FUNDAMENTALS OF NURSING

OVERVIEW

I. THEORETICAL FRAMEWORK of NURSING PRACTICE

A. NursingB. Concepts of Health and IllnessC. Concepts of StressD. HomeostasisE. AdaptationF. Adaptation to Stress – Physiological Response (Hans Selye)G. Physiologic Indicators of Stress

II. COPING STRATGIES (COPING MECHANISMS)A. 2 Types of Coping StrategiesB. Relaxation Techniques

III. PSYCHOLOGICAL RESPONSEA. Task – Oriented BehaviorsB. Defense MechanismsC. Common Defense Mechanisms

IV. TYPES of NURSING DIAGNOSESA. Formulating the Nursing DiagnosisB. Collaborative Problems

V. METHODS USED for ASSESSMENTA. Collection of Data: Objective and Subjective

VI. DOCUMENTING and REPORTINGA. Guidelines for Good Documentation and ReportingB. DocumentationC. Documentation SystemsD. Nursing Care Plan (NCP)E. KARDEXF. Nursing Discharge / Referral Summaries

VII. PHYSICAL EXAMINATIONA. PurposesB. Preparation of ExaminationC. Order of ExaminationD. Skills in Physical AssessmentE. Examples of Adventitious Breath Sounds

VIII. THE COMMUNICATION PROCESSA. Modes of CommunicationB. Verbal CommunicationC. Nonverbal CommunicationD. Factors Influencing the Communication ProcessE. Therapeutic Communication TechniqueF. Barriers to CommunicationG. Phases of the Helping Relationship

PRINCIPLES and PRACTICE of NURSING CARE

IX. PRINCIPLES of ASEPSIS and INFECTION CONTROL

A. Chain of InfectionB. Modes of TransmissionC. Course of InfectionD. InflammationE. Immune ResponseF. Nosocomial InfectionG. Factors Increasing Susceptibility to InfectionH. Diagnostic Tests Used to Screen for Infection

X. THEORIES OF PAINA. Specific TheoryB. Pattern TheoryC. Gate Control TheoryD. Current Developments in Pain Theory

XI. TYPES OF PAIN

A. Acute PainB. Chronic Pain

XII. PAIN ASSESSMENTA. TOOLS/INSTRUMENTS USEDB. A B C D E method of pain assessmentC. P Q R S T assessment for pain perceptionD. Pain History

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ADMINISTRATION OF MEDICATIONS

XIII. DRUG NOMENCLATURE and FORMSA. NamesB. ClassificationC. FormsD. Types of Drug ActionsE. Principles in Administering Medications

XIV. BASIC HUMAN NEEDSA. Abraham MaslowB. Maslow’s Characteristics of a Self–Actualized Person

XV. MEETING OXYGENATION NEEDSA. OxygenationB. Cardiovascular PhysiologyC. Structure and FunctionD. Steps in the Process of OxygenationE.

XVI. MEETING NUTRITIONAL NEEDSA. Principles of NutritionB. Nutrients

XVII. MEETING URINARY ELIMINATION NEEDSA. Normal Urinary FunctionB. Common Assessment Findings

XVIII. URINARY CATHETERIZATIONA. PurposesB. Necessary Equipment for CatheterizationC. Preparation of the PatientD. Retention or Indwelling Catheter (Foley)E. Procedure for InsertionF. Caring for the Patient with an Indwelling CatheterG. Removing the Indwelling Catheter and Aftercare of the Patient

XIX. MEETING BOWEL ELIMINATION NEEDSA. Factors that Influence Bowel EliminationB. Characteristics of Normal StoolC. Common Bowel Elimination Problems

XX. TYPES of ENEMASA. CleansingB. Oil-RetentionC. CarminativeD. Astringent

XXI. NASOGASTRIC and INTESTINAL TUBESA. Nasogastric TubesB. Intestinal Tubes

XXII. LOSS AND GRIEFA. LossB. Grieving Process (Theories of Grief, Dying, and Mourning)C. Anticipatory GriefD. Complications of BereavementE. Symptoms of Normal GriefF. Nursing Health Promotion (to facilitate mourning)

1. THEORETICAL FRAMEWORK of NURSING PRACTICE

A. 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. It’s 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.

1. 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

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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 energy2. conservation of structured integrity3. conservation of personal integrity4. conservation of social integrity

DOROTHY JOHNSON Developed the Behavioral System Model. 1. Patient’s behavior as a system that is a whole with interacting parts 2. how the client adapts to illness3. 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 client’s 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

2. ROLES AND FUNCTION OF A NURSE

a. Caregiver – the caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client’s dignity. Caregiving encompasses the physical, psychosocial, developmental, cultural and spiritual levels.

b. 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 nurse’s communication is an important factor in nursing care.

c. 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 client’s learning needs and readiness to learn, sets specific learning goals in conjunction with the client, enacts teaching strategies and measures learning.

d. Client advocate – a client advocate acts to protect the client. In this role the nurse may represent the client’s needs and wishes to other health professionals, such as relaying the client’s wishes for information to the physician. They also assist clients in exercising their rights and help them speak up for themselves.

e. 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.

f. 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.

g. 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

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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.

h. 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.

i. 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.

j. 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

B. 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. Characteristicsi. A concern for the individual as a total systemii. A view of health that identifies internal and external environmentiii. An acknowledgment of the importance of an individual’s 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. 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.

ii. 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.

iii. 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

iv. Health – Belief Model – Addresses the relationship between a person’s 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.

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

measures

v. Evolutionary – Based Model – Illness and death serves as a evolutionary function. Evolutionary viability reflects the extent to which individual’s 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 Promotion Model – A “complimentary counterpart models of health protection”. Directed at increasing a client’s level of well being. Explain the reason for client’s 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 client’s participation health-promotion behaviors

It explains the reasons that individuals engage in health activities

II. Illness – State in which a person’s 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.

a. 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 assistanceiii. Stage of Recovery (Rehabilitation or Convalescence) – The patient goes through of resolving loss

or impairment of function

b. 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

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iv. Emphasis is on restoring the patient to independence or regain his pre-illness/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.

c. Focuses of Rehabilitation i. Coping patternii. Functional ability – focuses on self-care: activities of daily living (ADL); feeding, bathing/hygiene,

dressing/grooming, toileting and mobilityiii. Mobilityiv. Integrity of skinv. Control of bowel and bladder function

C. Concepts of StressI. Stress (Theory by Hans Selye)

a. Non specific response of the body to nay demand made upon itb. Any situation in which a non specific demand requires an individual to respond or take action

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

b. Stress is not always the result of damage to the body

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

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

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

f. 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 Stressorsi. 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

b. Factors influencing response to stressors

i. Physiological functioningii. Personalityiii. Behavioral characteristicsiv. Nature of the stressor: integrity, scope, duration, number, and nature of other stressors

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

E. Adaptation – Body’s adjustment to different circumstances and conditions. Process by the physiological or psychological dimensions change in response to stress; attempt to maintain optimal functioning

F. 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 changea. Characteristics

i. The response is localized, it does not involve entire body systemsii. The response is adaptive, meaning that a stressor is necessary to stimulate itiii. The response is short term. It does not persist indefinitelyiv. The response is restorative, meaning that the LAS assists in restoring homeostasis to the body region or

part

b. Two Localized Responsesi. 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

i. 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.

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II. General Adaptation Syndrome (GAS) or Stress Syndrome – characterized by a chain or pattern of physiologic events.

a. 3 Stagesi. Alarm Reaction – initial reaction of the body which alerts the body’s defenses. SELYE divided

this stage into 2 parts: The SHOCK PHASE The COUNTERSHOCK PHASE

ii. Stage of Resistance – occurs when the body’s 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.

iii. 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

b.c.d.e.f.g.h.i.j. 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 intakeiii. Increased blood clottingiv. Increased cellular metabolismv. Increased fat mobilization to make energy available & to synthesize other compounds

needed by the body.

G. Physiologic Indicators of Stressa. 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.

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

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

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

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

g. Urinary output may increase or decreases.

h. The mouth may be dry.

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

j. For serious threats, mental alertness improves.

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

l. Blood sugar increases because of release of glucocorticoids & gluconeogenesis.

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H. Psychologic Indicators – psychologic manifestations of stress include anxiety, fear, anger, depression & unconscious ego defense mechanisms.

a. 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:

b. 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.

c. 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.

d. 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

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

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

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

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

e. 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 TypesI. Problem-focused coping – efforts to improve a situation by making changes or taking some actionII. 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 & realisticb. 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 individual’s 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.

D. Relaxation Techniques – used to quiet the mind, release tension & counteract the fight or flight responses of General Adaptation Syndrome (GAS).

I. Breathing ExercisesII. MassageIII. Progressive RelaxationIV. ImageryV. BiofeedbackVI. Yoga

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VII. MeditationVIII. Therapeutic TouchIX. Music TherapyX. 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 person’s 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 TypesI. Attack Behavior – Is acting to remove or overcome a stressor or to satisfy a needII. Withdrawal Behavior – Is removing the self physically or emotionally from the stressorIII. 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.

B. 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

A. Formulating the Nursing Diagnosis I. Actual

a. Clients demonstrates defining characteristics of a problemb. Nurse intervenes to resolve or help client cope with the problem

II. High-riska. A problem is likely to develop based on assessment of risk factorsb. Nurse intervenes to reduce risk factors or increase protective factorsc. Example: encourage smoking cessation

III. Wellnessa. Client is presently healthy but wishes to achieve a higher level of functionb. Nurse intervenes to promote growth or maintenance of the healthy response

B. 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 client’s response to this condition will be unique based on his/her developmental level, past experiences and family configuration

b. Refer to Table for examples of collaborative problems Example:

Disease/Situation Complication Related to EtiologyPotential complication of childbirth

Potential complication of diuretic therapy

Hemorrhage

Dysrhythmia

Related to

Related to

1.Uterine atony2. Retained placental fragment3. Bladder distention

Low serum potassium

5. METHODS USED for ASSESSMENT

A. Collaboration of Data: Objective & Subjective

I. Review of clinical recorda. Client records contain information collected by many members of the healthcare team, such as

demographics, past medical history, diagnostic test results and consultations

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

II. Interview

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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 datac. 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 client’s answer; e.g. “You don’t 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 Historya. Collection of information about the effect of the client’s illness on daily functioning and ability to cope with

the stressor (the human response)

b. Subjective datai. May be called “covert data”ii. Not measurable or observableiii. Obtained from client (primary source), significant others, or health professionals (secondary

sources).iv. For example, the client states, “I have a headache”

c. Objective datai. May be called “overt data”ii. Can be detected by someone other than the clientiii. Includes measurable and observable client behavioriv. For example, a blood pressure reading of 190/110 mmHg.

IV. Physical assessmenta. Systematic collection of information about the body systems through the use of observation, inspection,

auscultation, palpation and percussionb. A body system format for physical assessment is found below:

V. Psychosocial assessmenta. Helpful framework for organizing datab. A suggested format for psychosocial assessment is found below:

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

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

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

VI. Consultationa. 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 client’s database is helpful in achieving the most

complete and accurate information about a clientc. 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 client’s status prior to admission

VII. Review of literaturea. A professional nurse engages in continued education to maintain knowledge of current information related

to health careb. Reviewing professional journals and textbooks can help provide additional data to support or help analyze

the client database

6. DOCUMENTING and REPORTING

A. Guidelines for Good Documentation and ReportingI. 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 smellsII. Accuracy – information must be accurate so that health team members have confidence in itIII. Completeness – the information within a record or a report should be complete, containing concise and thorough

information about a client’s care. Concise data are easy to understandIV. Currentness – ongoing decisions about care must be based on currently reported information. At the time of occurrence

include the following:a. Vital signsb. Administration of medications and treatmentsc. Preparation of diagnostic tests or surgeryd. Change in statuse. Admission, transfer, discharge or death of a clientf. Treatment fro a sudden change in status

V. Organization – the nurse communicate in a logical format or orderVI. 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. CommunicationII. Planning Client CareIII. Auditing Health AgenciesIV. ResearchV. EducationVI. ReimbursementVII. Legal DocumentationVIII. Health Care Analysis

C. Documentation SystemsI. Source – Oriented Record

a. The traditional client recordb. Each person or department makes notations in a separate section or sections of the client’s chartc. 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 informationd. Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a

physician’s history sheet & progress notese. NARRATIVE CHARTING is a traditional part of the source-oriented record

II. Problem – Oriented Medical Record (POMR) a. Established by Lawrence Weedb. 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 physician’s 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. Physician’s write physician’s 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 client’s 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

Example: SOAP Format Or SOAPIE and SOAPIER S – Subjective data

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O – Objective dataA – AssessmentP – PlanI – InterventionE – EvaluationR- RevisionAdvantages of POMR:

It encourages collaboration Problem list in the front of the chart alerts caregivers to the client’s 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) categoriesb. This system consists of a client care assessment floe sheet & progress notesc. FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional

health patternsd. 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 careb. Three (3) columns fro recording are usually used: date & time, focus & progress notes

V. Charting by Exception a. Documentation system in which only abnormal or significant findings or exceptions to norms are recordedb. Incorporates three (3) key elements:

i. Flow sheetsii. Standards of nursing careiii. Bedside access to chart forms

VI. Computerized Documentation a. Developed as a way to manage the huge volume of information required in contemporary health careb. Nurses use computers to store the client’s 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 stayb. 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 institution’s standards of practice; thereby helping to provide a high quality of nursing care

E. 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 clientII. List of medicationsIII. List of IVFIV. List of daily treatments & proceduresV. List of Diagnostic proceduresVI. AllergiesVII. Specific data on how the client’s physical needs are to be metVIII. A problem list, stated goals & list of nursing approaches to meet the goals

F. 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 client’s physical, mental & emotional stateII. Resolved health problemsIII. Unresolved continuing health problemsIV. Treatments that can be continued (e.g. wound care, oxygen therapy)V. Current medicationsVI. Restrictions that relate to activity, diet & bathingVII. Functional/self-care abilitiesVIII. Comfort levelIX. Support networksX. Client education provided in relation to disease processXI. Discharge destinationXII. Referral Services (e.g. social worker, home health nurse)

7. PHYSICAL EXAMINATIONA. Purposes

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The nurse uses physical assessment for the following reasons:I. To gather baseline data about the client’s healthII. To supplement, confirm or refute data obtained in the nursing historyIII. To confirm and identify nursing diagnosesIV. To make clinical judgments about a client’s changing health status and management

B. Preparation of ExaminationI. Environment – A physical examination requires privacy. An examination room that is well equipped for all

necessary procedures is preferableII. Equipment – Hand washing is done before equipment preparation and the examination. Hand washing reduces the

transmission of microorganismsIII. 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 nurse’s highest priority before the examination

b. Physical Preparation – the client’s 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. Client’s abilities to assume positions will depend on their physical strength and degree of wellness.

C. Order of ExaminationI. General Survey – includes observation of general appearance and behavior, vital signs, height and weight

measurementII. Review of systemsIII. Head to toe examination

D. Skills in Physical ExaminationI. 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 availableb. Position and expose body parts so that all surface can be viewedc. Inspect each areas fro size, shape, color, symmetry, position and abnormalitiesd. If possible, compare each area inspected with the same area of the opposite side of the bodye. 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 body’s 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 soundsb. Breath sounds

i. Vesicularii. Bronchovesiculariii. Bronchial

E. Examples of Adventitious Breath SoundsI. Crackles (previously called rales)II. RhonchiIII. WheezeIV. Friction rub

Therapeutic Communication Techniques1. Using silence2. Providing general leads3. Being specific & tentative4. Using open-ended questions5. Using touch6. Restating to paraphrasing7. Seeking clarification8. Perception checking or seeking consensual validation9. Offering self10. Giving information11. Acknowledging12. Clarifying time or sequence13. Presenting reality14. Focusing15. Reflecting16. Summarizing & planning

B. Barriers to Communication1. Stereotyping2. Agreeing & disagreeing3. Being defensive4. Challenging5. Probing6. Testing

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7. Rejecting8. Changing topics & subjects9. Unwarranted reassurance10. Passing judgment11. Giving common advice

Phases of the Helping Relationship

12. Pre-interaction Phase13. Introductory Phase

a. Opening the relationshipb. Clarifying the problemc. Structuring & formulating the contract

14. Working Phasea. Exploring & understanding thoughts or feelingsb. Facilitating & taking action

15. Termination Phase

8. PRINCIPLES of ASEPSIS and INFECTION CONTROL

A. Chain of InfectionI. 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

V. 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 person’s 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 Transmission1. 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

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

C. 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

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Body’s responseI. 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. 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

III. 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.

D. Immune ResponseI. The immune response involves specific reactions in the body to antigens or foreign material

II. This specific response is the body’s 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 immunitya. When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they enter the circulation from

lymph tissue and seek out the antigenb. Once theantigen is found they produce proteins (lymphokines) that increase the migration of phagocytes to

the area and keep them there to kill the antigenc. After the antigen is gone, the lymphokines disappeard. 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 diseaseii. 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.

E. Nosocomial InfectionI. 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 client’s 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.

F. Factors Increasing Susceptibility to Infection

I. Age : young infants & older adults are at greater risk of infection because of reduced defense mechanismsa. Young infants have reduced defenses related to immature immune systemsb. 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 retentioniii. Diminished cough reflex, loss of elastic recoil by the lungs leading to inability to evacuate

normal secretionsiv. Gastrointestinal changes resulting in decreased swallowing ability and delayed gastric

emptying.

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 person’s 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 body’s immune system can respond to pathogens

V. Stress: stressors, both physical and emotional, affect the body’s 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 body’s protective, mechanisms and may cause physical stress to the body resulting in an increased risk of infection; personal health

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habits such as poor nutrition and unhealthy lifestyle habits increase the risk of infectious over time by altering the body’s 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 membranesb. Adequate blood cell production and differentiationc. A functional lymphatic system and spleend. An ability to differentiate foreign tissue and pathogens from normal body tissue and flora; in autoimmune

disease, the body has a problem with recognizing it’s 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.

X. 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

G. Diagnostic Tests Used to Screen for InfectionI. 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 PAINA. Specific Theory

I. Proposes that body’s 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.

B. 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.

C. 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”).

D. 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 levelb. Second-order neurons in the spinal cord that process nociceptor informationc. Third-order tracts & pathways in the spinal cord & brain that relay/process this information

II. 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 PAINA. 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 Paina. Somatic: arises from nerve receptors in the skin or close to body’s surface; may be sharp & well-localized or

dull & diffuse; often accompanied by nausea & vomiting

b. Visceral : arises from body’s organs; dull & poorly localized because of minimal noriceptors; accompanied by nausea & vomiting, hypotension & restlessness

c. 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).

II. Acute pain initiates the “fight-or-flight” response of the Autonomic Nervous System and is characterized by the following symptoms:

a. Tachycardiab. Rapid, shallow respirations

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c. Increased BPd. Sweatinge. Pallorf. Dilated pupilsg. Fear & Anxiety

B. Chronic Pain I. Prolonged, lasting longer than 6 months, often not attributed to a definite cause, often unresponsive to medical

treatment.

Types of Chronic Paina. Neuropathic: painfuil condition that results from damage to peripheral nerves caused by infection or

disease; post-therapeutic neuralgia (shingles) is an example

b. Phantom : pain syndrome that occurs following surgical or traumatic amputation of a limb.i. The client is aware that the body part is missingii. Pain may result of stimulation of severed nerves at the site of amputationiii. Sensation may be experienced as an itching, pressure, or as stabbing or burning in natureiv. 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 periodsvi. This type of pain requires treatment just as any other type of pain does.

c. Psychogenic : pain that is experienced in the absence of a diagnosed physiologic cause or event; the client’s emotional needs may prompt pain sensation.

II. 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

A. TOOLS/INTRUMENTS USEDI. 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 client’s 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)

V. 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

B. A B C D E method of pain assessmentI. This acronym was developed for cancer pain; however, it is very appropriate for clients with any type of pain,

regardless of the underlying disease.II. A = Ask about painIII. B = Believe the client & family reports painIV. C = Choose pain control options appropriate for the clientV. D = Deliver interventions in a timely, logical &coordinated fashionVI. E = Empower clients & families

C. P Q R S T assessment for pain receptionI. This method is especially helpful when approaching a new pain problemII. 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?

D. Pain HistoryI. 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 client’s 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 arthritisii. Visceral pain is squeezing, cramping pain; example: pain associated with ulcerative colitis

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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 FORMSA. Names

I. Chemical Name – provides an exact description of the drug’s 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.

B. 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.

C. 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.

D. Principles in Administering MedicationsI. Observe the 7 RIGHTS of Drug Administration:

a. Right Drugb. Right Dosec. Right Timed. Right Routee. Right Patientf. Right Recordingg. 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

V. 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

IX. Do not leave the medication at the bedside

X. 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

13. BASIC HUMAN NEEDSA. Abraham Maslow – developed the five (5) levels of human needs:

I. Physiologic Needs – needs such as air, food, water, shelter, rest, sleep, activity and temperature maintenance are crucial for survival

II. Safety and Security Needs – the need for safety has both physical and physiologic aspectsIII. 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 belongingIV. Self-Esteem Needs – the individual needs both self-esteem and esteem from othersV. Self-Actualization – when the need for self-esteem is satisfied, the individual strives for self-actualization, the

innate need to develop one’s maximum potential and realize one’s abilities and qualities

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B. Maslow’s Characteristics of a Self-Actualized PersonI. Is realistic, sees life clearly and is objective about his or her observationsII. Judges people correctlyIII. Has superior perception, is more decisiveIV. Has a clear notion of right or wrongV. Is usually accurate in predicting future eventsVI. Understands art, music, politics and philosophyVII. Possesses humility, listens to others carefullyVIII. Is dedicated to some work, task, duty or vocationIX. Is highly creative, flexible, spontaneous, courageous, and willing to make mistakesX. Is open to new ideasXI. Is self-confident and has self-respectXII. Has low degree of self-conflict; personality is integratedXIII. Respect self, does not need fame, possesses a feeling of self-controlXIV. Is highly independent, desires privacyXV. Can appear remote or detachedXVI. is friendly, loving and governed more by inner directives than by societyXVII. Can make decisions contrary to popular opinionXVIII. Is problem centered rather than self-centeredXIX.Accepts the world for what it is

14. MEETING OXYGENATION NEEDSA. Oxygenation – a basic human need & is required to sustain life.

B. 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

C. 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 deliveryII. 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 itselfIII. 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.

D. Steps in the Process of OxygenationI. 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”.

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 concentrationb. 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 NEEDSA. 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

V. Elimination – process of discarding unnecessary substances through evaporation, excretion

B. NutrientsI. Carbohydrates – the primary sources are plant foods

Types of Carbohydratesa. Simple (sugars) such as glucose, galactose, and fructoseb. Complex such as starches (which are polysaccharides) and fibers (supplies bulk or roughage to the diet)

II. Proteins – organic substances made up of amino acids

III. Lipids – organic substances that are insoluble in water but soluble in alcohol and ether.

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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 vitaminsb. Fat-soluble vitamins include A, D, E, and K and these can be stored in limited amounts in the body

V. Minerals – compounds that work with other nutrients in maintaining structure and function of the bodya. Macronutrients – calcium, phosphate, sodium, potassium, chloride, magnesium and sulfurb. Micronutrients (trace elements) – iron, iodine, copper, zinc, manganese and fluorideThe best sources are vegetables, legumes, milk and some meats

VI. Water – the body’s 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 NEEDSA. 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% waterIII. Solutes found in urine include:

a. Organic solutes: urea, ammonia, uric acid and creatinineb. Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium & phosphorus

B. Common Assessment FindingsI. Urgency – strong desire to void my be caused by inflammations or infections in the bladder or urethraII. Dysuria – painful or difficult voidingIII. Frequency – voiding that occurs more than usual when compared with the person’s regular pattern or the generally

accepted norm of voiding once every 3 to 6 hoursIV. Hesitancy – undue delay and difficulty in initiating voidingV. Polyuria – a large volume of urine or output voided at any given timeVI. Oliguria – a small volume of urine or output between 100 to 500 mL/24 hrVII. Nocturia – excessive urination at night interrupting sleepVIII. Hematuria – RBCs in the urine

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

A. PurposesI. To relieve urinary retentionII. To obtain a sterile urine specimen from a womanIII. To measure the amount of residual urine in the bladderIV. To obtain a urine specimen when a specimen cannot secure satisfactory by other meansV. 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.

C. Preparation of the PatientI. Adequate explorationII. Position – dorsal recumbent for the female and supine for the male using a firm mattress or treatment table, Sim’s

or lateral position can be an alternate for the female patientIII. Provision for privacy

D. Retention or Indwelling Catheter (Foley) – A catheter to remain in place for the following purposes:I. The gradual decompression of an over distended bladderII. For intermittent bladder drainageIII. 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.

E. Procedure for InsertionI. 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 manufacturer’s 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 bladderV. Connect the catheter to the drainage tubing and drainage bag if not already connectedVI. 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

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VII. Hang the drainage bag on the frame of the bed below the level of the bladder

F. Caring for the Patient with an Indwelling CatheterI. Be sure to wash hands before and after caring for a patient with an indwelling catheterII. Clean the perineal area thoroughly, especially around the meatus, twice a day and after each bowel movement.

This helps prevent organisms for entering the bladderIII. Use soap or detergent and water to clean the perineal area and rinse the area wellIV. Make sure that the patient maintains a generous fluid intake. This helps prevent infection and irrigates the catheter

naturally by increasing urinary outputV. Encourage the patient to be up and about as orderedVI. Record the patient’s intake and outputVII. Note the volume and character of urine and record observations carefullyVIII. Teach the patient the importance of personal hygiene, especially the importance of careful cleaning after having

bowel movement and thorough washing of hands frequentlyIX. 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 chillsX. 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

G. Removing the Indwelling Catheter and Aftercare of the PatientI. 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 valveII. 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 drapeIII. Clean the area at the meatus thoroughly with antiseptic swabs after the catheter is removedIV. See to it that the patient’s fluid intake is generous and record the patient’s intake and output. Instruct the patient

to void into the bedpan or urinalV. Observe the urine carefully for any signs of abnormalityVI. Record and report any usual signs such as discomfort, a burning sensation when voiding, bleeding and changes in

vital signs, especially the patient’s temperature. Be alert to any signs of infection and report them promptly

18. MEETING BOWEL ELIMINATION NEEDSA. Factors that influence Bowel Elimination

I. AgeII. DietIII. PositionIV. PregnancyV. Fluid IntakeVI. ActivityVII. PsychologicalVIII. Personal HabitsIX. PainX. MedicationsXI. Surgery/Anesthesia

B. Characteristics of Normal StoolI. Color – varies from light to dark brown foods & medications may affect colorII. Odor – aromatic, affected by ingested food and person’s bacterial floraIII. Consistency – formed, soft, semi-solid; moistIV. 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)

C. Common Bowel Elimination ProblemsI. Constipation – abnormal frequency of defecation and abnormal hardening of stoolsII. Impaction – accumulated mass of dry feces that cannot be expelledIII. 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 incontinenceIV. Incontinence – involuntary elimination of fecesV. Flatulence – expulsion of gas from the rectumVI. Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon

defecation.

19. TYPES OF ENEMASA. 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 reserveIII. Saline: For normal saline enemas, use smaller volume of solutionIV. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does not require further

preparation

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

C. Carminative Enema: Provides relief from gaseous distention

D. Astringent Enema: Contracts tissue to control bleedingKey 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

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III. Place client on left side in Sim’s positionIV. Lubricate the tip of the tubing with water-soluble lubricantV. Gently insert tubing into client’s rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3 inches for children), past

the external and internal sphinctersVI. Raise the water container no more than 12 to 18 inches above the clientVII. 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 solutionVIII. After you have instilled the solution, instruct client to hold solution for about 10 to 15 minutesIX. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10 to 15 minutes.

20. NASOGASTRIC and INTESTINAL TUBES

A. Nasogastric Tubes

I. Levin Tube – single lumena. Suctioning gastric contentsb. 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)

a. Suctioning gastric contentsb. Maintaining gastric decompression

Key Points:a. Prior to insertion, position the client in High-Fowler’s position if possible.b. Use a water-soluble lubricant to facilitate insertionc. Measure the tube from the tip of the client’s nose to the earlobe and from the nose to the xiphoid

process to determine the approximate amount of tube to insert to reach the stomachd. Flex the client’s head slightly forward; this will decrease the chance of entry into the tracheae. 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

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

g. 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

h. 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

B. 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 Tubesa. Cantor and Harris Tubes

i. Approximately 6-10 feet longii. Single lumeniii. Mercury placed in rubber bag prior to tube insertion

b. Miller-Abbot Tubes i. Approximately 10 feet longii. Double lumeniii. One lumen utilized for aspiration of intestinal contentsiv. Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted

into the stomach

II. Nursing Implicationsa. Maintain client on strict NPOb. Initial insertion usually done by physician and progression of the tube may be monitored via an X-rayc. After the tube has been placed in the stomach, position client on the right side to facilitae passage through

the pyloric valved. Advance the tube 2 to 4 inches at regular intervals as indicated by the physiciane. Encourage activity, to facilitate movement of the tube through the intestinef. Evaluate the type of gastric secretions being aspiratedg. Do not tape or secure the tube until it has reached the desired positionh. Tubes may attached to suction and left in place for several daysi. Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce thirstj. 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

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A. Loss – absence of an object, person, body part, emotion, idea or function that was valued

I. Actual loss is identified and verified by othersII. Perceived Loss cannot be verified by othersIII. Maturational Loss occurs in normal developmentIV. Situational Loss occurs without expectationsV. 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

B. Grieving Process (Theories of Grief, Dying and Mourning)

I. 3 Phases of Griefa. Protest: lack of acceptance, concerning the loss, characterized by anger, ambivalence and cryingb. Despair: denial and acceptance occurs simultaneously causing disorganized behavior, characterized by

crying and sadnessc. 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 Grievinga. Denial – characterized by shock and disbelief, serves as a buffer to mobilize defense mechanismb. Anger : resistance of the loss occurs, anger is typically directed toward othersc. Bargaining = deals are sought with God or other higher power in an effort to postpone the lossd. Depression: loss is realized; may talk openly or withdraw.e. Acceptance : recognition of the loss occurs, disinterest may occur; future thinking may occur.

III. Worden’s 4 Tasks of Mourninga. Accept the reality of the loss, the loss is acceptedb. 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

D. Complications of BereavementI. 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

E. Symptoms of Normal GriefI. 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, angerIII. Physical sensations include nausea, vomiting, anorexia, weight loss or gain, constipation or diarrhea, Diminished

hearing or sight, chest pain, shortness of breath, tachycardiaIV. Behaviors include crying, difficulty carrying out activities of daily living and insomia

F. Nursing Health Promotion (to facilitate mourning)

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

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

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

4. Encourage establishment with new relationships to facilitate healing.

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

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

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

8. 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.

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