Compilation Of Funda Notes

FUNDAMENTALS OF NURSING HISTORY OF NURSING PERIODS OF NURSING INTUITIVE NURSING/ PRIMITIVE NURSING/ INSTINCTIVE NURSING (Primitive times – 6th century) PRIMITIVE TIMES - Women practice nursing because of low status in society. - Took care of children and sick members of the family. - Personalistic cause of disease. - Sickness is due to active intervention of: a. human – caused by witchcraft. b. non human – caused by ghosts. c. superhuman beings – caused by deities. - Superstitious and believes in magic. - Slave society “slave nurses” - Wet nursing, take care of babies/children of their masters - Women also practices midwifery. - Masters/healers are the people who are responsible in decision making when it comes to health. 6th CENTURY - Founding of religious orders. 3 Attributes of Nurses 1. Self denial 2. Devotion to hard work and duty. 3. With spiritual calling. Main Guiding Principles 1. “Love thy neighbor as thy self”. Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

2. Parable of the Good Samaritan. - Beneficence (doing good to others). 2 Types of Beneficence 1. Ordinary – doing good to others. 2. Ideal – entails sacrifice. APPRENTICE NURSING PERIOD (6th Century – 18th Century) 6TH CENTURY - founding of religious orders. - women practiced nursing. - Daughters of Charity/Sisters of Charity founded by St. Vincent de Paul and Augustinian Sisters. CRUSADES - Men practiced nursing. - Knights of St. Lazarus a. established a standard among hospitals in Europe. b. took care of clients with skin problems like leprosy. - Knights of St. John of Jerusalem a. also known as Knights Hospitalers. b. founded hospitals. 18TH CENTURY 1836 - Theodore Fleidner reestablished order of Deaconesses. - Founded school of nursing in Kaisserwerth, Germany where Florence Nightingale was the most known student. 1854-1856 (CRIMEAN WAR) - Florence Nightingale was known as the Lady with a Lamp.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Compiled the “Notes on Nursing: What it is and What is not” and became the first nurse theorist.

EDUCATIONAL NURSING PERIOD (18th Century – 20th Century) 18TH CENTURY - Florence Nightingale established a nursing school in St. Thomas Hospital in London which adopted the Nightingale System. - Made Florence Nightingale the mother of modern nursing. Philosophy of Nightingale System 1. Government funds should be allotted to nursing education. - earned her the title of being the first nurse political activist. 2. Training schools of nursing should be in close affiliation. 3. Professional nurses should train nurses. 4. Nursing students should be provided with residence near their training hospitals. - written orders of doctors insisted. - nurses should go with doctors during rounds. LATE 20TH CENTURY - Specialization in medicine. - Conceptualization of the role of clinical nurse specialist. - Increase clinical content of education (1900’s). CONTEMPORARY PERIOD (21st Century) Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Globalization of nursing. - Period after world war II. - Borderless nursing or transcultural nursing. - Professionalization of nursing. PROFESSION – a special calling that requires special, skills, knowledge and attitudes. 7 CRITICAL ATTRIBUTES OF PROFESSION 1. Specialized education 2. Code of ethics 3. Research of orientation 4. Autonomy 5. Body of knowledge 6. Service orientation 7. Professional Organization SOCIALIZATION – process where a person learns the ways and means or skills, knowledge, attitudes of the group to which he belongs to. BENNER LEVEL OF PROFICIENCY 1. Novice – student nurse entering a clinical setting where he has no experience at all. 2. Advance – nurse who demonstrates a marginally acceptable performance: depends on rules and maxims. 3. Competent – 2 – 3 years experience demonstrates organizational ability but lacks speed and flexibility of a proficient nurse. 4. Proficient – concerned with long term goals, performance is fluid and flexible compared to competent nurse - has a wholistic view of the client. Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

5. Expert – no longer relies on maxims, performance is highly proficient, fluid flexible and has a wholistic view. - has high perceptual acuity or a clinical eye. DIMENSIONS OF NURSING 1. Nursing Practice 2. Nursing Education 3. Nursing Research FOCUS OF NURSING 1. Health Promotion – improve clients well being. 2. Health Maintenance 3. Health Instauration – help clients with illness to recover. 4. Care of the Dying – clients with cancer. ROLE – patterns of behavior expected of person assuming a status/position in society or a group. TASK – specific activities required of a person.

PATIENT - Has a disease

CLIENT - Not necessarily sick

- Very dependent on health

- Health promotion act till

professional

disease prevention - Client collaborates with health professional

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

LEVELS OF CLIENTELE 1. Individual 2. Family 3. Community 4. Population Groups – special groups with special needs attributed to the following: a. Cultural characteristics – indigenous people. b. Developmental stage c. Occupation – commercial sex workers are more prone to STD’s. ROLES OF NURSE 1. Nurse Educator - 3 domains of learning a. Cognitive – knowledge aspect b. Psychomotor – skills c. Affective – interest/emotion 2. Caregiver - Attends to physical/emotional (mostly physical) needs of the client. 3. Nurses as Leader - Process of influencing people to work towards the attainment of goals. 4. Manager - Organizational goals/works within an organization. PROCESS OF MANAGEMENT a. Planning (resources) b. Organizing (delegating tasks/tasking) c. Directing (motivating people) Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

d. Controlling – evaluation of output against standards. 5. Client advocate – protects rights of clients. 6. Change agent – improvement in organization. 7. Researcher – research process 8. Facilitator THEORIES – relationship between concepts 4 CONCEPTS OF NURSING THEORIES 1. Individual/Person 2. Nursing 3. Health 4. Environment

NURSING THEORIES A. GENERAL THEORIES 1. NIGHTINGALE’S ENVIRONMENTAL THEORY Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- What nursing has to do is to put the individual in best position for nature to work on him. - Nursing Action: manipulation of elements in the environment to contribute to reparative process. 10 ELEMENTS FOUND IN ENVIRONMENT 1. Air – importance to have moving air in room of patient to contribute in proper ventilation. 2. Light – patient should be near windows to be able to see sunlight and give hope. 3. Health of houses – environmental sanitation. 4. Cleanliness 5. Beddings – change linens/beddings in patients room to promote comfort. 6. Nutrition 7. Variety – change in environment for patient. 8. Ventilation – promote warming. 9. Noise – due to nurses clothing or roaming around. 10. Chattering hopes – deals with social aspect; nurse should be cautious with words when at bedside, GOALS

talk about positive things.

2. VIRGINIA HENDERSON’S DEFINITION OF NURSING INDEPENDENCE - Assisting individualsKNOWLEDGE sick or well in the performance of activity. RESTORATION - Role of nurse is complimentary.

- Supplementary

WILL

MAINTENANCE STRENGTH

- Individual person is a whole, complete and individual being. NURSE- PERSON INTERACTION PEACEFUL DEATH

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

NURSES

PERSON

ENVIRONMENT

14 BASIC COMPONENTS OF NURSING CARE 1. Breathe normally 2. Eat, drink adequately 3. Eliminate body waste 4. Move and maintain desirable posture 5. Sleep and rest 6. Select suitable clothes 7. Maintain body temperature 8. Keep body clean and well groomed 9. Avoid dangers in environment 10. Communicate with others 11. Worship according to ones faith 12. Work for accomplishment 13. Participate in recreation Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

14. Learn to satisfy the curiosity that leads to normal development

1-9 PHYSIOLOGIC 10 – 14 PSYCHOLOGICAL 12 – 13 SOCIOLOGIC 11 SPIRITUAL/MORAL

3. MARTHA ROGER’S SCIENCE OF UNITARY HUMAN BEINGS A. Nursing is humanistic science B. Parallel with Ludwig von Bertalanffy’s General System Theory C. 5 assumptions about human beings 1. Man is a unified whole – whole not equal to sum of parts. 2. Individual and environment are continuously exchanging matter and energy. 3. Lifecycle evolves irreversibly and uni-directionally along space and time continuum. 4. Life patterns identify individuals. 5. Humans have the capacity for absorption and imagery, language and thought, sensation and emotion. GENERAL SYSTEM THEORY - A set of interacting parts/ components with a boundary that filters the input and output from and to the environment. - Input and output: matter, energy, information. - Whole: physical, psychological, spiritual, intellectual. 4. DOROTHEA OREM’S SELF CARE DEFICIT THEORY Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Man is an integrated whole, biologically, symbolically and socially. - Man is self reliant and responsible for self care. - Man is requisite for all. - Nursing is a service, art and technology. 3 SUB THEORIES 1. Self Care – universal self care, developmental. 2. Self Care Deficit – demands, capabilities, deficits. 3. Theory of Nursing Systems – wholly compensatory, partly supportiveeducative. UNIVERSAL SELF CARE REQUISITES 1. Sufficient intake of air 2. Sufficient intake of water 3. Sufficient intake of food 4. Satisfactory eliminative functions 5. Activity balanced with rest 6. Time spent alone balanced with time spent with others 7. Prevention of danger 8. Being normal DEVELOPMENT OF SELF CARE REQUISITES - Specialized expression of universal self-care requisites for development process. HEATH DEVIATION - Additional demands for health care due to illness, disease or injury. THEORY OF NURSING SYSTEM 1. Wholly compensatory – nurse acts for patient. 2. Partly compensatory – both nurse and patient. 3. Supportive-Educative – patient able to perform self care. Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

B. SYSTEM THEORIES 5. SISTER CALLISTA ROY’S ADAPTATION MODEL - Grounded on humanism. - Person is adaptive system with coping mechanism. - Goal of nursing is to promote persons adaptation. STIMULI 1. Focal - immediate 2. Contextual – other internal and external factors 3. Residual – may or may not have effect like attitudes and beliefs.

COPING MECHANISMS 1. Regulator – neural – chemical – endocrine. 2. Cognator – processed through cognition. ADAPTIVE MODES - Physiologic – adaptive mode - Self concept mode - Interdependence mode - Role function mode - Adaptive/effective response - Maladaptive/ineffective response

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

6. IMOGENE KING’S GOAL-ATTAINMENT THEORY - Nursing is a process of human interaction between the nurse, client, each person perceive the other and situation and explore the means to achieve them. - Humans are open systems in constant interaction with their environment. - Nursing focus: human interact with the environment. - Nursing Goal: humanistic maintenance of individuals and groups. - Interacting components are personal, interpersonal, social. - Elements: interaction, communication, transaction role, stress. COMPONENTS PERSONAL SYSTEM - Perception, self, growth and development, image, space, learning time. - Organization, authority, power, status, decision making. 7. BETTY NEUMAN’S HEALTH CARE SYSTEMS MODEL - Based on 2 components stress, reaction to stress. - Client (individual, group, community) is an open system in interaction with environment. 4 CONCEPTS A. CLIENT Flexible – keeps system free from stressor reaction or symptom-matology. Line of Resistance – consist of internal defensive processes. Ex. Immune response. B. ENVIRONMENT - Environment has potential to alter system stability due to internal and external stressors.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

STRESSORS CAN BE 1. Extra personal – unemployment, microorganisms, peer pressure, radiation. 2. Inter personal – between 2 or more individual (parent expectations). 3. Intra personal – anger, physical abilities, financial condition. - Environment can also be source of resources that may help client cope with stressors. C. HEALTH D. NURSING - Primary: protection of normal line of defense. - Secondary: protection of basic structure by strengthening internal line of resistance. Ex. Treatment of symptoms, energy conservation - Tertiary: promotion of reconstitution by supporting existing strengths and resources. 8. DOROTHY JOHNSON’S BEHAVIORAL SYSTEMS MODEL Mans subsystem - Behavioral subsystem: addressed by nursing intervention. - Biological subsystem: addressed by medical intervention. Goal of Nursing a. demonstrate behavior commensurate to social demands. b. modify behavior to support biological needs. c. benefit from physicians skill and knowledge. d. demonstrate behavior that does not give evidence of unnecessary trauma. - Nursing focus: behavior modification to foster equilibrium.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

C. INTERPERSONAL/CARING THEORIES 9.

HILDEGARD

PEPLAU’S

INTERPERSONAL

RELATIONSHIP

IN

NURSING - purpose of nursing is to educate and to be a nurturing force to a patient for him to get a new view of himself. - interaction is a maturing force. Nurse

Patient

Counselor – identify stressor

(with a need)

Resource Person – health educator Surrogate – acts as caregiver Congruent Goals

PHASE OF NURSE – PATIENT RELATIONSHIP 1. Orientation – leveling off between nurse and client in term of expectation. 2. Identification – selective response of the client to those who can meet his needs; affected by clients belief. 3. Exploitation – client takes control of the situation by extracting help from nurse. 4. Resolution – evaluation of care and discharge of client.

10. MADELEINE LEININGER’S TRANSCULTURAL CARE THEORY

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Culture: way of life, total of all the material and non material’s produced by the people at their level of social development. - has universalities: same as other culture (hygiene, nutritional needs). - diversities: cultural peculiarities (caring ). 11. IDA JEAN ORLANDO’S DYNAMIC NURSE-CLIENT RELATIONSHIP - Types of nursing response: deliberate action(based on correct identification of patients needs) and automatic action. - nursing function is concerned with providing direct assistance to individuals in whatever setting to avoid, diminish, relieve individual’s sense of helplessness. - Nursing disciplined professional response. 12 JEAN WATSON’S PHILOSOPHY AND SCIENCE OF CARING - Nursing is the science of caring. - Caring is more healthogenic than caring. - Main focus of nursing is on curative factors that are derived from humanistic perspectives combined with a scientific base. 10 CARATIVE FACTORS 1. Formation of a humanistic-altruistic value system. 2. Faith – hope 3. Cultivation of sensitivity to self and others. (First 3 factors are the foundations for caring) 4. Establishing a helping trust relation 5. Expression of feelings, both positive and negative. 6. Research and systematic problem solving. 7. Promotion of interpersonal teaching-learning. 8. Provisions for a supportive, protective and corrective mental, physical, sociocultural and spiritual environment. Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

9. Assistance with the gratification of human. 10. Allowance for existential phenomenological factors. D. CLIENT CENTERED THEORIES 13. FAYE GLEN ABDELLAH’S 21 NURSING PROBLEMS - Nursing in the use of the problem solving approach - Covert: psychological problem - Overt: obvious (physical manifestations of health problems)

14. LYDIA HALL’S THEORY OF CORE, CARE, CURE - Patient is composed of 3 elements: body, pathology, person - Nursing is helping clients move in the direction of self awareness - Nursing operates in all 3 elements - Core: the person, therapeutic use of self - Care: the body, intimate body care (nurturing component) - Cure: the disease, medical care (client advocate) 15. MYRA ESTRINE LEVINE’S FOUR CONSERVATION PRINCIPLES OF NURSING - Promotion of the wholeness of the person - By improving the clients patterns of adaptive response

CONSERVATION OF -

Energy

-

Structural Integrity

-

Personal Integrity

-

Social Integrity

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Promotion of “wholeness” of the client towards

health

maintenance

or

health

restoration.

CONSERVATION - Defends wholeness of living systems by ensuring their ability to confront change 16. NOLA J. PENDER’S HEALTH PROMOTION MODEL - Directed towards increasing the level of well being and self actualization of a given individual or group - Importance Example: 6 – 8 hours of sleep of health - Disease prevention/Health protection: action directed towards decreasing Perceived control of health Biologic the probability of experiencing illness by active protection of the body against

pathological stressors. Perceived self efficacy

Interpersonal influences

- Example: BCG vaccination Situational factors

Depth of health

COGNITIVE PERCEPTUALBehavioral MODIFYING FACTORS factor Perceived health status FACTORS Perceived benefits of health promoting behaviors

Perceived barriers of health promoting behaviors

Demographic character

Cues to action Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

LIKELIHOOD IN ENGAGING IN HEALTH PROMOTING BEHAVIORS

Ex. Mass media

HEALTHY LIFESTYLE - Adequate nutrition 3 times a day - Regular exercise 3 times a week - Not smoking - Moderate intake of alcohol

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

CONCEPT OF MAN Atomistic – whole or sum of parts Holistic – the whole is not equal to the sum of parts Physiologic – genetic character, organs and functioning Psychological – emotions, affect, rationality, merciful Socio-cultural – socialization, family, language Intellectual – perception, cognition Spiritual – faith (unquestioning belief in someone, serves to unite humans), hope, charity Charity – outward expression of love for others BASIC HUMAN NEEDS 1. Universal 2. Met in different ways 3. Stimulated by external and internal factors 4. Maybe differed 5. Interrelated 6. Priorities maybe altered MASLOW’S HEIRARCHY OF NEEDS - Need: anything that is essential to the survival of man - Framework: basic need is something whose - Absence: may cause illness - Presence: prevent illness/signal health - Meeting unmet needs restore health

Physiologic Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- sex, nutrition, shelter, clothing, water, elimination, rest and sleep Safety and Security - physical freedom from harm, psychological knowing what to expect from others and what others expect from you. Love and Belongingness - nurturance with affection Self Esteem - persons sense of achievement and independence, competence, confidence and strength Self Actualization - not all people attain self actualization (attained by only 15%) - Accepts himself - Balance between rest and activity - Open mind - Positive outlook in life HEALTH - Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WELLNESS - State of well being - Subjective perception of balance, harmony and vitality engaging in attitudes and behaviors that enhance the quality of life and maximizes personal potential.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

DIMENSION OF WELLNESS - Physical: ADL, fitness of organ structures and functioning - Spiritual: faith and hope - Intellectual: use knowledge for personal, family, social, career development - Emotional: able to manage stress, express feelings and emotions appropriately - Social: interact successfully with others, tolerant of people with different beliefs

MODELS OF HEALTH AND WELLNESS LEAVELL AND CLARKS AGENT – HOST ENVIRONMENT MODEL OR ECOLOGICAL MODEL/EPIDEMIOLOGIC Agent

Host

Environment

DUNN’S HIGH LEVEL WELLNESS GRID Very Favorable Environment

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Protected poor health

High level wellness ( in favorable environment)

(in

favorable environment)

HEALTH AXIS Death

Peak Wellness

Poor health

Energetic, High level wellness

(in an unfavorable environment)

(in an unfavorable

environment)

Environmental axis Very Unfavorable Environment Both physical and social cultural environment

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

TRAVIS ILLNESS – WELLNESS CONTINUUM

Wellness model

.

.

.

.

.

.

Premature Death Disability Symptoms/Signs

Awareness/ Education/ Growth

High Level Wellness Treatment Models

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Neutral Point (no discernable illness or wellness) - Movement to the right of the neutral point indicates high level of health and well being for an individual and this may be achieved through awareness and education and growth. In contrast, movement to the left of the neutral point indicates a progressively decrease state of health

HEALTH BELIEF MODEL - Intended to predict whether individuals would or would not use preventive measure - Based on the motivational theory - Assumption: Good health is a motivation common to all people ILLNESS - Highly personal state in which the person feels unhealthy or ill, may or may not be related to disease DISEASE - Alteration in body function resulting in a reduction of capacities or a shortening of the normal lifespan Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

CAUSES OF DISEASE 1. Genetic – inherited, genetic defects 2. Developmental – resulting to exposure to virus or chemicals during pregnancy 3. Biologic – microorganisms (virus, bacteria, protozoa, fungi) and their toxins and helminthes 4. Physical – temperature extremes, electricity, radiation 5. Chemical – alcohol, strong acid and base, drugs 6. Mechanical – generalized tissue response to injury or irritation (trauma shearing force, friction) 7. Physiologic and Emotional reaction to stress 8. Faulty Chemical or Metabolic Processes – excessive or insufficient production of hormones, enzymes IGUN’S 11 STAGES OF HEALTH SEEKING - Any activity undertaken by a person who feels ill in order to define his state of health and seek a suitable remedy Stage 1: Symptom experience Stage 2: Self treatment or self medication Stage 3: Communication to others Stage 4: Assessment of symptoms Stage 5: Sick-role assumption Characteristics of Sick Role a. Expected to seek competent help b. Expected to get well in the shortest possible time c. Person is not blamed for his disease d. Exempted from usual task Stage 6: Concern Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Stage 7: Efficacy of treatment Stage 8: Selection of treatment Stage 9: Treatment Stage 10: Assessment of effectiveness of treatment Stage 11: Recovery and rehabilitation SUCHMAN’S 5 STAGES OF ILLNESS Stage I: Symptom Experience - Person believes that something is wrong - Physical experience of the symptoms - Cognitive aspect: interpretation of the symptoms - Emotional response: fear or anxiety Stage II: Assumption of Sick Role - People are excused from normal duties and role expectations - Clients are not held responsible for their condition - Clients are obliged to get well and resume normal activity - Clients are obliged to seek competent help Stage III: Medical Care Contact - Seeking medical advice to ask for the following o Validation of real illness o Explanation of symptoms in understandable terms o Reassurance that they will be fine or for a prediction of what the outcome would be - Client may accept or deny diagnosis Stage IV: Dependent Client Role - The client is dependent on the professional for help and give up their independence Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Client accepts treatment plan Stage V: recovery or Rehabilitation - Client relinquishes role and resumes former role and responsibilities - For permanent disability, this may require therapy to learn how to make major adjustments in functioning.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

CHARACTERISTICS OF NURSING PROCESS 1. Cyclic and dynamic rather than static 2. Client centered – nurse organizes plan of care according to client problems rather that nursing goals 3. Interpersonal and collaborative – depends on open and meaningful communication between client and the nurse 4. Universally applicable – can be used with clients of any age at any point of the wellness – illness continuum and useful in a variety of settings 5. Adaptation of problem solving techniques and system theory based on the scientific method 6. It can be viewed as parallel to but separate from the medical process

ASSESSMENT - Objective (physical exam) and subjective (nursing history) SOURCES OF DATA 1. Primary – client 2. Secondary – relatives, members of health team FOR

NURSING

HISTORY

USE

GORDON’S

TYPOLOGY

OF

11

FUNCTIONAL PATTERN 1. Health perception – health management pattern – describes clients perceived pattern of health and well being and how health is managed.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

2. Nutritional – metabolic pattern – describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply. 3. Elimination – describes pattern of excretory function (bowel, bladder and skin). 4. Activity – exercise – describes pattern of exercise, activity, leisure and recreation 5. Cognitive perceptual – describes sensory perceptual and cognitive system 6. Sleep rest – describes pattern of sleep, rest and recreation. 7. Self perception – self concept – self concept pattern and perceptions of self (body comfort, body image, feeling state). 8. Role relationship – describes pattern of role engagements and relationships 9. Sexual reproductive – client patterns of satisfaction and dissatisfaction with sexuality: describes reproductive pattern 10.

Coping stress tolerance – general coping pattern and effectiveness

of the pattern in terms of stress tolerance. 11.

Value belief – patterns of values, beliefs (including spiritual) or

goals that guide choices of decisions. NURSING DIAGNOSIS - Clinical judgment about an individual, family or community responses to actual and potential health problems - Professional nurses are responsible for making nursing diagnosis. - Nursing diagnosis describe a continuum of health states.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Actual

Potential Health

Healthy Problem Responses NURSING DIAGNOSIS MEDICAL DIAGNOSIS - Focus on identifying human - Identifies disease responses to health and illness

- Describe problems for which the

- Describe problems treated by physician nurses

within

the

scope

directs

the

primary

of treatment

independent nursing practice - Changes from day to day as - Remains the same for as long client responses change

as the disease is present

6 TYPES OF NURSING DIAGNOSIS 1. Actual nursing diagnosis – judgment about a clients response to a health problem at the time of assessment and is signified by the presence of associated signs and symptoms. Format: 2 part (problem related to etiology) 3 part (problem, etiology and signs and symptoms format) 2. Risk nursing diagnosis – clinical judgment about a clients vulnerability to develop a problem Format: 2 part statement (diagnostic label related to risk factors) 3. Possible nursing diagnosis – evidence about a certain problem is unclear and need to gather more data to support it Format: 2 part statement

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

4. Wellness nursing diagnosis – clinical judgment about an individual, family and community in transition from a specific level of wellness to a higher level of wellness Format: potential + desired higher level of wellness Readiness for + higher level of wellness 5. Syndrome nursing diagnosis – comprises of a cluster of problems Format: 1 part statement (rape trauma syndrome) 6. Alfaro’s rule for a collaborative problem –

focus on potential

complications Format: potential problem + related to + list of complications that may occur First Priority – is any threat to the vital functions of breathing, heart beat, blood pressure. Medium Priority – health-threatening problems that may result in delayed development or cause destructive physical or emotional changes. Low Priority – problems that arise from normal development needs or those that require minimal nursing support. OBJECTIVES - Should be SMART, client centered, statement of a single human response EVALUATION - Conclusion and supporting data - Goal met - Goal partially met - Goal not met GROWTH Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Physical change - Increase in size - Periods of very rapid growth rate: pre – natal, neonatal, infancy, adolescence DEVELOPMENT - Increase in complexity of function and skill progression - The behavioral aspect of growth PRINCIPLES OF DEVELOPMENT 1 Growth and development are continuous orderly, sequential process influenced by maturational environment and genetic factors 2. All humans follow the same pattern of growth 3. The sequence of each stage is predictable although the time of onset, the length of the stage and the effects of each stage vary with the person. 4. Growth and development occur in cephalocaudal direction. 5. Growth and development occur in a proximal to distal direction 6. Development occurs from simple to complex or from single acts to integrated acts. 7. Development becomes increasingly differentiated, begins with generalized response and progresses to a skilled specific response. 8. The pace of growth and development is asynchronous or uneven.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

KOHLBERG’S STAGES OF MORAL DEVELOPMENT LEVEL AND STAGE Level I: Pre Conventional (Egocentric Focus) Stage 1

- Activity is wrong if one is

Punishment and obedience

punished, activity is right if one

orientation

is not punished.

(toddler – 7 years) Stage 2

- Action is taken to satisfy ones

Instrumental – Relativist Orientation

needs.

(4 – 12 years) Level II: Conventional (Societal Focus)

- Action is taken to please

Stage 3

another and gain approvals.

Interpersonal concordance, good boy, nice girl (6 years thru adult

- Right behavior is obeying the

years)

law and follow the rules

Stage 4 Law and order orientation (adolescent – adult) - Standard of behavior is Level III: Post Conventional or

based on adhering laws that

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Principled Level (Universal

protect the welfare and rights

Focus)

of others: violating the rights of

Stage 5

others is avoided: personal

Social contract, legalistic orientation

values and opinions are

(middle age or older adult)

recognized. - Universal moral principles are internalized, person respects

Stage 6

other humans and believes

Universal ethical principles (middles

that relationship are based on

age or older adult)

mutual trust.

TYPES OF OLDER ADULT 1. Young old (65 – 74) – adaptation to retirement and changing physical abilities, chronic illness may develop. 2. Middle old (75 – 84) – adaptation to decline in speed of movement, reaction time and sensory abilities: increasing dependence in others. 3. Old old (85 – over) – increase physical problems.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

DEVELOPMENTAL TASK AND WHOLISTIC APROACH BY ROBERT HAVIGHURST AGE PERIOD Infancy and Early Childhood

DEVELOPMENTAL TASK - Learning to walk, to taste solid foods, to talk, to control elimination of body wastes, sex differences and sexual modes - Learning to relate emotionally to parents, siblings and others - Learning to distinguish right from wrong and developing a

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

conscience - Learning to form concepts of Middle Childhood

social and physical reality - Learning physical skills for ordinary games - Building wholesome attitude towards oneself - Learning to get along with age mates - Learning an appropriate masculine or feminine social role - Developing fundamental skills in

Adolescence

reading, writing and calculating - Develop concepts necessary for everyday living - Achieving personal independence - Achieving new and more mature relations with age mates of both sexes - Achieving masculine/feminine social role - Accepting ones physique and using the body effectively - Achieving emotional

Early Adulthood (20 – 40 yrs)

independence from parents

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Selecting and preparing for an occupation - Preparing for marriage and family life - Developing intellectual skills necessary for civic competence - Acquiring a set of values and an Middle Age (Emptiness Stage)

ethical system as a guide to behavior - Selecting a mate - Learning to live with a partner - Starting a family and rearing children - Managing a home - Getting started in an occupation - Taking on civic responsibility

Late Maturity

- Finding a congenial social group - Achieving adult civic and social responsibility - Establishing and maintaining an economic standard of living - Assisting teenage children to become responsible and happy adults - Developing adult leisure time activity Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Accepting and adjusting the physiologic changes of middle age - Adjusting to aging parent - Adjusting to decrease physical strength - Adjusting to retirement and reduced income - Adjusting to death of a spouse - Meeting social and civic obligations - Establishing satisfactory living arrangements NURSE – CLIENT RELATIONSHIP - Helping relationship for growth PHASES OF NURSE – CLIENT RELATIONSHIP Phase I: Pre Interaction - No face-to-face interaction with client Phase II: Introductory/Orientation - Rapport setting, contract setting, sets tone for rest of relationship - Testing behavior (orientation) resisting behavior (non compliance) Phase III: Working - Implementation of nursing care plans - View as unique individuals Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- Employ decision-making and technical skills and communication skills Phase IV: Termination - Characterized by ambivalence on both nurse and client - Discharge phase - Evaluation of care given by nurse

COMMUNICATION - Human function that enables people to relate with each other MODES Verbal

– spoken language

Non-Verbal – symbols, sign language ELEMENTS OF COMMUNICATION 1. Stimulus – reason why people communicate, motivation with each other (object, ideas, feeling) referent 2. Message – idea, feelings and emotions 3. Sender – also known as encoder, one that sends the message 4. Channels – kinesthetic: tactile stimulus, visual: symbols, auditory: spoken language 5. Receiver – decoder 6. Feedback – answer to questions, whether receiver understood or not FACTORS THAT AFFECT COMMUNICATION PROCESS 1. Ability of communicator – ability to speak, hear, see and comprehend stimulus Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

2. Perceptions – each has a unique trait, values, life experiences 3. Personal space – distance people prefer in interactions with one another Four distances a. Intimate - Physical contact to 1 ½ feet characterized by body contact heightened sensation of body heat and smell, low vocalization - Threatening to client b. Personal - 1 ½ feet to 4 feet - Less overwhelming than intimate distance - Usual distance between nurse and client - Best distance c. Social - 4 feet to 12 feet - Communication is non-formal - Allows more activity and movement back and forth - Often misused by nurse d. Public - 12 feet and beyond - Individuality is lost - Mass health education 4. Territoriality – concept of space and things that an individual considers as belonging to the self 5. Roles and Relationships 6. Time – events that precede and follow interactions 7. Environment – environment is comfortable, communication is more effective 8. Attitudes Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

THERAPEUTIC COMMUNICATION Using silence

RATIONALE Accepting pauses or silences without interjecting any verbal response

Providing general leads

Using statements or questions that a. encourage client to verbalize b. choose a topic of conversation

Being specific and tentative

Statements that are specific rather than general and tentative rather than absolute

Using open ended questions Specify only topic to be discussed and invite answers longer than one or two Using touch

words Touch

reinforces

caring

feelings,

however, nurse should be sensitive to Restating/Rephrasing

difference in attitude’s practice of clients self Actively listening for the client’s basic

Seeking clarification

message then repeats those thoughts and/or feelings in similar words.

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Used when communication is rambling Clarifying time or Sequence

or when paraphrasing is difficult

Offering self

Helping the client clarify an event situation or happening with respect to time

Giving information Suggesting ones presence, interest or Acknowledging

wish to understand the client without making any demands that could make client comply to suggestion

Presenting reality

A simple and direct manner, specific factual information

Focusing Giving recognition in a non judgmental way of Reflecting

a. change in behavior b. effort the client has made c. contribution to a communicator

Helping client differentiate real from Summarizing and Planning

unreal Helping the client expand on and

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Perception checking

develop a topic of importance The focus may be an idea or a feeling.Directing

ideas,

feelings,

questions or content back to clients to enable them to explore their own feelings

Stating the main points of discussion to clarify relevant parts discussed Verifies meaning of specific words than overall meaning of a message

NON THERAPEUTIC COMMUNICATION Stereotyping

RATIONALE Offering

generalized

and

over

simplified beliefs about groups of people Agreeing and Disagreeing Akin to judgmental responses implies client is either right or wrong Being defensive Attempting to protect a person Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Challenging Giving response that makes client prove their statement or point of view Probing Asking

information

chiefly

out

of

curiosity rather than intent Testing Question than make a client admit Changing topic

something

Unwarranted reassurance

Directing communication into areas of self intent

Passing judgment

Using

clichés

or

comforting

statements of advice as a means to reassure the client Giving common advice Giving opinions and approving or disapproving response Telling client what to do

VITAL SIGNS TEMPERATURE 1. Oral - Most accessible and convenient - Normal value: 37 o C – 98.6 o F Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

- 2 – 3 minutes 2. Rectal - Most reliable - Normal value: 37.7 o C – 99.6 o F - 3 – 5 minutes 3. Axila - Less accurate - Normal value: 36.4 o C – 97.5 o F - 5 – 10 minutes 4. Tympanic membrane - Directly reflects core temperature - Normal value: 37.7 o C – 99.9 o F - Automatic results CONVERSION - Fahrenheit to Celsius = (F-32) x 5/9 - Celsius to Fahrenheit = (C x 9/5) + 32 PULSE SITE 1. Temporal

6. Femoral

2. Carotid

7. Popliteal

3. Apical 4. Brachial

8. Posterior tibial 9. Dorsalis pedis

5. Radial  When palpating for pulse use 2 – 3 fingers except when taking the apical pulse use stethoscope  Apical pulse is in the 5th intercostals space  Landmark is the angle of Louie Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

 4th intercostals space left mid clavicular line child apical pulse  When using the stethoscope use the flat part when looking for high pitch sounds like (lung and bowel sounds) and use the bell for vascular or heart sounds RESPIRATION - Adult: 12 – 20 c/min - Newborn – 30 – 60 c/min ERRORS IN TAKING RESPIRATORY RATE Patient Factor  Insufficient rest before assessing  Assessing immediately after a meal or while client smokes or has pain Equipment Factor  Stethoscope fits poorly or hearing impaired  Bladder or cuff too wide  Bladder or cuff too narrow Errors in technique  Arm unsupported  Arm above heart level and not perpendicular to the body  Cuff wrapped to loosely  Deflating cuff to slowly  Deflating cuff to quick  Failure to identify auscultatory gap Auscultatory gap  Temporary cessation of sounds after initiation Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

 Gap of 10 – 40 mmHg  Common among hypertensive  Repeating assessment too quickly (wait for 2 – 3 minutes after taking again the bp, and maximum of 3 takes same arm and if still inaudible rest arm for 5 – 15 minutes)  Multiple examiner using different Kortkoff sounds for diastolic readings  Failure to use the same arm consistently Effects  Erroneously high readings

False low systolic and false high diastolic - False low reading - False high reading - Erroneously high readings - Erroneously low readings - False high readings - False low diastolic reading - False high diastolic reading - False low systolic bp and diastolic bp - False high systolic blood pressure, false low diastolic blood pressure



Inaccurate interpretation Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010



Inconsistent measurements

 For a client who’s blood pressure is to be taken for the first time, take the blood pressure of both arms  Difference of blood pressure for both arms should only be 10 mm Hg 

Use higher value as baseline

PALPATORY SYSTOLIC PRESSURE 

Point of pulsation stops with the use of stethoscope



Maximum pressure + 30 mmHg that is you limit when taking the blood

pressure KOROTKOFF SOUNDS Phases 1. Characterized by a thud, thump and tapping sound 2. Swooshing, whoosing sound 3. Sound decrease in intensity when compared to Korotkoff one 4. Muffling sound 5. Disappearance of sound - in adults record Korotkoff 1 and Korotkoff 5 of able to hear Korotkoff 4 record also - in children record Korotkoff 1 and Korotkoff 4 HYPERTENSION Average of 2 or more diastolic reading on at least 2 subsequent visits is 90 mmHg or higher or when an average of 2 or more systolic readings on at least 2 visits is higher than 140 mmHg SYSTOLIC

DIASTOLIC

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010

Optimal/ Normal

120 – 129

Above Normal

130 – 139

80 – 84 85 – 89

Hypertension Grade 1 (Mild) Grade

2

(Moderate) Grade 3 (Severe)

140 – 159

90 – 99

160 – 179

100 – 109

Greater than 180

Greater than 110

Greater than

Less 90

140Less 80

Fundamentals of Nursing | Compiled by: Karl Gerald C. Manalili, UASN 2010