & Clark)
HEALTH-ILLNESS CONTINUUM
(McCann/Flynn & Heffron, 1984)
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
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.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
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
Chain of infection
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.
Stress, Adaptation,
Homeostasis
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
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.
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)
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,
10 minutes
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
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
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.
Sputum Specimen:
1. Sputum Culture and Sensitivity Test
2. Acid-fast bacilli (AFB) staining (3 consecutive
mornings)
THANK YOU!