Professional Documents
Culture Documents
FUNDAMENTALS OF NURSING
OVERVIEW
A. Nursing
B. Concepts of Health and Illness
C. Concepts of Stress
D. Homeostasis
E. Adaptation
F. Adaptation to Stress – Physiological Response (Hans Selye)
G. Physiologic Indicators of Stress
A. Chain of Infection
B. Modes of Transmission
C. Course of Infection
D. Inflammation
E. Immune Response
F. Nosocomial Infection
G. Factors Increasing Susceptibility to Infection
H. Diagnostic Tests Used to Screen for Infection
X. THEORIES OF PAIN
A. Specific Theory
B. Pattern Theory
C. Gate Control Theory
D. Current Developments in Pain Theory
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A. Acute Pain
B. Chronic Pain
ADMINISTRATION OF MEDICATIONS
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Theorist Description
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.
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.
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 Presented the Adaptation Model. She viewed each person as a unified
ROY 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
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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 Introduced the Theory of Human Becoming. She emphasized free
PARSE 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.
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 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
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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
a. 3 Stages of Illness
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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
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 pattern
ii. Functional ability – focuses on self-care: activities of daily living (ADL);
feeding, bathing/hygiene, dressing/grooming, toileting and mobility
iii. Mobility
iv. Integrity of skin
v. Control of bowel and bladder function
C. Concepts of Stress
I. Stress (Theory by Hans Selye)
a. Non specific response of the body to nay demand made upon it
b. Any situation in which a non specific demand requires an individual to respond or
take action
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
a. Classification of Stressors
i. Internal Stressors – originate from within the body. E.g. fever,
pregnancy, menopause, emotion such as guilt
D. Homeostasis – Process of maintaining uniformity, stability and constancy with in the living
organisms. (from Greek word homotos – like, and stasis – position)
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iii. Third Phase – The last phase is repair of tissue by regeneration or scar
formation. Regeneration replaces damaged cells with identical or similar
cells.
stressor to the smallest area of the body that can deal with it.
iii. Shock
Stage of Exhaustion Phase
– the adaptation that the body made during
stage of resistance and the stage of exhaustion.
Epinephrine
Tachycardia
↑ Myocardial contractility Norepinephrine Cotisone
↑ Blood clotting ↓ Blood to kidney Protein catablism
↑ Metabolism ↑ Renin Gluconeogenesis
Stage of Resistance
↓ ↓ 7
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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.
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.
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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
a. Problem solving – involves thinking through the threatening situation, using a specific
steps to arrive at a solution
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.
Coping – dealing with problems & situations or contending with them successfully.
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”.
*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.
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*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.
D. Relaxation Techniques – used to quiet the mind, release tension & counteract the fight or
flight responses of General Adaptation Syndrome (GAS).
I. Breathing Exercises
II. Massage
III. Progressive Relaxation
IV. Imagery
V. Biofeedback
VI. Yoga
VII. Meditation
VIII.Therapeutic Touch
IX. Music Therapy
X. Humor & Laughter
3. PSYCHOLOGICAL RESPONSE
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.
II. High-risk
a. A problem is likely to develop based on assessment of risk factors
b. Nurse intervenes to reduce risk factors or increase protective factors
c. Example: encourage smoking cessation
III. Wellness
a. Client is presently healthy but wishes to achieve a higher level of function
b. 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
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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
II. Interview
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
data
c. 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
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b. Subjective data
i. May be called “covert data”
ii. Not measurable or observable
iii. Obtained from client (primary source), significant others, or health
professionals (secondary sources).
iv. For example, the client states, “I have a headache”
c. Objective data
i. May be called “overt data”
ii. Can be detected by someone other than the client
iii. Includes measurable and observable client behavior
iv. For example, a blood pressure reading of 190/110 mmHg.
• 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
V. Psychosocial assessment
a. Helpful framework for organizing data
b. A suggested format for psychosocial assessment is found below:
• Vocation/education/financial
• Home and Family
• Social, leisure, spiritual and cultural
• Sexual
• Activities of daily living
• Health Habits
• Psychological
VI. Consultation
a. 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 client
c. 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
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Purposes of Records:
I. Communication
II. Planning Client Care
III. Auditing Health Agencies
IV. Research
V. Education
VI. Reimbursement
VII. Legal Documentation
VIII.Health Care Analysis
C. Documentation Systems
I. Source – Oriented Record
a. The traditional client record
b. Each person or department makes notations in a separate section or sections
of the client’s chart
c. 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 information
d. Example: the admissions department has an admission sheet; the physician
has a physician’s order sheet, a physician’s history sheet & progress notes
e. NARRATIVE CHARTING is a traditional part of the source-oriented record
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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.
V. Charting by Exception
a. Documentation system in which only abnormal or significant findings or
exceptions to norms are recorded
b. Incorporates three (3) key elements:
i. Flow sheets
ii. Standards of nursing care
iii. Bedside access to chart forms
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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 client
II. List of medications
III. List of IVF
IV. List of daily treatments & procedures
V. List of Diagnostic procedures
VI. Allergies
VII. Specific data on how the client’s physical needs are to be met
VIII.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 state
II. Resolved health problems
III. Unresolved continuing health problems
IV. Treatments that can be continued (e.g. wound care, oxygen therapy)
V. Current medications
VI. Restrictions that relate to activity, diet & bathing
VII. Functional/self-care abilities
VIII.Comfort level
IX. Support networks
X. Client education provided in relation to disease process
XI. Discharge destination
XII. Referral Services (e.g. social worker, home health nurse)
7. PHYSICAL EXAMINATION
A. Purposes
B. Preparation of Examination
I. Environment – A physical examination requires privacy. An examination room that is
well equipped for all necessary procedures is preferable
II. Equipment – Hand washing is done before equipment preparation and the
examination. Hand washing reduces the transmission of microorganisms
III. 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 Examination
I. General Survey – includes observation of general appearance and behavior, vital
signs, height and weight measurement
II. Review of systems
III. Head to toe examination
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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 sounds
b. Breath sounds
i. Vesicular
ii. Bronchovesicular
iii. Bronchial
E. Examples of Adventitious Breath Sounds
I. Crackles (previously called rales)
II. Rhonchi
III. Wheeze
IV. Friction rub
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A. Chain of Infection
I. 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
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).
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 Transmission
1. 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
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- - > 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
Body’s response
I. 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 Response
I. 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 immunity
a. When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they
enter the circulation from lymph tissue and seek out the antigen
b. Once theantigen is found they produce proteins (lymphokines) that increase
the migration of phagocytes to the area and keep them there to kill the antigen
c. After the antigen is gone, the lymphokines disappear
d. 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
E. Nosocomial Infection
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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
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 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 membranes
b. Adequate blood cell production and differentiation
c. A functional lymphatic system and spleen
d. 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.
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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 PAIN
A. 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.
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 level
b. Second-order neurons in the spinal cord that process nociceptor information
c. 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
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a. 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. Tachycardia
b. Rapid, shallow respirations
c. Increased BP
d. Sweating
e. Pallor
f. Dilated pupils
g. Fear & Anxiety
B. Chronic Pain
I. Prolonged, lasting longer than 6 months, often not attributed to a definite cause, often
unresponsive to medical treatment.
II. Depression is a common associated symptom for the client experiencing chronic
pain; feelings of despair & hopelessness along with fatigue are expected findings.
A. TOOLS/INTRUMENTS USED
I. 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
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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
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 arthritis
ii. Visceral pain is squeezing, cramping pain; example: pain
associated with ulcerative colitis
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
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
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IV. Trade, Brand or Propriety Name – is the name under which a manufacturer markets.
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.
III. Nurses who administer medications are responsible for their own actions. Question
any order that you can consider incorrect.
VII. Return liquid that are cloudy or have changed in color to the pharmacy
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
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
aspects
III. 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 belonging
IV. Self-Esteem Needs – the individual needs both self-esteem and esteem from others
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Far Eastern University-Institute of Nursing
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V. 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
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
delivery
II. 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 itself
III. 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.
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Far Eastern University-Institute of Nursing
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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 concentration
b. 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
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. Nutrients
I. Carbohydrates – the primary sources are plant foods
Types of Carbohydrates
a. Simple (sugars) such as glucose, galactose, and fructose
b. Complex such as starches (which are polysaccharides) and fibers (supplies
bulk or roughage to the diet)
III. Lipids – organic substances that are insoluble in water but soluble in alcohol and
ether.
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 vitamins
b. 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 body
a. Macronutrients – calcium, phosphate, sodium, potassium, chloride, magnesium
and sulfur
b. Micronutrients (trace elements) – iron, iodine, copper, zinc, manganese and
fluoride
The 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
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Far Eastern University-Institute of Nursing
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A. Purposes
I. To relieve urinary retention
II. To obtain a sterile urine specimen from a woman
III. To measure the amount of residual urine in the bladder
IV. To obtain a urine specimen when a specimen cannot secure satisfactory by other
means
V. 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.
D. Retention or Indwelling Catheter (Foley) – A catheter to remain in place for the following
purposes:
I. The gradual decompression of an over distended bladder
II. For intermittent bladder drainage
III. 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.
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Far Eastern University-Institute of Nursing
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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 bladder
V. Connect the catheter to the drainage tubing and drainage bag if not already
connected
VI. 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
VII. Hang the drainage bag on the frame of the bed below the level of the bladder
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Far Eastern University-Institute of Nursing
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B. Oil-Retention Enemas: Lubricates the rectum and colon; the feces absorb the oil and become
softer and easier to pass
A. Nasogastric Tubes
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 contents
b. Maintaining gastric decompression
Key Points:
a. Prior to insertion, position the client in High-Fowler’s position if possible.
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Far Eastern University-Institute of Nursing
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b. Miller-Abbot Tubes
i. Approximately 10 feet long
ii. Double lumen
iii. One lumen utilized for aspiration of intestinal contents
iv. Second lumen utilized to instill mercury into the rubber bag after
the tube has been inserted into the stomach
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Far Eastern University-Institute of Nursing
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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 Bereavement
I. 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
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Far Eastern University-Institute of Nursing
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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
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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