FUNDAMENTALS OF NURSING CHAPTER 1:HISTORY OF NURSING A.

Periods and the Milestones in the Development of the Nursing profession The Period of Intuitive Nursing Pre-Nightingale Era Nursing of the sick was designated to the women of the tribes. Innumerable superstitions, beliefs and practices were developed. Early civilization Period Egyptian temples had housing for the sick. In the sick houses of the Hebrew people, women did nursing duties. India was the first country to record the use of nurse in the care of the sick. 300 AD Women entered the nursing profession Period of Apprentice Nursing Pastor Theodor Fliedner St. Elizabeth of Hungary St Catherine of Siena The Dark period of Nursing Mrs. Elizabeth Seton Clara Barton Sairy Gamp Period of Educated Nursing Florence Nightingale Edith Cavell (Mata hari) B. History of Nursing in the Philippines During the Spanish Regime Hospital Real de Manila San Lazaro Hospital Hospital de Indio Hospital de Aguas Santas San Juan De Dios Hospital Nursing Schools in the Philippines Iloilo Mission Hospital (1906) St. Paul, PGH, St. Lukes (Schools of Nursing) 1907 Mary Johnston Hospital School of Nursing (1907) First colleges of nursing in the Philippines University of Santo Tomas Manila Central University University of the Philippines Figures in Philippine Nursing Anastacia Giron-Tupas The first Filipina nurse to hold positions of Chief Nurse and Superintendent. Founder of PNA. Loreto Tupaz Known as the Dean of Philippine Nursing The Florence Nightingale of Iloilo.

CHAPTER 2: THEORETICAL FOUNDATIONS OF NURSING A. Nursing Theories Importance of Nursing Theories: Aids in the conceptualization of some aspect of nursing communicated for the purpose of describing, explaining, predicting and/or prescribing nursing care. Allows the nurse to plan and implement care purposely and proactively. Nursing Theories address and specify relationships among four major concepts: Person or client - the recipient of nursing care (includes individuals, families, groups, and communities) Environment - the internal and external surroundings of the client. Health/illness - the clients state of well-being. Nursing - a discipline from which client care interventions are provided.
Nightingales Environmental Theory (1860) Developed and described the 1st 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. Five environmental factors: Fresh air, Pure water, Efficient drainage, Cleanliness, Light (especially direct sunlight) She believed that in the nurturing environment, the body could repair itself. Hildegard Peplaus Interpersonal Relations Model (1952) Focused on the individual, the nurse, and the interactive process; resulting in a therapeutic nurse client relationship. Identified the 4 phases of nurse-client relationship: Orientation Exploitation Identification Resolution Virginia Hendersons Theory (1955) Defined nursing as assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or peaceful death and helping the individual learn self care. Enumerated the 14 Basic Needs: Faye Abdellahs Theory (1960) Identified 21 Nursing Problems Emphasizes delivery of nursing care to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family.

Ida Jean Orlandos Theory (1961) Focused on the 3 elements of nursing situation namely the clients behavior, nurses reaction, and nurses action. Lydia Halls Theory (1962) Views the client as composed of overlapping parts such as the person (core), pathological structure & treatment (cure), and body (care); and the nurse as caregiver. Ernestine Weidenbach (1964) Clinical nursing has the following components: philosophy, purpose, practice, and art. Myra Levines Theory (1968) Health is viewed in terms of conservation of clients energy, structural integrity, personal integrity and social integrity. Dorothy Johnsons Theory (1968) Focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. Martha Rogers Science of Unitary Human BeingTheory (1970) Believes that Nursing incorporates knowledge of basic sciences, physiology, and nursing practice. Views the person as an irreducible whole, the whole being greater than the sum of its parts. Unitary man and environment are energy fields interacting continuously and creatively. Dorothea Orems General Theory of Nursing (1971) Includes three related concepts: self care, self-care deficit, and nursing systems. Self-care Theory is based on four concepts: self-care, self-care agency, self-care requisites, and therapeutic self care demand. Orem identified three types of nursing systems: Wholly compensatory, partly compensatory & supportive-educative systems. Travelbees Theory (1971) Views interpersonal process as the human-to-human relationship formed during illness and experience of suffering. Betty Neumans Systems Model (1972 / 1992) Views the client as an open system consisting of a basic structure or central core of energy resources (physiologic, psychologic, sociocultural, developmental and spiritual) Jean Watsons Human Caring Theory (1979) Introduced Philosophy of Transpersonal Caring. Identified 10 Carative Factors. Focuses on the interrelationship among health, illness, and human behavior in achieving the clients needs. Imogene Kings Goal Attainment Theory (1981) 3 Dynamic Interacting Systems: Personal systems concept: perception, self, body image, growth and development, space and time. Interpersonal systems concepts: interaction, communication, transaction, role and stress. Social systems concepts: organization, authority, power, status, and decision making. Sr. Callista Roys Adaptation Model (1997) Focuses on the individual as a biopsychosocial adaptive system that employ a feedback cycle of input (stimuli), throughput (control processes), and output (behaviors or adaptive responses). Madeleine Leiningers Theory (1991) CULTURAL CARE DIVERSITY AND UNIVERSALITY THEORY Identified three intervention modes: Culture care preservation and maintenance. Culture care accommodation, negotiation or both. Culture care restructuring and repatterning.

B. Health and Illness 1. MODELS OF HEALTH AND ILLNESS Health-Illness Continuum Model (Betty Neuman) Health Belief Model (Rosenstock & Becker)

Health Promotion Model (Pender)

Basic Human Needs Model (Abraham Maslow) Holistic Health Model Wellness-illness Model (Jensen & Allen) Health-Healing / Disordering Model (McCabe)

2. Variables Influencing Health Beliefs and Practices Internal Variables Developmental Stage Intellectual Background Perception of Functioning External Variables

Emotional Factors Spiritual Factors

Family Practices Socio-economic Factors

Cultural Background

3. Variables Influencing Illness Behavior Internal Variables: Perception Nature of Illness External Variables: Visibility of Symptoms Social Group Cultural Background CHAPTER 3: HEALTH CARE DELIVERY SYSTEM

Coping Skills

Economic Variables Accessibility of the health Care System

A. LEVELS OF HEALTH CARE Preventive and Primary Care Services Preventive care focuses on reducing and controlling risk factors for disease through activities such as immunization and occupational health programs. Primary care aims to provide integrated, accessible health care services and majority of personal health services; develop a sustained partnership with clients; and render care to the family and community. Secondary & Tertiary Care Diagnostic and treatment are generally the most commonly used services of health. Restorative Care Assist an individual in regaining maximal functional status, enhancing the individuals quality of life while promoting clients independence and self-care. Continuing Care Long-term care offers services over a prolonged period of time to people who have lost or never acquired functional capacity. B. LEVELS OF PREVENTION Primary Prevention Generalized health promotion, specific protection against disease. It precedes disease or dysfunction and is applied to generally healthy individuals or groups Secondary Prevention Emphasizes early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems. Includes prevention of complications and disabilities Tertiary Prevention Restoration and Rehabilitation

C. THE NURSE IN HEALTH CARE 11 Core Competencies Safe and quality nursing care Management of resources and environment Health education Legal responsibility Ethico-moral responsibility Personal and professional development Roles and Functions of a Professional Nurse Care Provider Communicator/Helper Teacher Counselor Client Advocate Change Agent EXPANDED NURSING ROLES 1. Nurse Generalist 11 areas a) General Nursing Practice b) Medical-Surgical Nursing c) Gerontologic Nursing d) Pediatric( child and adolescent ) e) Perinatal Nursing f) College Health Nursing Quality improvement Research Records management Communication Collaboration and teamwork

Leader Manager Researcher Case Manager Collaborator

g) School Nursing h) Community Health Nursing i) Psychiatric and Mental Health Nursing j) Nursing continuing education and staff development k) Home health nursing

2. Nurse Clinician. 3. Nurse Practitioner 4. Nurse Specialist D. Types of Nursing Interventions Independent or nurse-initiated interventions Dependent or physician-initiated interventions Interdependent or collaborative interventions E. Nursing Care Delivery Models Total Patient Care Functional Nursing Team Nursing Primary Nursing Case Management CHAPTER 4: SAFE AND QUALITY CARE A. The Nursing Process - is a systematic, rational method of planning and providing individualized nursing care. - its purpose is to identify a clients health status, actual or potential health care problems or needs; to establish plans to meet the identified needs; and to deliver specific nursing intervention to meet those needs. COMPONENTS OF THE NURSING PROCESS ASSESSMENT collection, verification and analysis of the clients data NURSING DIAGNOSIS a clinical judgment about individual, family or community responses to actual or potential health problems or life processes. PLANNING development of client-centered goals and expected outcomes; determining possible nursing interventions. IMPLEMENTATION purpose is to alleviate clients health condition. EVALUATION measures the clients response to nursing actions and the clients progress toward achieving goals. B. Basic Nursing Skills 1. Vital Signs - quick and efficient way of monitoring clients condition, identifying problems, or evaluating clients response to interventions.

a. Temperature - is the balance between the heat produced by the body and the heat loss from the body. b. Pulse Rate - number of contractions over a peripheral artery in 1 minute c. Respiratory Rate
In other words, it is the heat of the body measured in heat units called degrees.

d.

number a complete cycle of inhalation and exhalation Rate: Normal is 12 20 cpm in adult. Depth: Normal, deep or shallow. Rhythm: Regular or irregular. Quality or character: Describes respiratory effort and sound of breathing Blood Pressure - refers to the force of the blood against arterial walls

Normal Ranges for Vital Signs for Healthy Adults Oral temperature 37.0C, 98.6F Pulse rate 60 to 100 (80 average) Respirations 12 to 20 breaths/minute Blood pressure 130/85 2. Medication Administration Nursing Responsibilities in Administration of Medication Assess clients medical history, history of allergies, medication history, and diet history. Gather physical examination, laboratory results that may affect medication administration. Provide information about medications: Purposes, actions, effects. Always consider the 5 Rs of medication administration. Wash hands before and after medication administration. Dispose used supplies properly. Observe clients response. Document medication administration immediately on the appropriate form. Report untoward side effects and adverse effects.

10 Rs OF MEDICATION ADMINISTRATION Right Patient Right Medication

Right Dose Right Route Right Time

EFFECTS OF DRUGS Therapeutic effect Side effect (secondary effect) Adverse Reaction Drug toxicity Drug allergy (anaphylactic reaction) Drug tolerance C. ASEPSIS AND INFECTION CONTROL

Right Assessment Right Documentation Right Monitoring & Evaluation Right to Education Right to refuse Cumulative effect Idiosyncratic effect Drug interaction(potentiating effect) or (inhibiting effect). Iatrogenic disease Asepsis and Infection Control

NATURE OF INFECTION Invasion and reproduction of microbes in or on body tissues resulting in signs and symptoms as well as immunologic response. The clients immune response may aggravate the tissue damage which may be localized or systemic. Severity depends on pathogenicity, number of invading microbes and resistance of the client. CHAIN OF INFECTION Etiologic / Infectious Agent Reservoir Portal of Exit

Susceptible Host Portal of Entry D. FIRST AID MEASURES

Mode of Transmission

Cardiopulmonary Resuscitation (CPR) CPR is also referred to as Basic Life Support System. It is a combination of: Oral resuscitation (mouth-to-mouth breathing) which supplies oxygen to the lungs External cardiac massage (Chest compression) which is intended to reestablish cardiac function and blood circulation. Cardiac arrest is the cessation of cardiac function; the heart stops beating. The three cardinal signs of a cardiac arrest are: *Apnea *Absence of a carotid or femoral pulse *Dilated pupils Respiratory arrest is the cessation of breathing. It often occurs as a result of a blocked airway, but it can occur following a cardiac arrest. E. WOUND CARE Physical injury to the tissues of the body causing disruption of the normal tissue pattern. Classification: ACCORDING TO CAUSE: Intentional,Unintentional ACCORDING TO STATUS OF SKIN INTEGRITY: Open, Close, Acute, Chronic ACCORDING TO SEVERITY OF INJURY: Superficial, Penetrating, Perforating ACCORDING TO DESCRIPTIVE QUALITIES: Incised, Lacerated, Contused, Punctured ACCORDING TO CLEANLINESS: - Clean, Clean-Contaminated, Contaminated, Infected, Colonized.

F. PERI-OPERATIVE CARE PREOPERATIVE PHASE Patient education / Teaching; Deep breathing exercises / coughing exercises. Mobility and related exercises. Cognitive coping strategies Providing information about specific devices that will be expected postoperatively. Informed consent: PREOPERATIVE NURSING INTERVENTIONS Night before and morning before surgery: Managing nutrition and fluids. Preparing the bowel for surgery. Preparing the skin. Immediate preoperative: Hairpins removed, hair completely covered with cap. Mouth is inspected, dentures / prostheses removed. Hearing aids are not removed. Jewelries for safekeeping; wedding band may be taped. Maintain preoperative record. Transport the patient to the surgical suite. Attend to family needs. INTRAOPERATIVE PHASE Scope of Nursing Activities: 1. Maintenance of safety -Position client -Provide physical support -Ensure sponge, needle, instrument count is correct. -Maintain aseptic controlled environment. -Effectively manage human resources. 2. Physiologic Monitoring: -Calculate effects of fluid loss and gain to theclient. -Monitor cardiopulmonary data. -Monitor VS and report abnormalities. POSTPERATIVE PHASE Scope of Nursing Activities (PACU / RR): 1. Transfer of patient to PACU, Recovery area or Unit. 2. Assess and monitor patient. 3. Maintain patent airway. 4. Maintain cardiovascular stabilty. 5. Promote comfort and safety. 6. Determine readiness for discharge from PACU. 7. Transfer from PACU to ward, room or home. Hours After Surgery Assess breathing and provide O2 if necessary. Monitor vital q every 15 minutes (1st hour), q 30 minutes (next 2 hours). Assess surgical site and wound drainage systems. Assess level of consciousness, orientation and ability to move extremities. Connect drainage tubes to gravity or suction as ordered. Assess pain provide analgesia as ordered. Position client for safety, comfort, maximal lung expansion. Assess and monitor IV sites and infusion. Assess urine output and bladder distention. Place call light, emesis basin, urinal / bedpan within reach. Provide adequate information.

G. NURSING CARE FOR THE DYING AND THE DEAD 1. Nursing Interventions for the Dying Client Assist the client achieve a dignified and peaceful death Maintain physiologic and psychologic comfort Provide spiritual support Nsg. Dx: Dying Clients Fear related to: Knowledge deficit Lack of social support in threatening situation Negative impact on survivors Hopelessness related to: Prolonged restriction of activity resulting in isolation Deteriorating physiologic condition Terminal illness Long-term stress Perceived significant loss of loved one, youth, influence Powerlessness related to: Chronic debilitating disease Terminal illness Institutional environment Interpersonal behavior of others

2.

POST-MORTEM CARE Body Changes After Death Rigor Mortis Stiffening of the body that occurs about 2-4 hrs after death Position the body, place dentures in the mouth and close the eyes ands mouth before rigor mortis sets in Algor Mortis Is the gradual decrease of the bodys temperature after death When blood circulation terminates and the hypothalamus ceases function, body temperature falls about 10C per hour until it reaches room temp Livor Mortis Discoloration of the skin after death after circulation has ceased. The red blood cells break down, releasing hemoglobin which discolors the surrounding tissues Nsg Interventions for the Body after Death Make the environment as clean and as pleasant as possible Make the body appear natural and comfortable Remove all equipment and supplies from the bedside Remove soiled linens, so the room is free from odors Place the body in supine position, the arms at the sides, palms down Place one pillow under the head and shoulders to prevent blood from discoloring the face Close the eyelids, insert dentures and close the mouth Wash soiled areas of the body Place absorbent pads under the buttocks to take up any feces and urine released because of the relaxation of sphincter muscles Provide clean gown, brush / comb the hair Remove all jewelries. All the clients valuables are listed and placed in a safe storage area for the family to take away Allow the family to vie the clients body Apply identification tags, one to the ankle and one to the wrist Wrap the body in shroud. Apply another identification tag to the outside of the shroud Bring the body to the morgue for cooling

CHAPTER 5: MEASURES TO MEET PHYSIOLOGICAL NEEDS A. Oxygenation Alterations in Respiratory Function Respiratory function can be altered by conditions that affect 3 areas of function: The movement of air into or out of the lungs The diffusion of oxygen and CO2 between the alveoli and the pulmonary capillaries The transport of oxygen and carbon dioxide via the blood to and from the tissue cells Hypoxia condition of insufficient oxygen.

Hypoxemia reduced oxygen in the blood and is characterized by a low partial pressure of oxygen or low saturation of oxyhemoglobin.

Altered Breathing Patterns Eupnea Tachypnea Bradypnea

Hyperventilation Kussmauls breathing Hypoventilation

Abnormal respiratory rhythms create an irregular breathing pattern and are: Cheyne-Stokes breathing Dyspnea Apneustic breathing Orthopnea Biots breathing Obstructed Airway A complete or partially obstructed airway can occur along the upper or lower respiratory passageways. Upper airway obstruction occurs in the nose, pharynx, larynx or trachea-can arise because of: Lower airway obstruction involves complete or partial occlusion of the passageways in the bronchi and lungs. Partial obstruction is indicated by low-pitched snoring sound during inspiration. Complete obstruction is indicated by extreme respiratory effort that produces no chest movement. May also have marked sternal and intercostals retractions..

Promoting Healthy Respirations Interventions by the nurse to maintain the normal respirations of clients include: Positioning the client to allow for maximum chest expansion. Encouraging or providing frequent changes in position. Encouraging ambulation Implementing measures that promote comfort, such as giving pain medications. Deep Breathing and Coughing Hydration adequate hydration maintains the moisture of the respiratory mucous membrane. Humidifiers- are devices that add water vapor to inspired air to prevent mucous membrane from drying and becoming irritated and to loosen secretions for easier expectoration. Medications are given to help remove excessive secretions from the lungs. Use of Lung Inflation Devices Use of Incentive spirometers Percussion, Vibration, and Postural Drainage (PVD) Oxygen Oropharyngeal and Nasopharyngeal Suctioning B. Nutrition Nutrition is the sum of all interactions between an organism and the food it consumes. In other words, nutrition is what a person eats and how the body uses it. Nutrients have three major functions: Providing energy for the body processes and movement Providing structural material for body tissues Regulating body processes Six Classes of Nutrients Nutrients that supply energy Carbohydrates, protein, lipids Nutrients that regulate body processes Vitamins, minerals, water Alternative Feeding Methods Enteral- Through gastrointestinal system Parenteral- Intravenous methods Nursing Responsibilities for Verifying tube placement Aspirate gastrointestinal secretions. Measure the ph. 2-3 pH Inject 5-20 mL of air through the feeding tube while auscultating the epigastrium or left upper abdominal quadrant and listening for whooshing, gurgling, or bubbling sound. Ask the client to speak or bum. It is generally assumed that large bore tubes placed in the trachea will interfere with clients ability to speak.

Observe the client for coughing and choking. *The most effective method appears to be radiographic verification of the tube placement.

C. Rest and Sleep REST- a period of quiet activity that promotes a sense of feeling refreshed and able to perform. SLEEP- a time of reduced consciousness that restores physical and mental well-being and occurs at periodic intervals.

Classification of Sleep Disorders Dyssomnias Parasomnias Sleep disorders associated with medical or psychiatric disorders Other proposed disorders INTERVENTIONS: reducing environmental distractions promoting bedtime rituals providing comfort measures scheduling nursing care to provide for uninterrupted sleep periods teaching stress reduction, relaxation techniques to develop good sleep habits promoting self-esteem administering sleep meds on a PRN basis D. Fluid & electrolyte balance Functions of Water in the Body Transporting nutrients to cells and wastes from cells Transporting hormones, enzymes, blood platelets, and red and white blood cells Facilitating cellular metabolism and proper cellular chemical functioning Acting as a solvent for electrolytes and nonelectrolytes Helping maintain normal body temperature Facilitating digestion and promoting elimination Acting as a tissue lubricant Two compartments of Fluids in the Body Intracellular fluid (ICF) fluid within cells (70%) Extracellular fluid (ECF) fluid outside cells (30%) Fluid Imbalances Involves either volume or distribution of water or electrolytes Hypovolemia deficiency in amount of water and electrolytes in ECF with near normal water/electrolyte proportions Dehydration decreased volume of water and electrolyte change Third-space fluid shift distributional shift of body fluids into potential body spaces Fluid Volume Excess Hypervolemia excessive retention of water and sodium in ECF Overhydration above normal amounts of water in extracellular spaces Edema excessive ECF accumulates in tissue spaces Interstitial-to-plasma shift movement of fluid from space surrounding cells to blood Basic types of fluid imbalances ISOTONIC - water and electrolytes are gained or lost in equal proportions OSMOLAR involve the loss or gain of ONLY water , ergo the osmolality of serum is altered THUS , There are FOUR CATEGORIES OF FLUID IMBALANCES that may occur: ISOTONIC LOSS OF WATER AND ELECTROLYTES OSMOLAR LOSS OF ONLY WATER ISOTONIC GAIN OF WATER AND ELECTORLYTES OSMOLAR GAIN OF ONLY WATER Interventions Oral Fluids and Electrolytes Fluids and Electrolytes can be provided orally in the home and hospital if clients health permits, and is not vomiting and has intact GIT and did not incur excessive fluid loss

Commonly ordered as increased fluids or push fluids - for those with diarrhea and fever, initially for surgical clients post op restricted fluids 0r nothing by mouth - for those clients with fluid retention or excess

INTRAVENOUS SOLUTIONS Giving IV therapy is a common practice It is an efficient and effective method of supplying fluids directly to the intravascular fluid compartment E. Elimination URINATION -refers to the emptying of the urinary bladder. Also called micturition and voiding. DEFECATION is the expulsion of feces from anus and rectum. Also called bowel movement URINE -is the amber colored fluid which is excreted from the kidneys at a rate of about 1500 ml every 24 hours in an adult. STOOL/FECES wastes products in or excreted from the large intestine. Characteristics of Normal Urine Volume (amount in 24 hrs.): adult 1200 1500 ml Color: straw, amber, transparent Odor: faint, aromatic Clarity: clear liquid pH: 4.5 8 Specific gravity: 1.010 1.025 Constituents: 96% water and 4% solutes (Organic solutes: urea, ammonia, creatinine and uric acid; Inorganic solutes: sodium, chloride, potassium, sulfate, magnesium, and phosphorus) Foods Affecting Bowel Elimination Constipating foods: cheese, lean meat, eggs, pasta Foods with laxative effect: fruits and vegetables, bran, chocolate, alcohol, coffee Gas-producing foods: onions, cabbage, beans, cauliflower Effect of Medications on Stool Aspirin, anticoagulants pink to red to black stool Iron salts black stool Antacids white discoloration or speckling in stool Antibiotics green-gray color Implementing measures that promote normal defecation in hospitalized clients Implementing medically prescribed therapies such as Cathartics, anti-diarrheal prep. & Enemas Checking for and digitally removing an impaction Teaching clients about appropriate lifestyle changes such as inc. fluid intake, exercise and intake of dietary fiber Providing special care for clients w/ bowel diversion ostomies and teaching them about ostomy management F. Safety, comfort & hygiene SAFETY Freedom from psychological and physical injury. FALLS Considerations: Modification in the home and health care environment can easily reduce the risks of falls. Putting safety bars on toilets and locks on wheelchair and bed and using of call bells can minimize falls. RESTRAINTS Considerations: The immobility imposed by restraining a client can lead to pressure ulcer formation, hypostatic pneumonia, constipation, urinary and fecal incontinence & urinary retention. Contractures, nerve damage, circulatory impairments are potential hazards. FIRES The nurse protects clients from immediate injury, reports the exact location of the fire, and controls it if possible. All personnel are mobilized to evacuate clients. Nursing measure include complying with the agencys smoking policies and keeping combustible materials away from heat sources. ELECTRICAL HAZARDS Electrical equipment must be in good working order and should be grounded.

Educating both the client and the family can reduce the risk for electrical hazards in the home environment.

SEIZURES Seizure precautions encompass all nursing interventions to protect the client from traumatic injury, positioning for adequate ventilation and drainage of oral secretions, and providing privacy and support following seizure. RADIATION Hospitals have strict guidelines on the care of the clients who are receiving radiation and radioactive materials. To reduce the nurses exposure to radiation, time spent near the sources should be limited, the distance from the source should be as great as possible, and shielding devices such as lead aprons should be used.

COMFORT Relief from pain and anxiety. The concept of comfort is as subjective as that of pain. Each individual has physiological, social, spiritual, psychological, and cultural characteristics that influence the perception and experience of comfort. PAIN Subjective and highly individualized. Stimulus for pain can be physical or mental in nature (damaged tissue or persons dampened ego). Interferes with personal relationships and influences the meaning of life. HYGIENE Activities: Health promotion Bath & skin care Perineal care Back rubs G. Mobility and immobility Concepts of Body Mechanics Body alignment or posture Balance Coordinated body movement Postural reflexes Factors Influencing Mobility Developmental considerations Physical health Mental health Lifestyle Types of Exercises Isotonic Isometric Isokinetic MOBILITY & IMMOBILITY Range of Motion maximum amount of movement available at a joint in one of the three planes of the body. Gait manner of walking; indicates the clients ability to walk without assistance. Exercise & Activity tolerance assessment of activity tolerance is necessary when planning activity such as walking, ROM exercises or ADLs Body Alignment SPECIFIC HAZARDS OF IMMOBILITY Inadequate Nutrition Altered Respiratory function Altered Cardiovascular Function ACTIVITIES FOR MOBILITY & IMMOBILITY NEEDS Health Promotion education, prevention, early detection. Acute Care Restorative Care Positioning Musculoskeletal Changes Pressure Sores Altered Excretory Function

Oral hygiene Foot and nail care Hair and scalp care Care of eyes, ears and nose

Attitude and values Fatigue and stress External factors

CHAPTER 6: HEALTH EDUCATION Domains of Learning Cognitive Learning Affective Learning Psychomotor learning Learning Principles: 1. Several factors affect ones motivation to learn. 2. Learning of an individual depends on his physical and cognitive abilities, developmental level, physical awareness, and intellectual thought processes. 3. Class size, privacy, ventilation, furniture are considered in selecting a place for teaching.

CHAPTER 7: RECORDS MANAGEMENT PURPOSES OF CLIENT RECORDS Planning client care. Communication. Legal Documentation. Research. Education Documentation Methods SOURCE ORIENTED PROBLEM ORIENTED COMPUTER RECORDS KARDEX SOAP Format Elements of Effective Charting Timing Confidentiality Permanence Signature Accuracy Quality Assurance Monitoring Nursing audit Peer Review Statistics Accrediting and Licensing. Reimbursement. The SOAPIE and SOAPIER PIE Charting FOCUS Charting Charting by Exception (CBE)

Completeness Use of Standard. Brevity Legal

CHAPTER 8: COMMUNICATION Communication Process It is a two-way process involving sending & receiving of message; the intent is to elicit a response, the process is ongoing; the receiver of message then becomes the sender of response, the original sender then becomes the receiver. FACTORS INFLUENCING COMMUNICATION PROCESS Ability of the Communicator Perceptions Personal Space Territoriality Roles & Relationships Time factor Environment

THERAPEUTIC NURSE-CLIENT RELATIONSHIP Nurse-client relationships are referred to as interpersonal or helping (therapeutic) relationships. This forms the basis for CARING, the hallmark of nursing practice. THERAPEUTIC COMMUNICATION Techniques: Active listening Sharing observations Sharing empathy Sharing hope Sharing humor Sharing feelings Using touch Using silence Providing general leads Being specific and tentative

Using open-ended questions Asking relevant questions Providing information Paraphrasing Clarifying Focusing Summarizing Self-disclosing confronting Offering self

Giving information Acknowledging

Summarizing and planning

NON-THERAPEUTIC RESPONSES Stereotyping Agreeing and Disagreeing Being defensive Challenging Probing Testing

Rejecting Changing topics and subjects Unwarranted reassurance Passing judgment Giving common advice

THERAPEUTIC USE OF SELF The process of using ones humanity, personality, experience, values, feelings, intelligence, needs, coping skills, and perceptions to help client grow, change and heal. Peplaus theory described the therapeutic use of self as being able to clearly understand one self to promote the clients growth and to avoid limiting the clients choices to those valued by the nurse.