FUNDAMENTALS IN NURSING

 EVOLUTION OF NURSING
NURSING IN THE PAST (TRADITIONAL NURSING) –FOCUS WAS TAKING CARE OF SICK
PEOPLE
 CONTEMPORARY NURSING
EMPHASIZES CARE OF THE “WHOLE PERSON, “ OR HOLISTIC HEALTH CARE
 HISTORICAL PERSPECTIVES

1. INTUITIVE
▪ WOMEN WHO TOOK CARE OF THEIR CHILDREN, ELDERLY AND SICK MEMBERS OF
THE FAMILY
▪ SHAMANS – INCANTATIONS, TREPHININGS
• CONTRIBUTIONS TO MEDICINE AND NURSING
1. BABYLONIA – CODE OF HAMMURABI
2. EGYPT – ART OF EMBALMING; ID 250 RECOGNIZED DISEASES
3. ISRAEL – MOSES “FATHER OF SANITATION”
4. CHINA – MATERIA MEDICA (PHARMACOLOGY)
2. PERIOD OF APPRENTICE NURSING
 EXTENDS FROM THE FOUNDING OF RELIGIOUS ORDERS IN THE 11TH CENTURY AND
ENDED IN 1836
 “ON –THE-JOB TRAINING”
 HOSPITALS WERE ESTABLISHED IN THE 16TH CENTURY BUT WERE UNSANITARY,
CHEERLESS, GLOOMY AND AIRLESS
3. DARK PERIOD OF NURSING
 17TH TO 19TH CENTURY
 NURSING CARE GIVEN BY CRIMINALS AND WOMEN OF LOW MORAL
STANDARDS
 ENDED IN 1836 WITH THE ESTABLISHMENT OF THE KAISERWERTH INSTITUTE
FOR THE DEACONESSES IN GERMANY BY PASTOR FLIEDNER
4. EDUCATIVE PERIOD
 ESTABLISHMENT OF NIGHTINGALE SCHOOL OF NURSING AT ST. THOMAS
HOSPITAL IN LONDON ON JUNE 15, 1860
 GUARDIAN ANGEL OR ANGEL OF MERCY IMAGE
 DOCTOR’S HANDMAIDEN
» FLORENCE NIGHTINGALE (May 12, 1820 - Aug. 13, 1920)
 MOTHER OF MODERN NURSING
 LADY WITH THE LAMP
 ANGEL OF CRIMEA
 NOTES ON NURSING
 NOTES ON HOSPITAL
» NURSING LEADERS
  CLARA BARTON (1812-1912) – AMERICAN RED CROSS
 LILLIAN WALD (1867-1940) – FOUNDER OF PUBLIC HEALTH NURSING
 MARY ADELAIDE NUTTING, ISABEL HAMPTON ROBB AND LAVINIA DOCK-
AMERICAN SOCIETY OF SUPERINTENDENTS OF TRAINING SCHOOLS FOR
NURSES IN THE US & CANADA
» CONTEMPORARY

 DEFINITION OF NURSING BY FLORENCE NIGHTINGALE AND VIRGINIA

HENDERSON
 NIGHTINGALE, 1860 – NURSING IS “THE ACT OF UTILIZING THE
ENVIRONMENT…”
 VIRGINIA HENDERSON, 1960 – “TO ASSIST THE INDIVIDUAL, SICK OR WELL”
Events and Trends
 Establishment of WHO by UN
 Atomic/ nuclear energy for dx and tx
 Use of computers
 Aerospace nursing
 Laws amended perceiving health as a fundamental right
 Disposable supplies and equipments
 Development of the expanded roles of nurses.
 Community health nursing intensified
 ROLES AND FUNCTIONS OF THE NURSES
I. Caregiver (Care Provider)
» it includes those activities, which usually carried out by a professional, that
assist the client physically and psychologically while preserving client’s dignity. It
if often referred to as “Mothering Actions”
II. Communicator
» nurses identify client problems and then communicate these verbally or in
writing to other members of the health team through coordination.
III. Client Advocate
» one who expresses and defends the cause of another. The nurse promotes
what is best for the client, ensuring that the client’s needs are met and protects
their rights.
IV. Counselor
» Helps a client to recognize and cope with stressful psychological or social
problems, to develop improved interpersonal relationships and to promote
personal growth. Counseling requires therapeutic communication skills, and the
nurse should be prepared to provide emotional, psychological and intellectual
support appropriately.
V. Leader
» Nursing leadership is defined as a mutual process of interpersonal influence
through which the nurse helps a client make decision in establishing and
achieving goals to improve the client’s well being
VI. Manager
» Ability to handle or control something successfully, which in this case applies
on the nursing care of individuals, families and communities. Roles in nursing
management includes planning, organizing, staffing, leading, communicating,
decision making and controlling.
VII. Nurse Administrator
» manages client care, including the delivery of nursing services, making sure
that the nursing services are organized, coordinated, and dispensed, to meet
the patient’s needs.
VIII. Nurse Educators
» help to coordinate and assess the education needs of nurses in the institution.
They coordinate internship and orientation programs to prepare newly hired
function in special areas.
IX. Role Model
» Nurses serve as good models when they observe healthful practices of daily
living.

♥ EXPANDED ROLES
1. NURSE-PRACTIONER – GRADUATE OF A NURSE-PRACTIONER PROGRAM
2. CLINICAL NURSE SPECIALIST – ADVANCED DEGREE, CONSIDERED AN EXPERT
IN A SPECIALIZED AREA OF PRACTICE
3. NURSE-ANESTHETIST
4. NURSE-MIDWIFE
5. NURSE-RESEARCHER – DOCTORAL LEVEL
6. NURSE-ADMINISTRATOR-HEAD NURSES, SUPERVISORS
7. NURSE EDUCATORS
8. NURSE-ENTREPRENEUR
▪ SCOPE OF NURSING
♥ R.A. 9173 Article VI Section 28 of the Philippine Nursing act of 2002 cites the
Scope of Nursing.
FOUR AREAS OF NURSING PRACTICE:
1. Promotion of Health & Wellness
w Nurses promote wellness in clients who are both healthy & ill.
w This may involve individual & community activities to enhance healthy lifestyles,
such as nutrition & physical fitness, preventing drug & alcohol misuse, restricting
smoking & preventing accidents & injury in the home & workplace.
w The nursing process is the best tool for the nurse in the health promotion role.
w As the nurse moves towards greater autonomy in providing client care, a
thorough assessment of the client’s health status is essential to provide a
meaningful data.
2. Prevention of Illness
w The goal of illness prevention programs is to maintain optional health by
preventing disease.
w Prevention, in a narrow sense, means avoiding the development of disease in
the future, & in broader sense, consists of all interventions to limit progression
of a disease.
w Nursing activities that prevent illness include immunizations, prenatal & infant
care, Umbilical cord care, prevention of sexually transmitted disease (use of
condom), use of first aid, pap smears, mammograms, routine physical
examination, & safety.
♥ 3 LEVELS OF PREVENTION
1. PRIMARY PREVENTION – FOCUS IS ON HEALTH PROMOTION EX. NUTRITION,
IMMUNIZATION, FAMILY PLANNING SERVICES, STRESS MANAGEMENT
2. SECONDARY PREVENTION – EMPHASIZES EARLY DETECTION, EARLY
INTERVENTIONS (EX. SCREENING SURVEYS, TSE, BSE)
3. TERTIARY PREVENTION – FOCUS IS TO HELP REHABILITATE INDIVIDUALS (EX.
TEACHING CLIENTS WITH DM ABOUT SELF-MEDICATION & PREVETION OF
COMPLICATIONS)
3. Restoration of Health
w focuses on the ill client & it extends from early detection of disease through
helping the client during the recovery period.
w Nursing activities include the following:
 Providing direct care to ill person such as administering medications, baths, &
specific procedures & treatment.
 Performing diagnostic & assessment procedures. (such as measuring BP)
 Consulting with other health care professionals about client problems
 Teaching client about recovery activities, such as exercises that will
accelerate recovery after a stroke.
 Rehabilitating clients to their optimal level following physical or mental
illness, injury, or addiction.

4. Alleviation of Suffering / Care of Dying

 it involves comforting & caring for people of all ages who are suffering &
dying.
 It aims to restore maximum functional health pattern.
 It includes helping clients adapt to altered health & function, live as
comfortably as possible until death & helping support persons cope with
death.
 Nursing activities involve problem solving skills, adaptation to changing
health status & lifestyle, Strategies to deal with current (e.g. medications,
diets, activity limitations, prosthesis) & future ( e.g. fear of pain) problems,
facilitation of strong self-image, or grief & bereavement counseling.
 Nurses carrying out these activities work in homes, hospitals, & extended
care facilities.
NURSING THEORISTS
1. DOROTHY E. JOHNSON – BEHAVIORAL SYSTEM MODEL (EACH PERSON HAS 7
SUBSYSTEMS – INGESTIVE, ELIMINATIVE, AFFILIATIVE, AGGRESSIVE,
DEPENDENCE, ACHIEVEMENT & SEXUAL)
2. IMOGENE KING – GOAL ATTAINMENT THEORY – ASSISTS INDIVIDUALS AND
GROUPS IN SOCIETY TO ATTAIN, MAINTAIN, AND RESTORE HEALTH. IF THIS IS
NOT POSSIBLE, NURSES HELP INDIVIDUALS DIE WITH DIGNITY.
3. MADELEINE LEININGER – TRANSCULTURAL NURSING MODEL (HUMANISTIC &
SCIENTIFIC MODE OF HELPING A CLIENT THROUGH SPECIFIC CARING
PROCESSES (CULTURAL VALUES, BELIEFS AND PRACTICES) TO IMPROVE OR
MAINTAIN A HEALTH CONDITION
4. MARTHA ROGERS – SCIENCE OF UNITARY HUMAN BEINGS (MAN IS AN ENERGY
FIELD IN CONSTANT INTERACTION WITH THE ENVIRONMENT.
5. SR. CALLISTA ROY – ADAPTATION MODEL (A PERSON IS A UNIFIED
BIOPSYCHOSOCIAL SYSTEM IN CONSTANT INTERACTION WITH A CHANGING
ENVIRONMENT.
6. LYDIA HALL – COINED THE TERM “NURSING PROCESS” IN 1955; NURSING
CENTERS AROUND 3 COMPONENTS (CARE, CORE, CURE)
7. JEAN WATSON – THE HUMAN CARING MODEL (MIND-BODY-SOUL HARMONY)
8. DOROTHEA OREM – SELF CARE & SELF-CARE DEFICIT THEORY
♥ 3 NURSING SYSTEMS
1. WHOLLY COMPENSATORY – 100% CARE GIVEN TO THE CL
2. PARTIALLY COMPENSATORY – NURSE/CL ENGAGE IN MEETING SELF-
CARE NEEDS
3. SUPPORTIVE-EDUCATIVE – ASSISTS IN DECISION-MAKING AND
ACQUISITION OF KNOWLEDGE AND SKILLS
9. HILDEGARD PEPLAU – INTERPERSONAL MODEL
♥ 4 PHASES OF THE NURSE-CLIENT RELATIONSHIP
1. ORIENTATION – THE NURSE AND THE CL DO NOT KNOW EACH OTHER’S
GOALS; PHASE WHERE CL TESTS THE NURSE; CL TRIES TO SEEK HELP,
NURSE ASSISTS CL TO UNDERSTAND THE PAST & EXTENT OF NEEDS)
2. IDENTIFICATION – THE CLIENT RESPONDS TO THE PROFESSIONALS ;
ASSUMES THE POSITION OF DEPENDENCE, INDEPENDENCE AND
INTERDEPENDENCE
3. EXPLOITATION – CL UTILIZES ALL AVAILABLE RESOURCES TO MOVE
TOWARD A GOAL OF MAXIMAL HEALTH
4. RESOLUTION – TERMINATION PHASE
LEGAL ASPECTS OF NURSING
▪ CRIME – ACT COMMITTED IN VIOLATION OF PUBLIC LAW; FELONIES OR
MISDEAMENOR
▪ FELONY – A SERIOUS CRIME SUCH AS MURDER; 2ND DEGREE MURDER
▪ MISDEAMENOR – AN OFFENSE OF A LESS SERIOUS NATURE
 ▪ TORTS – CIVIL WRONG COMMITTED AGAINST A PERSON OR A PERSON’S
PROPERTY; INTENTIONAL,
♥ Intentional Torts
 Fraud – false presentation of some facts with the intention that it will be
acted upon to another person.
 Invasion of Privacy
 Defamation – false communication
> Libel – print, writing, pictures
> Slander – spoken word
 Assault – attempt or threat to touch another person unjustifiably
 Battery – willful touching of a person (or clothing) that may or may not cause
harm
• False Imprisonment – unlawful restraint or detention of another person
against his/her will
♥ Unintentional torts
 NEGLIGENCE – COMMISSION OR OMISSION TO DO SOMETHING THAT A
REASONABLE PERSON WOULD DO or would not do which cause injury
 MALPRACTICE – “A PROFESSIONAL NEGLIGENCE” Improper or unskillful care
of a patient
♥ MOST COMMON NURSING ERRORS THAT RESULT IN NEGLIGENCE
 MEDICATION ERRORS
 BURNING A CLIENT
 FALLS
 IGNORING A CLIENT’S COMPLAINTS OR FAILURE TO OBSERVE AND TAKE
APPROPRIATE ACTION
 MISTAKEN IDENTITY
♥ LEGAL DOCTRINES R/T NEGLIGENCE
 RESPONDEAT SUPERIOR – “LET THE MASTER ANSWER”
 RES IPSA LOQUITOR – “THE THING SPEAKS FOR ITSELF” No proof is needed.
ETHICAL ASPECT OF NURSING
 ETHICS – RULES OR PRINCIPLES THAT GOVERN RIGHT CONDUCT
 BIOETHICS – THE ETHICS CONCERNING LIFE
 MORALITY – CONCERNS BEHAVIOR WHICH INVOLVES JUDGEMENTS, ACTIONS
AND ATTITUDES BASED ON NORMS
• CODE OF ETHICS – PROVIDES A MEANS BY WHICH PROFESSIONAL
STANDARDS OF PRACTICE ARE ESTABLISHED, MAINTAINED AND IMPROVED
♥ ETHICAL ISSUES IN NURSING
 CARING FOR AIDS PATIENTS
 ABORTION
 CONFIDENTIALITY
 TERMINATION OF LIFE-SUSTAINING TREATMENT
 DNR

♥ NURSING PROCESS
 • SYSTEMATIC, RATIONAL METHOD OF PLANNING AND P•ROVIDING
INDIVIDUALIZED NURSING CARE; IT PROVIDES A FRAMEWORK FOR
ACCOUNTABILITY AND RESPONSIBILITY IN NURSING AND IT MAXIMIZES
RESPONSIBILITY FOR STANDARDS OF CARE.
• GAINED LEGITIMACY IN 1973 WHEN ANA PUBLISHED STANDARDS OF NURSING
PRACTICE, DESCRIBING THE 5 STEPS OF THE NURSING PROCESS
♥ CHARACTERISTICS OF THE NURSING PROCESS:
 CYCLICAL AND DYNAMIC, RATHER THAN STATIC
 CLIENT CENTERED
 OPEN AND FLEXIBLE
 INTERPERSONAL AND COLLABORATIVE
 IT IS PLANNED
 GOAL DIRECTED
 PERMITS CREATIVITY OF THE NURSE
 EMPHASIZES FEEDBACK
 UNIVERSALLY APPLICABLE
♥ BENEFITS FOR THE CLIENT
 QUALITY OF CARE
 CONTINUITY OF CARE
 CLIENT PARTICIPATION IN THEIR HEALTH CARE
♥ BENEFITS FOR THE NURSE
 CONSISTENT AND SYSTEMATIC NURSING EDUCATION
 JOB SATISFACTION
 PROFESSIONAL GROWTH
 AVOIDANCE OF LEGAL ACTION
NURSING PROCESS
It was popularized by Lydia Hall in 1955
» It is both a problem solving process and a framework in which nurses can apply
their knowledge and skills.
» It is a GOSH approach
G – oal oriented
O – rganize
S – ystematic
H – umanistic Care
» Phases / Steps in Nursing Process:
1. Assessment
▪ Get the facts. Collect, organize, validate, and record client data.
Types of Data:
1. Subjective (symptoms) – apparent only to the client (e.g. Pain, dizziness)
2. Objective (signs) – can be observed (by the use of senses) and measured
Sources of data:
1. Primary Data – provided by the client
2. Secondary Data – provided by a source other than the patient.
Methods of collecting Data:
 1. Interview – a planned communication with the client.
2. Observation – use of 5 sense and instruments
3. Physical Assessment- to validate and confirm subjective and objective data.
2. Diagnosis – identify the client’s status and health care needs.
▪ Uses the PES format
P- roblem
E- tiology
S- igns and symtoms
▪ Prioritizing nursing diagnosis is based on what endangers life.
▪ Types of Nursing Diagnosis:
1. Actual – problem is present
2. Potential – problems may arise
3. Possible – problem may be present
4. Wellness – transition from a specific level of wellness to a higher level.
3. Planning – Determine goals and outcomes. Identifying the specific actions to be
done.
▪ Formulation of NCP which is used mainly as a guide to individualize care.
▪ Characteristics of a well stated goal:
S- pecific
M- easurable
A- ttainable
R- ealistic
T- ime framed
4. Implementing- putting the NCP into action
▪ Requirement for implementation :
▬ TUOS - technical skills
▬ knowledge - communication skills
5. Evaluating – measuring the client’s health achievements based on the goals
specified.

VITAL SIGNS

1. TEMPERATURE- the balance between heat produce by the body and heat loss from the
body. (normal- 36◦C – 37.5◦C)
▪ Types of Body Temperature:
a. Core temperature- deep tissue temperature of the body. Normal ranges from
36.7◦C -37◦C
b. Surface temp.- temperature of the skin, subcutaneous tissue, and fats.
▪ Routes of temperature- taking
Route No. of minutes Normal value Description
oral 2 - 3 mins. 37o C– 98.6o F Most convenient and
Rectal 2 mins. 37.7o C– 99.6oF accessible
Axilla 7 – 10 mins 36.4 o C– 97.5 o F Most accurate and
Tympanic Automatic 37.7 o C– 99.9 o F invasive
membrane results Least invasive and least
accurate
Directly reflects core
temperature
▪ FACTORS AFFECTING BODY TEMPERATURE
AGE
Infants –
Elderly – hypothermia (lack of SC)
Diurnal variables
Highest temp – 8pm-12am, lowest 4-6am
Exercise
Hormones – progesterone
Stress
Environment – elderly cl susceptible to heat stroke
▪ Four common types of fever
♥INTERMITTENT – ALTERNATES BETWEEN PERIODS OF FEVER AND PERIODS OF
NORMAL TEMP
♥ REMITTENT – WIDE RANGE OF TEMP FLUCTUATION OCCURRING OVER THE 24-
HOUR PERIOD, ALL OF WHICH ARE ABOVE NORMAL
♥ RELAPSING FEVER – TEMP IS ELEVATED FOR A FEW DAYS ALTERNATED WITH 1
OR 2 DAYS OF NORMAL TEMPERATURE
♥ CONSTANT FEVER – BODY TEMP IS CONSISTENTLY HIGH
▪ CONVERSION:
Fahrenheit to Celsius = (o F-32) x 5/9
Celsius to Fahrenheit = (o C x 9/5) + 32
2. PULSE - it is the wave of blood created by the contraction of the left
ventricle.
▪ it is regulated by the autonomic nervous sys.
▪ Normal PR for adult – 60-100 bpm
Pulse Site Purposes
Temporal Used when radial pulse is not accessible
Carotid Used for infants and in cardiac arrest
Apical Used for infants and children up to 3 y/o. To determine
Brachial discrepancies
Radial with radial pulse
Femoral Used to measure blood pressure
Readily accessible and routinely use
Determine the circulation of the legs
PULSE SCALE
SCALE FOR MEASURING PULSE STRENGTH
0 ABSENT
1+ PULSE IS DIMINISHED, BARELY
PALPABLE
2+NORMAL
3+FULL PULSE
4+STRONG, BOUNDING PULSE
Pulse rate vary in different age levels
1 y/o – 80 – 100 bpm 10 y/o – 50 – 90 bpm
2 y/o – 80 – 140 bpm adult – 60 – 100 bpm
6 y/o – 75 – 120 bpm
3. RESPIRATION – it is the act of breathing.
▪ Medulla Oblongata is the primary respiratory center of the body.
▪ Normal Adult breathes 16-20 times per min.
▪ Characteristics :
a. Normal breathing – quiet, regular, rhythmic
b. Cheyne – Stoke – alternate waxing and waning with temporary period of
apnea.
c. Biot’s – irregular respiration with period of apnea.
d. KAUSSMAUL’S – INCREASED RR, DEPTH (SEEN IN METABOLIC ACIDOSIS, RENAL
FAILURE
4. BLOOD PRESSURE
BLOOD PRESSURE– it is the pressure exerted by the blood in the arteries.
▪ Normal Adult’s BP is 120/80
▪ Systolic Pressure – pressure resulting from the contraction of ventricles.
▪ Diastolic Pressure – pressure when the ventricles are at rest.
▪ Pulse Pressure – the difference between the systolic and diastolic pressure
▪ the series of sounds during BP reading is called Korotkoff sounds.
PULSE PRESSURE – DIFFERENCE BETWEEN SYSTOLIC AND DIASTOLIC
WIDENED PULSE PRESSURE – WITH INCREASED ICP BP130/60
NARROWED PULSE PRESSURE – HYPOVOLEMIC SHOCK BP 70/60
▪ If the BP cuff is too small for the patient, the BP reading may result to false high
measurement; if the cuff is too big for the patient, the BP reading may result to
false measurement.

ASEPSIS AND INFECTION CONTROL

▪ Six Links in the Chain of infection: (SHARE ME)
S-usceptible H-ost
A-gent
R-eservoir
E-ntry
M-ode of transmission
E-xit
1. Infectious Agent – also known as pathogens
▪ Types of Infection-producing microorganism
Virus – HIV, influenza, hepetitis
Bacteria- E. Coli, S. Aureus
Fungi – Candida Albicans
Parasites – ticks, protozoa, worms
2. Reservoir – sources or places for growth of pathogens
3. Portal of Entry and exit – provides the way for the pathogen to leave one host and
enter another host.
4. Modes of Transmission
▪ Direct Transmission – person to person
Droplet Transmission – if the source and host are within 3 feet
▪ Vehicle-borne – any object or substance that provides a means of transport and
introduce pathogen into a host.
▪ Vector – borne - any animal or insect
5. Susceptible Host – a carrier
Body Defenses Against Infection:
1. Anatomic and physiologic barriers- such as cilia, tears, acidity of the stomach,
saliva, intact skin and mucous membrane.
2. Inflammatory Response –
3. Immune Response – immunity is the resistance of the body to a specific
infection
NOSOCOMIAL INFECTION – occurs when the client is in the hospital.
▪ Handwashing – one of the most effective measures for preventing nosocomial
infection.
▪ Nosocomial infection can be:
1. Exogenous – infection acquired from the environment or other people.
2. Endogenous – infection acquired by microorganisms that the client himself
harbors.
 3. Iatrogenic – infection receives as the direct result of a treatment or diagnostic
procedure.
Manifestations of Infection:
▪ General (LATENT)
Loss of energy, Anoxia, Tachycardia and tachypnea, Enlarged lymph nodes,
Nausea and vomiting, Temperature is high.
▪ Local (RED Heat)
Redness, Edema, Discomfort, Heat
Medical Asepsis Surgical Asepsis
Terminologies: Sterile Technique – practice to keep an object or area
Clean – implies the absence of nearly all free from all microorganism
microorganism Principles:
Dirty – presence of microorganism 1. Sterile objects become unsterile when
Sepsis – it is the state of being infected touched by unsterile objects
Disinfectant – chem. prep. Used to 2. Sterile items are considered unsterile if it is
inanimate obj. out of vision or below waist level
Bactericidal – preparations that destroy 3. All objects used in a sterile field must be
bacteria sterile
Bacteriostatic- preparations 4. The edges of the sterile field are considered
Prevents growth and reproduction of unsterile
some bacteria. 5. Skin is unsterile and cannot be sterilized
Remember: 6. When sterile objects become unsterile, it does
1. Hand washing not necessarily change appearance.
2. Keep fingernails short
7. Alertness, conscientiousness, and honesty are
3. Remove all jewelries
essential in maintaining sterile asepsis
4. Wear latex gloves for dirty procedure

Isolation Precaution
▪ Isolation – describes measures taken to prevent the spread of microorganism to
client, visitors and health care workers
▪ Standard Precaution – also known as universal precaution.
▪ Isolation Practices:
1. Strict Isolation – indicated to highly transmissible diseases by direct contact
and airborne routes of transmission such as Herpes Zoster, Varicella,
Pneumonia.
2. Respiratory Isolation – indicated if the mode of transmission is droplet
transmission. Examples : measles, mumps, influenza
3. Contact Isolation – indicated for infectious diseases or multiple resistant
microorganism that are spread by direct or close contact. Example : Herpes
Simplex, Scabies, Syphilis
4. Enteric Precaution – infectious diseases transmitted through direct or indirect
contact with infected feces. Example: diarrhea, typhoid fever
5. Drainage / Secretion Precaution – patients with wound drainage or infected
wounds. Example: Burns
6. Universal / Blood and body fluids precaution – blood borne, body fluids
pathogens (blood, semen, vaginal secretion, pleural fld.) Ex: AIDS, Hepa B, STD’s
 7. Reverse Isolation – patient is protected from pathogens and nosocomial
infections. Ex: Burns and open wounds, immunocompromised patient

MEDICATION ADMINISTRATION
Terminologies:
» Desired Effect – “therapeutic effect”
» Adverse Effect – a harmful reaction; unexpected
» Toxic Effect – plasma concentration of the drug reaches threatening level
» Side Effect – a response that is unrelated to the desired action of the drug;
expected
» Drug dependence – the physical or psychological reliance on a chemical agent
resulting from addiction.
» Hypersensitivity – abnormal, excessive response
» Paradoxical reaction - opposite reaction
» Drug Allergy – a hypersensitive response to an allergen which the individual has
been exposed and developed antibodies.

▪ Route of administration
1. Oral Medication – most common method of drug administration and generally
the safest route. Onset is slower.
▪ Sublingual – drugs are placed under the tongue.
▪ Buccal – drugs are placed in the inner cheek
* Rule: Never swallow the drug and do not follow with water
√ might cause aspiration and choking
√ Assess for gag reflex, dysphagia or altered LOC
√ Do not give if the client is on NPO.
√ If the drug has an offensive taste, offer oral hygiene.
Eye Medication (optic)
▪ Effects: pupil constriction (miotics), pupil dilation(mydriatic)
▪ Types:
Liquid – 2gtts (conjunctival sac)
Ointment – lower conjunctiva (inner to outer canthus)
• Note:
1. no to cornea
2. press the nasolacrimal gland
3. don’t let the tip of canister touch any part of the eye.
Ear Medication (otic)
▪ Position: lateral for 5mins.
▪ Age: <3y/o – pull the pinna down and back;
> 3y/o – pull the pinna up and back
▪ Solution: side of the ear and warm temp.
▪ Press the tragus of the ear 3x for absorption

ROUTE :

Intradermal
Amount : < 1 cc
Needle Gauge # 26-27
Angle of Insertion : 5 -15 ◦

Sites :
▪Anterior aspect of lower arm
▪Lateral aspect of upper arm
▪Upper aspect of the chest
Others
▪ Used for mantoux test and allergy test
▪ Do not massage the bleb
▪ Bevel up
▪ No red ink

Subcutaneous
Sites
▪outer aspect of the upper arm
▪abdomen
▪thigh
Amount : > 1 cc
Needle Gauge # 25-26
Angle of Insertion : 45 ◦<
Used for:
▪Insulin
▪Heparin
▪Do not massage
▪Do not aspirate

Intramuscular
Amount : 1-3cc
Needle Gauge
Child: # 24 – 25
Adult: # 23 - 24
Angle of Insertion: 90 ◦
Sites
1. Deltoid- 1 ml, non-irritating drug
2. Vastus Lateralis- Below 7 months of age
3. Ventro Gluteal – 7 months and above
4. Dorso-gluteal – children 3 yrs and above
▪ used for large amounts of drug or highly irritating drug such as Dextran

Z-TRACK METHOD
 Do not massage the site after injection to prevent tissue irritation.
 Used to administer IM medication that are highly irritating to subcutaneous
and skin tissues
 Attach a new sterile needle to the syringe after drawing up the medication
 Retract the skin to the side before piercing the skin with the needle to
prevent tracking.

Intravenous Medications
▪ IV meds enter the client’s bloodstream directly by the way of a vein, they are
appropriate when a rapid effect is required
▪ Medications are administered intravenously by the following methods:
 1. Large volume infusion – the safest and easiest way to administer IV meds. The
drugs are diluted in volumes of 1,000ml or 500 ml of compatible fld. Normal
Saline or LR are frequently used.
2. Intermittent IV infusions – a method of administering a medication mixed in a
small amount of IV solution such as 50 or 100ml. Secondary IV setups are the
tandem and piggyback.
3. Volume- control Infusions – intermittent meds may also be administered by a
volume-control infusion set such as Soluset, Volutrol and Pediatrol. They are
small fluid containers (100-150ml) attached below the primary infusion
container. Frequently used to infuse solutions into children.
4. IV Push (bolus)- the IV administration of an undiluted drug directly into the
systemic circulation. It is used in emergency cases, introduced directly into a
vein by venipuncture.
5. Intermittent Infusion Devices- may be affixed to an IV catheter or needle to
allow medications to be administered intravenously. Intermittent injection ports
have either a resealable latex injection site for needle access.

FORMULA FOR DOSAGE COMPUTATION

♦ ORAL MEDICATIONS: Solids (D/S=Q)

Desired dose = quantity of

Stock dose drug
♦ ORAL/PARENTERAL MEDICATIONS: Liquids (D/S X DILUTION = Q)

Desired dose x dilution = quantity of

Stock dose drug

♦ IV FLUID FLOW RATE:

 gtts/min = volume in cc x gtt factor
no. of hours x 60 min.
 cc/hr = volume in cc or gtts/min x 4
no. of hours
 duration in hours = volume in cc
cc/hr
» The following is a method to calculate drops per minute:
Volume to be infused (cc/hour) X gtt/ml
60 minutes

• 10 Rights in giving medications:

1. Right Drug
2. Right Dosage
3. Right Route
4. Right Time
5. Right Patient
6. Right Approach
7. Right Documentation
8. Right Frequency
9. Right Action
 1O.Right Preparation

PROCEDURES
1. Blood Glucose Screening
▪ The glucose value measures the effectiveness of the treatment of the client with
diabetes.
▪ Capillary blood glucose is monitored by using commercial glucose meter such as
Glucometer. Protect test tips from exposure to light.
▪ Measurement is done 30 minutes before meal.
▪ Normal Blood Glucose is 60-120 mg/dl

Signs and Symptoms of Abnormal Blood Glucose Level

Hypoglycemia- Bld glucose < 60 mg/dL
Shakiness
Hunger
Rapid Pulse
Irritability
Loss of concentration
Seizure

Hyperglycemia – Bld glucose > 120 mg/dL

Weakness
Polydipsia
Dry skin and mouth
Nausea and Vomiting
Glucosuria
Thirst
Kussmaul breathing (late)

2. Insertion of NGT
▪ NGT is inserted through the nose and into the stomach .
▪ Purposes:
a. Gavage – gastric feeding
b. Lavage – stomach irrigation
c. For decompression
d. Medication and supplemental fld. Adm.
▪ Principles:
» Position: High Fowler’s Position
» Length of tube to inserted: (NEX) from the tip of the nose to the earlobe down
to the xiphoid process.
» Remember to stop and remove if the client cannot talk, is coughing, or
becomes cyanotic.
3. Enema – act by distending the intestine, and sometimes by irritating the
intestinal mucosa; increases peristalsis and expulsion of the feces and flatus.
▪ Purpose :
Bowel training program to establish bowel fxn
Eliminate feces and flatus
Avoid contamination of the sterile field
Treat constipation and impaction
Support visualization of intestine
 ▪ Principles:
» lubricate tube 3 -4 inches
» Position: left lateral position or sims position
» Administration: deliver slowly to minimize discomfort
» Height of container: 12” above the rectum
» Temperature: not more than 42◦C
▪ Solutions commonly used:
1. Hypertonic solution – increased osmotic pressure will draw fluid from the
interstitial space into the colon (e.g. Saline)
2. Hypotonic solution – lower osmotic pressure will cause water to move from the
colon to the interstitial space (e.g. Tap water)
* watch out for circulatory overload
3. Isotonic solution - no movement of fluid in or out of the colon. The volume of
solution stimulates peristalsis (e.g. Normal saline)
▪ Types of Enemas :
1. Cleansing – used to cleanse the bowel
* instruct the client to hold the fluid for 10 -15 mins.
* If client complains of cramping, clamp the tube for 30 secs.
2. Carminative – release gas; it distends the rectum and colon and stimulates
peristalsis.
3. Oil retention – given to soften feces and lubricate the rectum and anal canal.
▪ the force of the solution is controlled by REST
Resistance of the rectum
Elevation of the solution container
Size of the tubing
Thickness of the fluid
4. Urinary Catheterization – introduction of a catheter into the urethra towards the
urinary bladder.
▪ Principles : (sterile technique is a must)
» do not allow the catheter bag to lie on the floor. Do not allow the drainage spout
to touch the collection receptacle.
» Client should void within 4 – 6 hrs after an indwelling catheter is removed
» Acidify the urine – offer food such as cranberries, plums and prunes
» Increase fluid intake to 3L/day to prevent urinary stasis
▪ Types of catheter :
a. Indwelling catheter (foley, retention) – for long period catheterization, usually
with 2
lumens
b. Straight Catheter – for short-period catheterization, single lumen
c. Suprapubic catheter – small insertion is made above the pubic area and the tube
is directly in-
serted into the baldder.
d. External Urine Drainage Device (condom cath)
 MALE FEMALE
Position Supine / flaccid penis at 90◦ angle Dorsal
Recumbent
Length 40 cm catheter
22 cm catheter
Length to be inserted 6 – 9 inches
2 – 3 inches

5. Suctioning – is aspirating secretions through a catheter connected to a suction

machine or ▪ wall suction outlet.
▪ Principles : (sterile technique is a must)
» performed to clear the airways
» irritates mucosa and removes oxygen from the resp. Tract
» it is normal for suctioning to cause coughing, sneezing and gagging
▪ Manifestations of the need for suctioning: 4D
a. Dyspnea, pallor and cyanosis
b. Drooling; bubbling breath sound
c. Decreased oxygen saturation
d. Decreased breath sound
ROUTE ORO NASO TRACHEOSTOMYENDOTRACH
PHARYNGEAL PHARYNGEAL EAL
Position Conscious- semi- Semi fowler’s with
fowler’s neck hyperextended Semi fowler’s unless contra-
Unconscious – side Indicated
lying
Pressure 110-150 mmHg Depends upon the
age and type of 90 – 110 mmHg
suction apparatus

Length of tube 3 – 5 inches 3 – 5 inches

to be inserted 2 – 3 inches
Lubricant water Water-soluble
Duration 5 – 15 secs. 5 – 15 secs. Saline solution
Resting pd 20 – 30 secs 20 – 30 secs 5 – 10 secs.
bet. 2 – 3 minutes
suctioning

6. Oxygenation
▪ Oxygen is a clear, odorless gas that constitutes approximately 21% of the air
we breathe, is necessary for all living cells.
▪ 3 - 5 mins. absence of oxygen in the brain may cause permanent damage.
▪ Therapeutic Nursing Intervention for Oxygenation :
a. Facilitate ventilation
» position in semi or high fowler’s
» Incentive spirometer provides an “incentive” to breath deeply.
b. Ensure adequate hydration.
 c. Promote patent airway
d. Administer oxygen
Oxygen Delivery Devices :
a. Cannula – tubes with two prongs for insertion into the nostrils. Oxygen flow rate-
1-6L/min,
b. Face Masks – the mask covers the client’s nose and mouth
1. Simple face mask – delivers oxygen concentration 60 – 90%. Flows- 5-8L/min.
2. partial rebreather – delivers oxygen concentration; flows : 6-10 L/min
3. Non-rebreather – 95 -100 %, flow 10-15 L/min.
4. Venturi mask - 25-50%, flow 4-10L/min. Preferably used for patient with COPD.
▪ Safety Precaution
1. No smoking sign on the door
2. No objects that cause static electricity
3. No volatile subs. near the patient

PHYSICAL ASSESSMENT
▪ Methods of Assessment:
1. Inspection – is the visual examination, that is assessing by using the sense of
sight.
2. Palpation – examination of the body using the sense of touch. The pads of the
fingers are used
3. Percussion – the act of striking a body surface to elicit sounds that can be heard
or vibrations that can be felt.
» flatness – produced by very dense tissue such as muscle or bone
» dullness – produced by dense tissue such as liver, heart.
» Resonance – produced by lung filled with air
» Hyperresonance – booming sound that can be heard over an emphysematous
lung.
» Tympany – sound produced from an air-filled stomach.
4. Auscultation – is the process of listening to sounds produced within the body.

Palpation:
 DEVIATION FROM NORMAL
p ASSESSMENT NORMAL FINDINGS

1. Skin
p percussion Varies from light to deep Pallor, cyanosis, jaundice,
a. color
brown erythema
b. b. Edema
No edema +1 barely detectable
+2 indentation of 2-4mm
c.
+3 indentation of 5-7mm
+4 indentation >7mm
c. Skin lessions Papule, nodule, vesicle, pustule
Freckles, some birthmarks
d. moisture Excessive moisture
Moisture in skin folds
(hyperthermia)
Excessive dryness (dehydration)
e. Temperature
Uniform ; within normal
Localized hyperthermia
(infection) ; generalized
f. Skin turgor hypothermia (shock)
When pinched skin springs back
to previous state
2. HAIR Skin stays pinched or tented or
a. Distribution moves back slowly
Evenly distributed
b. Thickness or Alopecia
thinness thick
c. Amount of body
hair Very thin hair (hypothyroidism)
variable
Hirsutism in women
3. NAILS
a. Curvature and 180◦ or greater (clubbing), spoon
angle Convex; angle of nail plate - 160◦ nail
b. Nail bed color Highly vascular and pink
Bluish (cyanosis), pallor (poor
c. Perform blanche Prompt return of pink or usual arterial circulation)
test color (1-2 secs.) Delayed return of color
ASSESSMENT (circulatory impairment)

Lack of symmetry: increased

Normocephalic and symmetrical skull size;
4. SKULL AND FACE Longer mandible (may indicate
Slightly asymmetric facial excessive growth hormone)
a. Size, shape and
feature, symmetric facial Exophthalmos, myxedema
symmetry
b. Facial features movement
and
Mydriasis, miosis, anisocoria
movement
3 – 7mm in dm Absent response
5. EYES Illuminated pupils constrict and
when looking at near objects Strabismus, nystagmus
a. Pupil size Both eyes coordinated, moves
b. PERRLA in unison Denominator of 40 or more on
Snellen chart
c. Extraocular Muscle 20/20 vision on Snellen chart Myopia, hyperopia, presbyopia
(six ocular movement) DEVIATION FROM NORMAL
NORMAL FINDINGS
d. Visual acuity Low-set ears (down syndrome)
Aligned with the outer canthus
of the eye Pink to red, yellow-amber, white
ASSESSMENT Pearly gray color, semi-
transparent
6. EARS (+) weber- sound is heard better
a. Auricle alignment (-) weber- sound is heard on in ear w/o a problem
 (+) Rinne – air conduction is greater than air conduction (BC >
b. Tympanic membrane greater than bone conduction AC) or BC=AC
c. Weber’s test (AC > BC)
Air movement is restricted in one
d. Rinne test Air moves freely as the client or both nares
breathes through the nares
Purulent discharge, mucosa red,
7. NOSE AND SINUSES Clear watery discharge, pink edematous, presence of lesions
a. Patency of both nasal mucosa
cavities Tenderness in one or more
not tender sinuses
b. Observe for presence
of redness, swelling
and discharge
c. Palpate sinuses for Pallor; cyanosis, fissures, crust
tenderness Uniform pink in color, symmetry or scales (may result to
of contour, soft, moist, smooth nutritional deficiency or fld.
8. MOUTH texture. Ability to purse lips Deficit). Inability to purse lip
a. Color, symmetry and (facial damage)periodontal
texture of the outer lip Excessively red gums,
32 adult teeth, smooth, white, tenderness, bleeding (periodontal
shiny tooth enamel. Pink gums disease)
Deviated from center (damage to
b. Teeth and gums Central position; slightly rough; hypoglossal) smooth red tongue
pink color (iron, vit. B12 deficiency
ABDOMEN Deviation to one side from tumor
c. Position,
 SUPINEcolor and or trauma; immobility(damage to
texture of the tongue Positioned in midline of soft
 INSPECT,AUSCULTATE,PERCUSS AND PALPATE trigeminal or vagus nerve)
palate
 BOWEL SOUNDS-HIGH PITCHED GURGLES HEARD AT 5 – 20 SECOND
INTERVALS( 5-25/MIN NORMAL) Inflammed, presence of discharge
d.
 IF NOT and
Mobility position
HEARD IN 1 MINUTE
Pink andSTAY FORno3 discharge,
smooth; -5 MINS MORE. SEQUENCE IS
Grade:
of the uvula
CLOCKWISE FROM RLQ of normal size 1-behind the tonsilar pillar
 HYPOACTIVE < 3 2 – between the pillars and uvula
 HYPERACTIVE =CONTINOUS,LOUD,FREQUENT3 – touch the uvula
e. Inspect
 the tonsils SOUND – BOWEL OBSTRUCTION
TINKLING 4 – one or both sides extend to
the midline of oropharynx

Absent (problem with

Present glossopharyngeal or vagus nerve
DEVIATION FROM NORMAL
NORMAL FINDINGS
f. Elicit gag reflex
Enlarged, palpable, possibly
Not palpable
ASSESSMENT tender (infection or tumor)

9. NECK Central placement in midline of Deviation to one side (possible

a. Lymph nodes neck neck tumor; thyroid enlargement;
enlarge lymph nodes)

b. Trachea Visible or enlarged; not movable

Not visible, ascends during with swallowing; presence of
swallowing; absence of bruit bruit

a. Thyroid Gland Pigeon chest (rickets)

Elliptical in shape, AP dm is half
its transverse dm Funnel chest- abnormal pressure
10. THORAX on the heart may result in altered
function.
a. Shape and size
(anterior) Barrel chest- ratio of AP to
Vertically aligned; (R) and (L) transverse dm is 1:1
shoulders and hips are at the (emphysema, chronic pulmonary
same height
condition)
b. Alignment of the spine
 Full and symmetric lung
expansion side’ shoulders or hips not even
(thumb separates 3-5cm during
deep inspiration)
c. Respiratory excursion Asymmetric or decreased chest
Bilateral symmetry of vocal expansion
fremitus. Fremitus heard most
clearly at the apex of the lung
RUQ
Decrease or absent
✔ Liver and Gall Bladder Resonance except over the
d. Palpate the chest for (pneumothorax); increase
✔ Pylorus
vocal (tactile) fremitus scapula; lowest point of (pneumonia)
✔ Duodenum resonance is at the diaphragm
✔ Head of the Pancreas
✔ Right Dullness or flatness over the lung
e. Percuss theAdrenal
thoraxGland Vesicular and bronchovesicular
✔ Portion of the Right Kidneysound tissue (consolidation of lung
✔ Hepatic Flexure of Colon tissue or mass)
✔ Portions of Ascending and Transverse Colon Adventitious breath sounds
f. Auscultate the chest
RLQ (crackles, rhonchi, wheeze,
○ Cecum and Appendix friction rub)
○ Portion of Ascending Colon
○ Bladder (usually if distended)
○ Lower pole of Right Kidney
○ Right Ovary
○ Right Spermatic Cord
○ Right Ureter
LUQ
 Left lobe of Liver
 Spleen
 Stomach
 Body of Pancreas
 Left Adrenal Gland
 Portion of the Left Kidney
 Splenic portion of Colon
 Portions of transverse and descending colon
LLQ
➢ Lower pole of Left Kidney
➢ Sigmoid Colon
➢ Portion of Descending Colon
➢ Bladder (usually if distended)
➢ Left Ovary
➢ Uterus (if enlarged)
➢ Left Spermatic Cord
➢ Left Ureter

9 Regions of the Abdomen

Right Hypochondriac Epigastric Left Hypochondriac

R Lumbar Umbilical Left Lumbar
Right Iliac Hypogastric Left Lumbar

NEUROLOGIC TESTS
 MENTAL STATUS-
 LANGUAGE-CEREBRAL CORTEX-APHASIA
 ORIENTATION(TIME,PLACE,PERSON)(CONFUSION)
 MEMORY- IMMEDIATE RECALL, RECENT MEMORY AND REMOTE MEMORY
 ATTENTION SPAN AND CALCULATION (SERIAL 7S/3S TESTS)
 CEREBELLAR FUNCTION- COORDINATION , POINT TO POINT TOUCHING,ALTERNATING
MOVEMENTS,GAIT
 SENSORY FUNCTION(e.g. PROPRIOCEPTION-POSITION SENSE- ROMBERG’S TEST)
 CRANIAL NERVE FUNCTIONS

Cranial Nerves
CN I – Olfactory – sense of smell
CN II – Optic – visual field testing
CN III – Oculomotor, IV – (Trochlear), VI – ( Abducens) – visual pathways – pupil size, papillary
reactions, extraocular movements
CN V – Trigeminal – mm of mastication, facial sensation
CN VIII – Vestibulocochlear/ Auditory – nystagmus, hearing capacity
CN VII – Facial, IX – Glossopharyngeal, X – Vagus, XII- Hypoglossal - ARTICULATION
> TASTE – CN VII – Ant. 2/3
CN IX – Post. 1/3
CN X – region of epiglottis
> SWALLOWING – CN IX, X, XII
> FACIAL EXPRESSION – CN VII
CN XI - Spinal Accessory – SCM and Trapezius mm
Glasgow Coma Scale
> Eye Opening >Best Motor Response
Spontaneous ---- 4 Obeys ------------------ 6
To Speech ----- 3 Localizes ------------- 5
To Pain ----------- 2 Withdraws ------------ 4
Nil ------------------- 1 Abnormal Flexion --- 3
Extensor response ---2
Nil ------------------- 1

>Verbal Response
Oriented -------------------------- 5 Coma score:
Confused conversation ------- 4 (E + M + V) = 3 to 15
Inappropriate Words ---------- 3 GCS : 13-15 = Normal
Incomprehensible sounds --- 2 GCS : 9-12 = Moderately
Nil ---------------------------------- 1 depressed
GCS : 3-8 = Severely depressed/comatose

DEEP TENDON REFLEX

– 0 - NO REFLEX
– +1 – MINIMAL ACTIVITY(HYPOACTIVE)
– +2 – NORMAL RESPONSE
– +3 – MORE ACTIVE THAN NORMAL
– +4 – MAXIMUM ACTIVITY ( HYPERACTIVE)

PRESENCE OF INFANTILE REFLEXES(BABINSKI) IN AN ADULT SIGNIFIES CNS PATHOLOGY

LABORATORY AND DIAGNOSTIC EXAMINATIONS
 1. URINE
A. CLEAN-CATCH, MIDSTREAM URINE SPECIMEN
B. 24-HR URINE SPECIMEN
C. SECOND-VOIDED URINE SPECIMEN
D. CATHETERIZED URINE SPECIMEN
2. STOOL
ROUTINE FECALYSIS – TO ASSESS GROSS APPEARANCE OF STOOL & PRESENCE OF
OVA/PARASITES
STOOL CULTURE & SENSITIVITY TEST
GUIAIC STOOL EXAM – BLEEDING IN THE GIT
3.SPUTUM SPECIMEN
GROSS APPEARANCE OF THE SPUTUM
SPUTUM CULTURE & SENSITIVITY TEST
ACID-FAST BACILLI STAINING
3. SERUM CREATININE (0.5-1.5 mg/100 ml)
Most accurate measure of GFR. If GFR fails, the serum creatinine rises; reflects the degree
of renal impairment

KEY INFO ABOUT VITAMINS

WATER-SOLUBLE – NOT STORED IN THE BODY, NEEDS DAILY SUPPLY IN THE DIET
VITAMIN C – DEF WILL RESULT IN SCURVY, SKIN SPOTS, BLEEDING, DELAYED WOUND
HEALING, IMPAIRED IMMUNE RESPONSE (FOUND IN CITRUS FRUITS, TOMATO, BROCCOLI,
POTATOES)
VITAMIN B1 (THIAMINE) – BERIBERI (NERVE CHANGES, EDEMA, HEART FAILURE, MUSCLE
WEAKNESS); FOUND IN PORK, LIVER, PEAS, EGGS, MILK; COMMONLY SEEN IN ALCOHOLICS
VIT B2 (RIBOFLAVIN) – SKIN LESIONS, CHEILOSIS; FOUND IN MILK AND MILK PRODUCTS,
EGGS, CHEESE, ORGAN MEATS
VIT B3 (NIACIN) – PELLAGRA (DIARRHEA, DERMATITIS, DEMENTIA); FOUND IN BEEF, PORK,
FISH, LIVER, WHOLE GRAINS
VIT B6 (PYRIDOXINE) – NERVOUS AND MUSCULAR PROBLEMS; SEEN IN PATIENTS TAKING
INH; FOUND IN MEAT, LIVER, TUNA, POULTRY, NUTS, GREEN BEANS
C/I TO PX TAKING L-DOPA
VIT B9 (FOLIC ACID) – MEGALOBLASTIC ANEMIA; NTDs; FOUND IN GREEN, LEAFY VEG, MEA
NUTS, COTTAGE CHEESE
VIT B12 (COBALAMIN) – PERNICIOUS ANEMIA; FOUND IN ANIMAL PRODUCTS
FAT-SOLUBLE VITAMINS
A (RETINOL) – NIGHT BLINDNESS, FOUND IN DEEP ORANGE FRUITS AND VEG
D (CHOLECALCIFEROL) – RICKETS, OSTEOMALACIA, FOUND IN MILK AND DAIRY PRODUCTS
E (TOCOPHEROLS) – ANTIOXIDANT; PREVENTS CELL MEMBRANE DAMAGE; FOUND IN VEG
K - ESSENTIAL FOR BLOOD CLOTTING; FOUND IN GREEN LEAFY VEG

SPECIAL DIET
CLEAR LIQUID – PROVIDED FOR CL POST-OP, OR IN THE ACUTE STAGES OF INFX,
PARTICULARLY GI (EX. WATER, TEA, COFFEE, CLEAR BROTHS, GINGER ALE, APPLE JUICE)
FULL-LIQUID DIET – LIQUIDS OR FOODS THAT TURN TO LIQUID AT ROOM TEMP (EX. MILK)
SOFT DIET – FOR CL WHO HAVE DIFFICULTY CHEWING AND SWALLOWING; LIGHTLY
SEASONED, LOW-RESIDUE (LOW-FIBER DIET); EX. SPAG SAUCE, PUDDING, CUSTARD
PUREED DIET – MODIFICATION OF THE SOFT DIET IN WHICH LIQUID IS ADDED AND BLENDED
 CONSISTENCY

Normal values:
RBC (Erythrocytes) – 5,000,000 / mm³
WBC (Leukocytes) – 5,000 – 10,0000 / mm³
Platelets – 150,000 – 450,000 mm³
Hct – male: 38-54 vol%, female: 35-45
Hgb – 12-17 g/ dl
Bld. Prothrombin – 10-15 mg/100 ml plasma
Bld. Fibrinogen – 350 mg/ 100 ml plasma
Prothrombin time – 11 -16 sec
PTT – 60 – 70 secs
APTT – 30 – 45 sec
Bleeding time – 3- 5 mins
Clotting time – 8 – 15 mins
GFR – 125 ml/ min
MAP- 80- 120 mmHg
ESR – male : 15-20 ml/hr, female: 20-30
Differential counts:
> Neutrophils: 60 – 100%
> Eosinophils : 0 – 5 %
> Basophils : 0- 3 %
> Lymphocytes: 30 – 40%
> Monocytes : 0 -5 %
Blood Studies:
> BUN : 10 -20 mg/dl
> Serum Creatinine: .4 – 1.2 mg/ dl
> Serum uric acid : 2.5 – 8 mg/dl
> Albumin : 3.2 – 5.5 mg/ dl
> Cholesterol : 150 – 250 mg/dl
> Triglycerides – 140 – 200 mg/dl
Genito- urinary
Color – amber/ straw
Ph – 4.5 – 8.0
Spe. Gr. – 1.010 – 1.025
Protein – Absent
RBC – 0-5 hpf
WBC – 0-5 hpf
Pus – absent
Glucose – absent
Ketones – absent
Cast – 0-4
Serum Electrolytes:
Sodium – 135- 145 mEq / L
Chloride – 98- 108 mEq / L
Calcium – 4.5 – 5.5 mEq / L
Potassium – 3.5 – 5 mEq / L
 Phosphorus – 3.5 – 5.5 mEq / L
Magnesium – 1.5 – 2.5

Do not lose hope if a door was locked.

God holds the key and He’ll open it on the right time!

If you think YOU CAN DO IT…. YOU CAN!

Believe in yourself!

GOOD LUCK AND GOD BLESS!

Ms. Carmela perez, rn MAN