FUNDAMENTALS OF NURSING e.

Melchora Aquino (Tandang Sora)

Nurse the wounded Filipino soldiers
NURSING- As defined by the INTERNATIONAL and gave them shelter and food.
COUNCIL OF NURSES as written by Virginia f. Captain Salome A revolutionary
Henderson. leader in Nueva Ecija; provided nursing
care to the wounded when not in
The unique function of the nurse is to assist the combat.
individual, sick or well, in the performance of g. Agueda Kahabagan Revolutionary
those activities contributing to health, its leader in Laguna, also provided
recovery, or to a peaceful death. The client will nursing services to her troop.
perform these activities unaided if he had the h. Trinidad Tecson Ina ng Biac na
necessary strength, will or knowledge. Nurses Bato, stayed in the hospital at Biac na
help the client gain independence as rapidly as Bato to care for the wounded soldier.
possible. Hospitals and Nursing Schools
1. Iloilo Mission Hospital School of Nursing
The Earliest Hospitals Established were the (Iloilo City, 1906)
following: It was ran by the Baptist Foreign
a. Hospital Real de Manila (1577). It was Mission Society of America.
established mainly to care for the Miss Rose Nicolet, a graduate of
Spanish Kings soldiers, but also New England Hospital for woman
admitted Spanish civilians. Founded by and children in Boston,
Gov. Francisco de Sande Massachusetts, was the first
b. San Lazaro Hospital (1578) built superintendent.
exclusively for patients with leprosy. Miss Flora Ernst, an American
Founded by Brother Juan Clemente nurse, took charge of the school in
c. Hospital de Indio (1586) Established by 1942.
the Franciscan Order; Service was in general 2. St. Pauls Hospital School of Nursing
supported by alms and contribution from (Manila, 1907)
charitable persons. The hospital was established by the
d. Hospital de Aguas Santas (1590). Archbishop of Manila, The Most
Established in Laguna, near a medicinal Reverend Jeremiah Harty, under
spring, Founded by Brother J. Bautista of the the supervision of the Sisters of St.
Franciscan Order. Paul de Chartres.
e.San Juan de Dios Hospital (1596) Founded It was located in Intramuros and it
by the Brotherhood de Misericordia and provided general hospital services.
support was derived from alms and rents. 3. Philippine general Hospital School of
Rendered general health service to the Nursing (1907)
public. In 1907, with the support of the
Nursing During the Philippine Revolution Governor General Forbes and the
The prominent persons involved in the Director of Health and among
nursing works were: others, she opened classes in
a. Josephine Bracken wife of Jose Rizal. nursing under the auspices of the
Installed a field hospital in an estate Bureau of Education.
house in Tejeros. Provided nursing care Anastacia Giron-Tupas, was the
to thw wounded night and day. first Filipino to occupy the position
b. Rosa Sevilla De Alvero converted of chief nurse and superintendent
their house into quarters for the filipino in the Philippines, succeded her.
soldier,during the Philippine-American 4. St. Lukes Hospital School of Nursing
war that broke out in 1899. (Quezon City, 1907)
c. Dona Hilaria de Aguinaldo Wife of The Hospital is an Episcopalian
Emilio Aguinaldo; Organized the Filipino Institution. It began as a small
Red Cross under the inspiration of dispensary in 1903. In 1907, the
Apolinario Mabini. school opened with three Filipino
d. Dona Maria de Aguinaldo- second girls admitted.
wife of Emilio Aguinaldo. Provided Mrs. Vitiliana Beltran was the
nursing care for the Filipino soldier first Filipino superintendent of
during the revolution. President of the nurses.
Filipino Red Cross branch in Batangas. 5. Mary Johnston Hospital and School of
Nursing (Manila, 1907)
It started as a small dispensary on Calle
Cervantes (now Avenida)
 It was called Bethany Dispensary and was 4. The need to establish fruitful and
founded by the Methodist Mission. meaningful relationships with people,
Miss Librada Javelera was the first Filipino institution, or organization
director of the school. Self-Esteem Needs
6. Philippine Christian mission Institute 1. Self-worth
School of Nursing. 2. Self-identity
The United Christian Missionary of Indianapolis, 3. Self-respect
operated Three schools of Nursing: 4. Body image
1. Sallie Long Read Memorial Hospital Self-Actualization Needs
School of Nursing (Laoag, Ilocos Norte,1903) 1. The need to learn, create and understand
2. Mary Chiles Hospital school of Nursing or comprehend
(Manila, 1911) 2. The need for harmonious relationships
3. Frank Dunn Memorial hospital 3. The need for beauty or aesthetics
7. San Juan de Dios hospital School of 4. The need for spiritual fulfillment
Nursing (Manila, 1913) Characteristics of Basic Human Needs
8. Emmanuel Hospital School of Nursing 1. Needs are universal.
(Capiz,1913) 2. Needs may be met in different ways
9. Southern Island Hospital School of Nursing 3. Needs may be stimulated by external and
(Cebu, 1918) internal factor
The hospital was established under the 4. Priorities may be deferred
Bureau of Health with Anastacia Giron- 5. Needs are interrelated
Tupas as the organizer. Concepts of health and Illness
HEALTH
The First Colleges of Nursing in the 1. Is the fundamental right of every human
Philippines being. It is the state of integration of the
University of Santo Tomas .College of body and mind
Nursing (1946) 2. Health and illness are highly individualized
Manila Central University College of Nursing perception. Meanings and descriptions of
(1948) health and illness vary among people in
University of the Philippines College of relation to geography and to culture.
Nursing (1948). Ms. Julita Sotejo was its first 3. Health - is the state of complete physical,
Dean mental, and social well-being, and not
The Basic Human Needs merely the absence of disease or infirmity.
Each individual has unique characteristics, (WHO)
but certain needs are common to all people. 4. Health is the ability to maintain the
A need is something that is desirable, useful internal milieu. Illness is the result of
or necessary. failure to maintain the internal
Human needs are physiologic and environment.(Claude Bernard)
psychologic conditions that an individual 5. Health is the ability to maintain
must meet to achieve a state of health or homeostasis or dynamic equilibrium.
well-being. Homeostasis is regulated by the negative
Maslows Hierarchy of Basic Human Needs feedback mechanism.(Walter Cannon)
Physiologic 6. Health is being well and using ones
1. Oxygen power to the fullest extent. Health is
2. Fluids maintained through prevention of diseases
3. Nutrition via environmental health factors.(Florence
4. Body temperature Nightingale)
5. Elimination 7. Health is viewed in terms of the
6. Rest and sleep individuals ability to perform 14
7. Sex components of nursing care unaided.
Safety and Security (Henderson)
1. Physical safety 8. Positive Health symbolizes wellness. It
2. Psychological safety is value term defined by the culture or
3. The need for shelter and freedom from harm individual. (Rogers)
and danger 9. Health is a state of a process of being
Love and belonging becoming an integrated and whole as a
1. The need to love and be loved person.(Roy)
2. The need to care and to be cared for. 10. Health is a state the characterized by
3. The need for affection: to associate or to soundness or wholeness of developed
belong
 human structures and of bodily and mental 5. Recovery/Rehabilitation
functioning.(Orem) Gives up the sick role and returns to
11. Health- is a dynamic state in the life cycle; former roles and functions.
illness is interference in the life cycle. (King) Risk Factors of a Disease
12. Wellness is the condition in which all 1. Genetic and Physiological Factors
parts and subparts of an individual are in For example, a person with a family
harmony with the whole system. (Neuman) history of diabetes mellitus is at risk in
13. Health is an elusive, dynamic state developing the disease later in life.
influenced by biologic, psychologic, and 2. Age
social factors. Health is reflected by the Age increases and decreases susceptibility
organization, interaction, interdependence ( risk of heart diseases increases with age
and integration of the subsystems of the for both sexes
behavioral system.(Johnson) 3. Environment
Illness and Disease The physical environment in which a
Illness person works or lives can increase the
Is a personal state in which the person feels likelihood that certain illnesses will occur.
unhealthy. 4. Lifestyle
Illness is a state in which a persons Lifestyle practices and behaviors can also
physical, emotional, intellectual, social, have positive or negative effects on
developmental, or spiritual functioning is health.
diminished or impaired compared with Classification of Diseases
previous experience. 1. According to Etiologic Factors
Illness is not synonymous with disease. a. Hereditary due to defect in the
genes of one or other parent which is
Disease transmitted to the
An alteration in body function resulting in i. offspring
reduction of capacities or a shortening of b. Congenital due to a defect in the
the normal life span. development, hereditary factors, or
Common Causes of Disease prenatal infection
1. Biologic agent e.g. microorganism c. Metabolic due to disturbances or
2. Inherited genetic defects e.g. cleft palate abnormality in the intricate processes
3. Developmental defects e.g. imperforate of metabolism.
anus d. Deficiency results from inadequate
4. Physical agents e.g. radiation, hot and cold intake or absorption of essential
substances, ultraviolet rays dietary factor.
5. Chemical agents e.g. lead, asbestos, e. Traumatic- due to injury
carbon monoxide f. Allergic due to abnormal response
6. Tissue response to irritations/injury e.g. of the body to chemical and protein
inflammation, fever substances or to physical stimuli.
7. Faulty chemical/metabolic process e.g. g. Neoplastic due to abnormal or
inadequate insulin in diabetes uncontrolled growth of cell.
8. Emotional/physical reaction to stress e.g. h. Idiopathic Cause is unknown; self-
fear, anxiety originated; of spontaneous origin
Stages of Illness i. Degenerative Results from the
1. Symptoms Experience- experience some degenerative changes that occur in the
symptoms, person believes something is tissue and organs.
wrong j. Iatrogenic result from the treatment
3 aspects physical, cognitive, of the disease
emotional 2. According to Duration or Onset
2. Assumption of Sick Role acceptance of a. a. Acute Illness An acute illness
illness, seeks advice usually has a short duration and is
3. Medical Care Contact severe. Signs and symptoms appear
Seeks advice to professionals for validation abruptly, intense and often subside
of real illness, explanation of symptoms, after a relatively short period.
reassurance or predict of outcome b. Chronic Illness chronic illness
4. Dependent Patient Role usually longer than 6 months, and can
The person becomes a client dependent on also affects functioning in any
the health professional for help. dimension. The client may fluctuate
Accepts/rejects health professionals between maximal functioning and
suggestions. serious relapses and may be life
Becomes more passive and accepting.
 threatening. Is is characterized by -avoidance to allergens
remission and exacerbation. b. Secondary Prevention also known
Remission- periods during which the as Health Maintenance. Seeks to identify
disease is controlled and symptoms specific illnesses or conditions at an early
are not obvious. stage with prompt intervention to prevent
Exacerbations The disease or limit disability; to prevent catastrophic
becomes more active given again at effects that could occur if proper attention
a future time, with recurrence of and treatment are not
pronounced symptoms. provided.
c. Sub-Acute Symptoms are pronounced Early Diagnosis and Prompt
but more prolonged than the acute Treatment
disease. -case finding measures
3. Disease may also be Described as: -individual and mass screening
a. Organic results from changes in the survey
normal structure, from recognizable -prevent spread of
anatomical changes in an organ or tissue communicable disease
of the body. -prevent complication and
b. Functional no anatomical changes are sequelae
observed to account from the symptoms -shorten period of disability
present, may result from abnormal Disability Limitations
response to stimuli. - adequate treatment to arrest
c. Occupational Results from factors disease process and prevent further
associated with the occupation engage complication and sequelae.
in by the patient. -provision of facilities to limit
d. Venereal usually acquired through disability and prevent death.
sexual relation c. Tertiary Prevention occurs after a
e. Familial occurs in several individuals disease or disability has occurred and the
of the same family recovery process has begun; Intent is to halt
f. Epidemic attacks a large number of the disease or injury process and assist the
individuals in the community at the person in obtaining an optimal health status.
same time. (e.g. SARS) To establish a high-level wellness.
g. Endemic Presents more or less To maximize use of remaining capacities
continuously or recurs in a community. Restoration and Rehabilitation
(e.g. malaria, goiter) -work therapy in hospital
h. Pandemic An epidemic which is - Use of shelter colony
extremely widespread involving an
entire country or continent. CONCEPTUAL AND THEORETICAL
i. Sporadic a disease in which only MODELS OF NURSING PRACTICE
occasional cases occur. (e.g. dengue,
leptospirosis) A. NIGHTANGLES THEORY ( mid-1800)
Leavell and Clarks Three Levels of Focuses on the patient and his
Prevention environment.
a. Primary Prevention seeks to Developed the described the first theory
prevent a disease or condition at a of nursing. Notes on Nursing: What It Is,
prepathologic state; to stop What It Is Not. She focused on changing
something from ever happening. and manipulating the environment in
Health Promotion order to put the patient in the best
-health education possible conditions for nature to act.
-marriage counseling She believed that in the nurturing
-genetic screening environment, the body could repair itself.
-good standard of nutrition adjusted Clients environment is manipulated to
to developmental phase of life include appropriate noise, nutrition,
Specific Protection hygiene, socialization and hope.
-use of specific immunization B. PEPLAU, HILDEGARD (1951)
-attention to personal hygiene Defined nursing as a therapeutic, interpersonal
-use of environmental sanitation process which strives to develop a nurse- patient
-protection against occupational relationship in which the nurse serves as a
hazards resource person, counselor and surrogate.
-protection from accidents Introduced the Interpersonal
-use of specific nutrients Model. She defined nursing as an interpersonal
-protections from carcinogens
process of therapeutic between an individual who is four conservation principles of nursing
sick or in need of health services and a nurse which are concerned with the unity
especially educated to recognize and respond to and integrity of the individual. The four
the need for help. She identified four phases of conservation principles are as follows:
the nurse client relationship namely: 1. Conservation of energy. The human body
1. Orientation: the nurse and the client initially functions by utilizing energy. The human
do not know each others goals and body needs energy producing input
testing the role each will assume. The client (food, oxygen, fluids) to allow energy
attempts to identify difficulties and the amount utilization output.
of nursing help that is needed; 2. Conservation of Structural Integrity. The
2. Identification: the client responds to help human body has physical boundaries (skin
professionals or the significant others who can and mucous membrane) that must be
meet the identified needs. Both the client maintained to facilitate health and prevent
and the nurse plan together an harmful agents from entering the body.
appropriate program to foster health; 3. Conservation of Personal Integrity. The
3. Exploitation: the clients utilize all nursing interventions are based on the
available resources to move toward a goal conservation of the individual clients
of maximum health functionality; personality. Every individual has sense of
4. Resolution: refers to the termination identity, self worth and self esteem,
phase of the nurse-client relationship. it which must be preserved and enhanced by
occurs when the clients needs are met nurses.
and he/she can move toward a new goal. 4. Conservation of Social integrity. The
Peplau further assumed that nurse-client social integrity of the client reflects the
relationship fosters growth in both the client family and the community in which the
and the nurse. client functions. Health care institutions may
separate individuals from their family. It is
C. ABDELLAH, FAYE G. (1960) important for nurses to consider the individual
Defined nursing as having a problem- in the context of the family.
solving approach, with key nursing
problems related to health needs of E. JOHNSON, DOROTHY (1960, 1980)
people; developed list of 21 nursing- Focuses on how the client adapts to
problem areas. illness; the goal of nursing is to reduce
Introduced Patient Centered stress so that the client can move
Approaches to Nursing Model She more easily through recovery.
defined nursing as service to individual Viewed the patients behavior as a
and families; therefore the society. system, which is a whole with
Furthermore, she conceptualized nursing interacting parts.
as an art and a science that molds the The nursing process is viewed as a
attitudes, intellectual competencies and major tool.
technical skills of the individual nurse Conceptualized the Behavioral System Model.
into the desire and ability to help people, According to Johnson, each person as a
sick or well, and cope with their health behavioral system is composed of seven
needs. subsystems namely:
1. Ingestive. Taking in nourishment in socially
and culturally acceptable ways.
2. Eliminative. Riddling the body of waste in
socially and culturally acceptable ways.
D. LEVINE, MYRA (1973) 3. Affiliative. Security seeking behavior.
4. Aggressive. Self protective behavior.
Believes nursing intervention is a 5. Dependence. Nurturance seeking behavior.
conservation activity, with 6. Achievement. Master of oneself and ones
conservation of energy as a primary environment according to internalized
concern, four conservation principles of standards of excellence.
nursing: conservation of client energy, 7. Sexual role identity behavior
conservation of structured integrity,
conservation of personal integrity, F. ROGERS, MARTHA
conservation of social integrity. Considers man as a unitary human being
co-existing with in the universe, views
Described the Four Conversation nursing primarily as a science and is
Principles. She advocated that nursing committed to nursing research.
is a human interaction and proposed
G. OREM, DOROTHEA (1970, 1985) Presented the Adaptation
Model. She viewed each person
Emphasizes the clients self-care needs, as a unified biopsychosocial
nursing care becomes necessary when system in constant interaction
client is unable to fulfill biological, with a changing environment. She
psychological, developmental or social contented that the person as an
needs. adaptive system, functions as a
Developed the Self-Care Deficit Theory. whole through interdependence of
She defined self-care as the practice of its part. The system consists of
activities that individuals initiate to perform input, control processes, output
on their own behalf in maintaining life, feedback.
health well-being. She conceptualized
three systems as follows: K. LYDIA HALL (1962)
1. Wholly Compensatory: when the The client is composed of the ff.
nurse is expected to accomplish all overlapping parts: person (core),
the patients therapeutic self-care or pathologic state and treatment
to compensate for the patients (cure) and body (care).
inability to engage in self care or Introduced the model of Nursing:
when the patient needs continuous What Is It?, focusing on the notion
guidance in self care; that centers around three
components of CARE, CORE and
2. Partially Compensatory: when CURE. Care represents nurturance
both nurse patient engage in and is exclusive to nursing. Core
meeting self care needs; involves the therapeutic use of self
3. Supportive-Educative: the system and emphasizes the use of
that requires assistance decision reflection. Cure focuses on nursing
making, behavior control and related to the physicians orders.
acquisition knowledge and skills. Core and cure are shared with the
other health care providers.
H. IMOGENE KING (1971, 1981)
Nursing process is defined as L. Virginia Henderson (1955)
dynamic interpersonal process Introduced The Nature of Nursing
between nurse, client and health Model. She identified fourteen basic
care system. needs.
Postulated the Goal Attainment She postulated that the unique function of
Theory. She described nursing as a the nurse is to assist the clients, sick or
helping profession that assists well, in the performance of those activities
individuals and groups in society to contributing to health or its recovery, the
attain, maintain, and restore health. clients would perform unaided if they had
If is this not possible, nurses help the necessary strength, will or knowledge.
individuals die with dignity. She further believed that nursing involves
In addition, King viewed nursing as assisting the client in gaining
an interaction process between client independence as rapidly as possible, or
and nurse whereby during assisting him achieves peaceful death if
perceiving, setting goals, and acting recovery is no longer possible.
on them transactions occurred and
goals are achieved. M. Madaleine Leininger (1978, 1984)
Developed the Transcultural Nursing
I. BETTY NEUMAN Model. She advocated that nursing is a
Stress reduction is a goal of system humanistic and scientific mode of helping
model of nursing practice. Nursing a client through specific cultural caring
actions are in primary, secondary or processes (cultural values, beliefs and
tertiary level of prevention. practices) to improve or maintain a health
J. SIS CALLISTA ROY (Adaptation Theory) condition.
(1979, 1984)
Views the client as an adaptive N. Ida Jean Orlando (1961)
system. The goal of nursing is to help Conceptualized The Dynamic Nurse
the person adapt to changes in Patient Relationship Model.
physiological needs, self-concept, She believed that the nurse helps patients
role function and interdependent meet a perceived need that the patient
relations during health and illness. cannot meet for themselves. Orlando
 observed that the nurse provides direct S. Helen Erickson, Evelyn Tomlin, and Mary
assistance to meet an immediate need for Ann Swain (1983)
help in order to avoid or to alleviate distress Developed Modeling and Role
or helplessness. Modeling Theory. The focus of this
She emphasized the importance of theory is on the person. The nurse models
validating the need and evaluating care (assesses), role models (plans), and
based on observable outcomes. intervenes in this interpersonal and
interactive theory.
O. Ernestine Weidanbach (1964) They asserted that each individual unique,
Developed the Clinical Nursing A has some self-care knowledge, needs
Helping Art Model. simultaneously to be attached to the
She advocated that the nurses individual separate from others, and has adaptive
philosophy or central purpose lends potential. Nurses in this theory, facilitate,
credence to nursing care. nurture and accept the person
She believed that nurses meet the unconditionally.
individuals need for help through the T. Margaret Newman
identification of the needs, administration of Focused on health as expanding
help, and validation that actions were consciousness. She believed that human
helpful. Components of clinical practice: are unitary in whom disease is a
Philosophy, purpose, practice and an art. manifestation of the pattern of health.
She defined consciousness as the
P. Rosemarie Rizzo Parse (1979-1992) information capability of the system which
Introduced the theory of Human is influenced by time, space movement
Becoming. She emphasized free choice of and is ever expanding.
personal meaning in relating value U. Patricia Benner and Judith Wrudel (1989)
priorities, co creating the rhythmical Proposed the Primacy and Caring
patterns, in exchange with the environment, Model. They believed that caring central
and co transcending in many dimensions as to the essence of nursing. Caring creates
possibilities unfold. the possibilities for coping and creates the
possibilities for connecting with and
Q. Joyce Travelbee (1966,1971) concern for others.
She postulated the Interpersonal Aspects
of Nursing Model. She advocated that the V. Anne Boykin and Savina Schoenhofer
goal of nursing individual or family in Presented the grand theory of Nursing
preventing or coping with illness, regaining as Caring. They believed that all person
health finding meaning in illness, or are caring, and nursing is a response to a
maintaining maximal degree of health. unique social call. The focus of nursing is
She further viewed that interpersonal on nurturing person living and growing in
process is a human-to-human relationship caring in a manner that is specific to each
formed during illness and experience of nurse-nursed relationship or nursing
suffering situation. Each nursing situation is
She believed that a person is a unique, original.
irreplaceable individual who is in a They support that caring is a moral
continuous process of becoming, evolving imperative. Nursing as Caring is not based
and changing. on need or deficit but is egalitarian model
R. Josephine Peterson and Loretta Zderad helping.
(1976) Moral Theories
Provided the Humanistic Nursing 1. Freud (1961)
Practice Theory. This is based on their Believed that the mechanism for
belief that nursing is an existential right and wrong within the
experience. individual is the superego, or
Nursing is viewed as a lived dialogue that conscience. He hypnotized that a
involves the coming together of the nurse child internalizes and adopts the
and the person to be nursed. moral standards and character or
The essential characteristic of nursing is character traits of the model parent
nurturance. Humanistic care cannot take through the process of
place without the authentic commitment of identification.
the nurse to being with and the doing with The strength of the superego
the client. Humanistic nursing also depends on the intensity of the
presupposes responsible choices. childs feeling of aggression or
attachment toward the model
 parent rather than on the actual Included the concepts of caring and
standards of the parent. responsibility. She described three
2. Erikson (1964) stages in the process of developing an
Eriksons theory on the Ethic of Care which are as follows.
development of virtues or unifying 1. Caring for oneself.
strengths of the good man suggest 2. Caring for others.
that moral development continuous 3. Caring for self and others.
throughout life. He believed that if She believed the human see morality in
the conflicts of each psychosocial the integrity of relationships and
developmental stages favorably caring. For women, what is right is taking
resolved, then an ego-strength or responsibility for others as self-chosen
virtue emerges. decision. On the other hand, men
3. Kohlberg consider what is right to be what is
Suggested three levels of moral just.
development. He focused on the
reason for the making of a decision, Spiritual Theories
not on the morality of the decision 1. Fowler (1979)
itself. Described the development of faith. He
1. At first level called the premolar or the believed that faith, or the spiritual
preconventional level, children are dimension is a force that gives meaning to
responsive to cultural rules and labels of a persons life.
good and bad, right and wrong. However He used the term faith as a form of
children interpret these in terms of the knowing a way of being in relation to an
physical consequences of the actions, i.e., ultimate environment. To Fowler, faith is
punishment or reward. a relational phenomenon: it is an active
2. At the second level, the conventional made-of-being-in-relation to others in
level, the individual is concerned about which we invest commitment, belief, love,
maintaining the expectations of the family, risk and hope.
groups or nation and sees this as right.
3. At the third level, people make 2. Westerhof
postconventional, autonomous, or principal Proposed that faith is a way of behaving.
level. At this level, people make an effort to He developed a four-stage theory of faith
define valid values and principles without development based largely on his life
regard to outside authority or to the experiences and the interpretation of those
expectations of others. These involve experienced.
respect for other human and belief that
relationships are based on mutual ROLES AND FUNCTIONS OF THE NURSE
trust. Care giver
4. Peter (1981) Decision-maker
Proposed a concept of rational Protector
morality based on principles. Client Advocate
Moral development is usually Manager
considered to involve three separate Rehabilitator
components: moral emotion (what Comforter
one feels), moral judgment (how one Communicator
reasons), and moral behavior (how Teacher
one acts). Counselor
In addition, Peters believed that the Coordinator
development of character traits or Leader
virtues is an essential aspect or Role Model
moral development. And that Administrator
virtues or character traits can be
learned from others and encouraged Selected Expanded Career Roles of
by the example of others. Nurses
Also, Peters believed that some can 1. Nurse Practitioner
be described as habits because they A nurse who has an advanced
are in some sense automatic and education and is a graduate of a
therefore are performed habitually, nurse practitioner program.
such as politeness, chastity, tidiness, These nurses are in areas as adult
thrift and honesty. nurse practitioner, family nurse
5. Gilligan (1982)
 practitioner, school nurse A nurse who usually has an advanced
practitioner, pediatric nurse degree and manages a health-related
practitioner, or gerontology nurse business.
practitioner. The nurse may be involved in education,
They are employed in health care consultation, or research, for example.
agencies or community based
settings. They usually deal with non- Nursing Process
emergency acute or chronic illness A deliberate, problem-solving approach to meeting the
and provide primary ambulatory health care & nursing needs of patients -Sandra
care. Nettina
2. Clinical Nurse Specialist The most efficient way to accomplish
A nurse who has an advanced degree or personalized care in a time of exploding
expertise and is considered to be an expert knowledge and rapid social change. It assists in
in a specialized area of practice (e.g., solving or alleviating both simple and complex
nursing problems. Changing, expanding, more
gerontology, oncology).
responsible role demands knowledgeably
The nurse provides direct client care, planned, purposeful, and accountable action by
educates others, consults, conducts nurses
research, and manages care. Steps in the Nursing Process (ADPIE)
The American Nurses Credentialing Center 1. Assessment : Collection of personal, social,
provides national certification of clinical medical, and general data
specialists. a. Sources: Primary (client and diagnostic test
results) and secondary (family, colleagues,
3. Nurse Anesthetist Kardex, literature)
A nurse who has completed advanced b. Methods
education in an accredited program in Interviewing formally (nursing health
anesthesiology. history) and informally during various
The nurse anesthetist carries out pre- nurse-client interactions
operative visits and assessments, and Observation
Administers general anesthetics for surgery Review of records
under the supervision of a physician Performing a physical assessment
prepared in anesthesiology. 2. Nursing Diagnosis : Definition of client's
The nurse anesthetist also assesses the problem: making a nursing diagnosis
postoperative of clients A nursing diagnosis is a definitive
statement of the client's actual or
4. Nurse Midwife potential difficulties, concerns, or deficits
An RN who has completed a program in that are amenable to nursing interventions
midwifery. .
The nurse gives pre-natal and post-natal This step is to organize, analyze and
care and manages deliveries in normal summarize the collected data. There are
pregnancies. two components to the statement of a
nursing diagnosis joined together by the
The midwife practices the association with a phrase "related to"
health care agency and can obtain medical Part I: a determination of the problem
services if complication occurs. (unhealthful response of client)
The nurse midwife may also conduct routine Part II: identification of the etiology
Papanicolaou smears, family planning, and (contributing factors)
routine breast examination. 3. Planning: the nursing care plan, a blueprint
5. Nurse Educator for action remembering client is the center of the
Nurse educator is employed in nursing health team; client, family, and nurse collaborate
programs, at educational institutions, and in with appropriate health team members to
hospital staff education. formulate the plan
The nurse educator usually ha a The nursing care plan is formulated.
baccalaureate degree or more advanced Steps in planning include:
preparation and frequently has expertise in Assigning priorities to nursing Dx.
a particular area of practice. The nurse Specifying goals
educator is responsible for classroom Identifying interventions
and clinical teaching. Specifying expected outcomes
6. Nurse Entrepreneur Documenting the nursing care plan
IDENTIFY GOALS
 GOALS are general statements that direct 4. FEEDBACK is the message returned by
nursing interventions, provide broad the receiver. It indicates whether the
parameters for measuring results and meaning of the senders message was
stimulate motivation. understood.
LONG term goal - one that will take time to Modes of Communication
achieve 1. Verbal Communication use of spoken
SHORT term goal - can be achieved or written words.
relatively quick 2. Nonverbal Communication use of
GOALS should be: (S M A R T) gestures, facial expressions, posture/gait,
Patient centered, Specific (measurable) body movements, physical appearance
Realistic, Achievable within a time frame and body language
4. IMPLEMENTATION Characteristics of Good Communication
Actions that you take in the care of your client. 1. Simplicity includes uses of commonly
- Implementation includes: understood, brevity, and completeness.
Assisting in the performance in ADLs 2. Clarity involves saying what is meant.
Counseling and educating the patient and The nurse should also need to speak
family slowly and enunciate words well.
Giving care to patients 3. Timing and Relevance requires choice
Supervising and evaluating the work of of appropriate time and consideration of
other members of the health team the clients interest and concerns. Ask one
5. EVALUATION question at a time and wait for an answer
Final step of the nursing process before making another comment.
Measures the patients response to nursing 4. Characteristics of Good Communication
intervention 5. Adaptability Involves adjustments on
it indicates the patients progress what the nurse says and how it is said
toward achieving the goals established depending on the moods and behavior of
in the care plan. the client.
It is the comparison of the observed 6. Credibility Means worthiness of belief.
results to expected outcomes. To become credible, the nurse requires
adequate knowledge about the topic being
discussed. The nurse should be able to
COMMUNICATION IN NURSING provide accurate information, to convey
COMMUNICATION confidence and certainly in what she says.
Refers to reciprocal exchange of information, Communicating With Clients Who
ideas, beliefs, feelings and attitudes between 2 Have Special Needs
persons or among a group.
The need to communicate is universal. People
1.Clients who cannot speak clearly
communicate to satisfy needs. (aphasia, dysarthria, muteness)
Clear and accurate communication among 1. Listen attentively, be patient, and do not
members of the health team, including the client, interrupt.
is vital to support the client's welfare 2. Ask simple question that require yes and
Is the means to establish a helping-healing no answers.
relationships 3. Allow time for understanding and
Communication is essential to the nurse- response.
patient relationship for the following 4. Use visual cues (e.g., words, pictures, and
reasons: objects)
Is the vehicle for establishing a 5. Allow only one person to speak at a time.
therapeutic relationship 6. Do not shout or speak too loudly.
It the means by which an individual 7. Use communication aid:
influences the behavior of another, -pad and felt-tipped pen, magic slate,
which leads to the successful outcome of pictures denoting basic needs, call bells or alarm.
nursing intervention. 2. Clients who are cognitively impaired
Basic Elements of the Communication Process 1. Reduce environmental distractions while
1. SENDER is the person who encodes and conversing.
delivers the message 2. Get clients attention prior to speaking
2. MESSAGES is the content of the 3. Use simple sentences and avoid long
communication. It may contain verbal, explanation.
nonverbal, and symbolic language. 4. Ask one question at a time
3. RECEIVER is the person who receives the 5. Allow time for client to respond
decodes the message. 6. Be an attentive listener
 7. Include family and friends in conversations, 6. Effective documentation ensures
especially in subjects known to client. continuity of care saves time and
3. Client who are unresponsive minimizes the risk of error.
1. Call client by name during interactions 7. As members of the health care team,
2. Communicate both verbally and by touch nurses need to communicate information
3. Speak to client as though he or she could about clients accurately and in timely
hear manner
4. Explain all procedures and sensations 8. If the care plan is not communicated to all
5. Provide orientation to person, place, and members of the health care team, care
time can become fragmented, repetition of
6. Avoid talking about client to others in his or tasks occurs, and therapies may be
her presence delayed or omitted.
7. Avoid saying things client should not hear 9. Data recorded, reported, or c0mmunicated
4. Communicating with hearing impaired to other health care professionals are
client CONFIDENTIAL and must be protected.
1. Establish a method of communication CONFIDENTIALITY
(pen/pencil and paper, sign-language) 1. Nurses are legally and ethically obligated
2. Pay attention to clients non-verbal cues to keep information about clients
3. Decrease background noise such as confidential.
television 2. Nurses may not discuss a clients
4. Always face the client when speaking examination, observation, conversation, or
5. It is also important to check the family as to treatment with other clients or staff not
how to communicate with the client involved in the clients care.
6. It may be necessary to contact the 3. Only staf directly involved in a
appropriate department resource person for specific clients care have legitimate
this type of disability access to the record.
4. Client who do not speak English 4. Clients frequently request copies of their
1. Speak to client in normal tone of voice medical record, and they have the right to
(shouting may be interpreted as anger) read those records.
2. Establish method for client o signal desire to 5. Nurses are responsible for protecting
communicate (call light or bell) records from all unauthorized readers.
3. Provide an interpreter (translator) as needed 6. When nurses and other health care
4. Avoid using family members, especially professionals have a legitimate reason to
children, as interpreters. use records for data gathering, research,
5. Develop communication board, pictures or or continuing education, appropriate
cards. authorization must be obtained according
6. Have dictionary (English/Spanish) available to agency policy.
if client can read. 7. Maintaining confidentiality is an important
Reports aspect of profession behavior.
8. It is essential that the nurse safe-guard
Are oral, written, or audiotape exchanges of
the client right to privacy by carefully
information between caregivers.
protecting information of a sensitive,
Common reports:
private nature.
1. Change-in-shift report
9. Sharing personal information or gossiping
2. Telephone report
about others violates nursing ethical codes
3. Telephone or verbal order only RNs are
and practice standards.
allowed to accept telephone orders.
10. It sends the message that the nurse
4. Transfer report
cannot be trusted and damages the
5. Incident report
interpersonal relationships.
Documentation
Guidelines of Quality Documentation and
1. Is anything written or printed that is relied
Reporting
on as record or proof for authorized person.
1.Factual
2. Nursing documentation must be:
a record must contain descriptive, objective
3. accurate
information about what a nurse sees, hears,
4. comprehensive
feels, and smells.
5. flexible enough to retrieve critical data,
The use of vague terms, such as appears,
maintain continuity of care, track client
seems, and apparently, is not acceptable
outcomes, and reflects current standards of
because these words suggests that the nurse
nursing practice
is stating an opinion.
 Example: the client seems anxious (the Black ink is more legible when records
phrase seems anxious is a conclusion are photocopied or transferred to
without supported facts.) microfilm.
2. Accurate 9. If order is questioned, record that clarification
The use of exact measurements establishes was sought.
accuracy. (example: Intake of 350 ml of If you perform orders known to be
water is more accurate than the client incorrect, you are just as liable for
drank an adequate amount of fluid prosecution as the physician is.
Documentation of concise data is clear and 10. Chart only for yourself
easy to understand. Never chart for someone else.
It is essential to avoid the use of You are accountable for information
unnecessary words and irrelevant details you enter into chart.
3. Complete 11. Avoid using generalized, empty phrases such
1. The information within a recorded entry or a as status unchanged or had good day.
report needs to be complete, containing 12. Begin each entry with time, and end with your
appropriate and essential information. signature and title.
Example: 13. Do not wait until end of shift to record
The client verbalizes sharp, important changes that occurred several
throbbing pain localized along lateral hours earlier. Be sure to sign each entry.
side of right ankle, beginning 14. For computer documentation keep your
approximately 15 minutes ago after password to yourself.
twisting his foot on the stair. Client Maintain security and confidentiality.
rates pain as 8 on a scale of 0-10. Once logged into the computer do not
4. Current leave the computer screen unattended.
1. Timely entries are essential in the clients Vital Signs
ongoing care. To increase accuracy and Vital Signs or Cardinal Signs are:
decrease unnecessary duplication, many Body temperature
healthcare agencies use records kept near the Pulse
clients bedside, which facilitate immediate Respiration
documentation of information as it is collected Blood pressure
from a client Pain
I. Body Temperature
The balance between the heat
5. Organized produced by the body and the heat loss
1. The nurse communicates information in a from the body.
logical order. Types of Body Temperature
For example, an organized note Core temperature temperature of
describes the clients pain, nurses the deep tissues of the body.
assessment, nurses interventions, and Surface body temperature
the clients response Alteration in body Temperature
Legal Guidelines for recording Pyrexia Body temperature above
1. Draw single line through error, write word error normal range ( hyperthermia)
above it and sign your name or initials. Then record Hyperpyrexia Very high fever,
note correctly. 41C(105.8 F) and above
2. Do not write retaliatory or critical comments Hypothermia Subnormal temperature.
about the client or care by other health care Normal Adult Temperature Ranges
professionals. Oral 36.5 37.5 C
3. Enter only objective descriptions of clients Axillary 35.8 37.0 C
behavior; clients comments should be quoted. Rectal 37.0 38.1 C
4. Correct all errors promptly, errors in recording Tympanic 36.8 37.9C
can lead to errors in treatment
5. Avoid rushing to complete charting, be sure Methods of Temperature-Taking
information is accurate. Oral most accessible and convenient method.
6. Do not leave blank spaces in nurses notes. 1. Put on gloves, and position the tip of the
7. Chart consecutively, line by line; if space is left, thermometer under the patients tongue
draw line horizontally through it and sign your on either of the frenulum as far back as
name at end. possible. It promotes contact to the
8. Record all entries legibly and in black ink superficial blood vessels and ensures a
Never use pencil, felt pen. more accurate reading.
2. Wash thermometer before use.
 3. Take oral temp 2-3 minutes. b. Assess skin color and temperature
4. Allow 15 min to elapse between clients food c. Monitor WBC, Hct and other pertinent lab
intakes of hot or cold food, smoking. records
5. Instruct the patient to close his lips but not d. Provide adequate foods and fluids.
to bite down with his teeth to avoid breaking e. Promote rest
the thermometer in his mouth. f. Monitor I & O
Contraindications g. Provide TSB
Young children an infants h. Provide dry clothing and linens
Patients who are unconscious or disoriented i. Give antipyretic as ordered by MD
Who must breath through the mouth
Seizure prone II. Pulse Its the wave of blood created by
Patient with N/V contractions of the left ventricles of the
Patients with oral lesions/surgeries heart.
Normal Pulse rate
2. Rectal- most accurate measurement of 1 year 80-140 beats/min
temperature 2 years 80- 130 beats/min
a. Position- lateral position with his top legs flexed 6 years 75- 120 beats/min
and drapes him to provide privacy. 10 years 60-90 beats/min
b. Squeeze the lubricant onto a facial tissue to Adult 60-100 beats/min
avoid contaminating the lubricant supply.
c. Insert thermometer by 0.5 1.5 inches Tachycardia pulse rate of above 100 beats/min
d. Hold in place in 2minutes Bradycardia- pulse rate below 60 beats/min
e. Do not force to insert the thermometer Irregular uneven time interval between
Contraindications beats.
Patient with diarrhea What you need:
Recent rectal or prostatic surgery or injury a. Watch with second hand
because it may injure inflamed tissue b. Stethoscope (for apical pulse)
Recent myocardial infarction c. Doppler ultrasound blood flow detector if
Patient post head injury necessary
Radial Pulse
3. Axillary safest and non-invasive Wash your hand and tell your client that
a. Pat the axilla dry you are going to take his pulse
b. Ask the patient to reach across his chest and Place the client in sitting or supine
grasp his opposite shoulder. This promote skin position
contact with the thermometer with his arm on his side or across his chest
c. Hold it in place for 9 minutes because the Gently press your index, middle, and ring
thermometer isnt close in a body cavity fingers on the radial artery, inside the
4. Tympanic thermometer patients wrist.
a. Make sure the lens under the probe is clean Excessive pressure may obstruct blood
and shiny flow distal to the pulse site
b. Stabilized the patients head; gently pull the ear Counting for a full minute provides a more
straight back (for children up to age 1) or up accurate picture of irregularities
and back (for children 1 and older to adults) Doppler device
c. Insert the thermometer until the entire ear a. Apply small amount of transmission gel to
canal is sealed the ultrasound probe
d. Place the activation button, and hold it in place b. Position the probe on the skin directly over
for 1 second a selected artery
5. Chemical-dot thermometer c. Set the volume to the lowest setting
a. Leave the chemical-dot thermometer in place d. To obtain best signals, put gel between the
for 45 seconds skin and the probe and tilt the probe 45
b. Read the temperature as the last dye dot that degrees from the artery.
has change color, or fired. e. After you have measure the pulse rate,
c. Store chemical-dot thermometer in a cool area clean the probe with soft cloth soaked in
because exposure to heat activates the dye antiseptic. Do not immerse the probe
dots. III. Respiration - is the exchange of oxygen and
Note: carbon dioxide between the atmosphere
Use the same thermometer for repeat and the body
temperature taking to ensure more consistent Assessing Respiration
result Rate Normal 14-20/ min in adult
Nursing Interventions in Clients with Fever The best time to assess respiration is
a. Monitor V.S immediately after taking clients pulse
 Count respiration for 60 second 1. Giving medication as per MDs order
As you count the respiration, assess and record 2. Giving emotional support
breath sound as stridor, wheezing, or stertor. 3. Performing comfort measures
Respiratory rates of less than 10 or more than 4. Use cognitive therapy
40 are usually considered abnormal and should Height and weight
be reported immediately to the physician. a. Height and weight are routinely measured
IV. Blood Pressure when a patient is admitted to a health care
Adult 90- 132 systolic facility.
60- 85 diastolic b. It is essential in calculating drug dosage,
Elderly 140-160 systolic contrast agents, assessing nutritional status
70-90 diastolic and determining the height-weight ratio.
a. Ensure that the client is rested c. Weight is the best overall indicator of fluid
b. Use appropriate size of BP cuff. status, daily monitoring is important for
c. If the b/p cuff is narrow an loosely applied- clients receiving a diuretics or a medication
false high BP that causes sodium retention.
d. Position the patient on sitting or supine d. Weight can be measured with a standing
position scale, chair scale and bed scale.
e. Position the arm at the level of the heart, if e. Height can be measured with the measuring
the artery is below the heart level, you may bar, standing scale or tape measure if the
get a false high reading client is confine in a supine position.
f. Use the bell of the stethoscope since the Pointers:
blood pressure is a low frequency sound. a. Reassure and steady patient who are at
g. If the client is crying or anxious, delay risk for losing their balance on a scale.
measuring his blood pressure to avoid false- b. Weight the patient at the same time each
high BP day. (Usually before breakfast), in similar
Electronic Vital Sign Monitor clothing and using the same scale.
a. An electronic vital signs monitor allows you c. If the patient uses crutches, weigh the
to continually tract a patients vital client with the crutches or heavy clothing
sign without having to reapply a blood and subtract their weight from the total
pressure cuff each time. determined patient weight.
b. Example: Dinamap VS monitor 8100 Laboratory and Diagnostic
c. Lightweight, battery operated and can be examination
attached to an IV pole Urine Specimen
d. Before using the device, check the client7s 1.Clean-Catch mid-stream urine specimen for
pulse and BP manually using the same arm routine urinalysis, culture and sensitivity test
youll using for the monitor cuff. a. Best time to collect is in the morning, first
e. Compare the result with the initial reading voided urine
from the monitor. If the results differ call the b. Provide sterile container
supply department or the manufacturers c. Do perineal care before collection of the
representative. urine
V. Pain d. Discard the first flow of urine
How to assess Pain e. Label the specimen properly
a. You must consider both the patients f. Send the specimen immediately to the
description and your observations on his laboratory
behavioral responses. g. Document the time of specimen collection
b. First, ask the client to rank his pain on a and transport to the lab.
scale of 0-10, with 0 denoting lack of pain h. Document the appearance, odor, and
and 10 denoting the worst pain imaginable. usual characteristics of the specimen.
Ask: 2. 24-hour urine specimen
c. Where is the pain located? a. Discard the first voided urine.
d. How long does the pain last? b. Collect all specimen thereafter until the
e. How often does it occur? following day
f. Can you describe the pain? c. Soak the specimen in a container with ice
g. What makes the pain worse d. Add preservative as ordered according to
h. Observe the patients behavioral response hospital policy
to pain (body language, moaning, 3. Second-Voided urine required to assess
grimacing, withdrawal, crying, restlessness glucose level and for the presence of albumen in
muscle twitching and immobility) the urine.
i. Also note physiological response, which may a. Discard the first urine
be sympathetic or parasympathetic b. Give the patient a glass of water to drink
Managing Pain
 c. After few minutes, ask the patient to void d. Dont wipe off the povidine-iodine with
4. Catheterized urine specimen alcohol because alcohol cancels the effect
a. Clamp the catheter for 30 min to 1 hour to of povidine iodine.
allow urine to accumulate in the bladder e. If the patient has a clotting disorder or is
and adequate specimen can be collected. receiving anticoagulant therapy, maintain
b. Clamping the drainage tube and emptying pressure on the site for at least 5 min after
the urine into a container are withdrawing the needle.
contraindicated after a genitourinary Arterial puncture for ABG test
surgery. a. Before arterial puncture, perform Allens
II. Stool Specimen test first.
1. Fecalysis to assess gross appearance of stool b. If the patient is receiving oxygen, make
and presence of ova or parasite sure that the patients therapy has been
a. Secure a sterile specimen container underway for at least 15 min before
b. Ask the pt. to defecate into a clean, dry bed collecting arterial sample
pan or a portable commode. c. Be sure to indicate on the laboratory
c. Instruct client not to contaminate the request slip the amount and type pf
specimen with urine or toilet paper( urine oxygen therapy the patient is having.
inhibits bacterial growth and paper towel d. If the patient has just received a nebulizer
contain bismuth which interfere with the treatment, wait about 20 minutes before
test result. collecting the sample.
2. Stool culture and sensitivity test III. Blood specimen
To assess specific etiologic agent causing a. No fasting for the following tests:
gastroenteritis and bacterial sensitivity to various - CBC, Hgb, Hct, clotting studies, enzyme
antibiotics. studies, serum electrolytes, HbA1C
3. Fecal Occult blood test b. Fasting is required:
are valuable test for detecting occult blood - FBS, BUN, Creatinine, serum lipid
(hidden) which may be present in colo-rectal (cholesterol, triglyceride), blood uric acid
cancer, detecting melena stool IV. Sputum Specimen
Instructions: 1. Gross appearance of the sputum
a. Advise client to avoid ingestion of red meat for a. Collect early in the morning
3 days b. Use sterile container
b. Patient is advise on a high residue diet c. Rinse the mount with plain water before
c. avoid dark food and bismuth compound collection of the specimen
d. If client is on iron therapy, inform the MD d. Instruct the patient to hack-up sputum
e. Make sure the stool in not contaminated with e. Send the specimen immediately
urine, soap solution or toilet paper 2. Sputum culture and sensitivity test
f. Test sample from several portion of the stool. a. Use sterile container
Venipuncture b. Collect specimen before the first dose of
Venipuncture involves piercing a vein with a antibiotic
needle and collecting a blood sample in a 3. Acid-Fast Bacilli
syringe or evacuating tube. a. To assess presence of active pulmonary
Typically using the antecubital fossa tuberculosis
A plebhotomist from the laboratory usually b. Collect sputum in three consecutive
perform the procedure. morning
Strict asepsis to prevent infection. 4. Cytologic sputum exam-
If client has clotting disorder or under -to assess for presence of abnormal or cancer
anticoagulant therapy, apply pressure on the cells.
site for 5 minutes to prevent hematoma Collect sputum in three consecutive morning
formation Diagnostic Test
Pointers 1. PPD test
a. Never collect a venous sample from the arm read result 48 72 hours after injection.
or a leg that is already being use d for I.V For HIV positive clients, induration of 5 mm is
therapy or blood administration because it considered positive
mat affect the result. Induration of more than 10 for non-HIV client
b. Never collect venous sample from an is considered positive
infectious site because it may introduce
pathogens into the vascular system
2. Bronchography
c. Never collect blood from an edematous a radiopaque medium is instilled directly
area, AV shunt, site of previous hematoma, into the trachea and bronchi through
or vascular injury. bronchoscope and the entire bronchi tree
 or selected areas may be visualized through Lower than 85% - hypo-oxygenation
X-ray. Lower than 70% - life-threatening
Secure consent situation
Check for allergies to seafood or iodine or 7.Holter Monitor
anesthesia it is continuous ECG monitoring, over 24
NPO 6-8 hours before the test hours period
NPO until gag reflex return to prevent The portable monitoring is called
aspiration telemetry unit
3. BRONCHOSCOPY Avoid magnets, metal detectors, high-
direct visualization of the larynx, trachea and voltage areas, and electric blankets.
bronchi through a flexible fiber-optic bronchoscope Stress the importance of logging his usual
Informed consent activities, emotional upset, fatigue, chest
NPO 6-12 hrs prior to test pain, and ingestion of medication
Coagulation studies
Remove dentures or eyeglasses 8. Echocardiogram
IV Sedatives to relax the client ultrasound to assess cardiac structure and
Lidocaine spray to suppress the gag reflex mobility
Resuscitation equipment available Client should remain still, in supine
POST-PROCEDURE NURSING CARE position slightly turned to the left side,
V/S with HOB elevated 15-20 degrees
Fowlers The conductive gel is applied to the to the
Check gag reflex left of the sternum, third or fourth
NPO until gag reflex return intercostal space
Monitor for bloody sputum The test takes about 30-45 minutes
Monitor respiration 9. Electrocardiography-
Monitor for complications a. If the patients skin is oily, scaly, or
Notify the MD if complications occur diaphoretic, rub the electrode with a dry
4. Thoracentesis aspiration of fluid in the 4x4 gauze to enhance electrode contact.
pleural space. b. If the area is excessively hairy, clip it
a. Secure consent, take V/S c. Remove clients jewelry, coins, belt or any
b. Position upright leaning on overbed table metal
c. Avoid cough during insertion to prevent pleural d. Tell client to remain still during the
perforation procedure
d. Turn to unaffected side after the procedure to 10. Cardiac Catheterization
prevent leakage of fluid in the thoracic cavity Secure consent
e. Check for expectoration of blood. This indicate Assess allergy to iodine, shellfish
trauma and should be reported to MD V/S, weight for baseline information
immediately. Have client void before the procedure
5. LUNG BIOPSY Monitor PT, PTT, ECG prior to test
PRE-PROCEDURE NURSING CARE NPO for 4-6 hours before the test
Secure consent Shave the groin or brachial area
Check coagulation After the procedure: bed rest to prevent
Have vit K at bedside bleeding on the site, do not flex extremity
Maintain sterile technique Elevate the affected extremities on
Local anesthetic required extended position to promote blood supply
Pressure during insertion and aspiration back to the heart and prevent
Administer analgesics & sedatives as Rx thromboplebitis
POST-PROCEDURE NURSING CARE Monitor V/S especially peripheral pulses
Pressure dressing to prevent bleeding Apply pressure dressing over the puncture
Monitor for bleeding site
Monitor for respiratory distress Monitor extremity for color, temperature,
Monitor for complications tingling to assess for impaired circulation.
Prepare for CXR 11. MRI
6. PULSE OXIMETRY secure consent,
- NORMAL VALUE: 95%-100% the procedure will last 45-60 minute
A sensor is placed: finger, toe, nose, Assess client for claustrophobia
earlobe or forehead Remove all metal items
Dont select an extremity with an Client should remain still
impediment to blood flow Tell client that he will feel nothing but may
Lower than 91% - immediate treatment hear noises
 Client with pacemaker, prosthetic valves, h. Position:
implanted clips, wires are not eligible for sitting on a chair with feet
MRI. supported with footstool or
Client with cardiac and respiratory Place in high Fowlers position
complication may be excluded i. Strict aseptic technique to prevent
Instruct client on feeling of warmth or peritonitis
shortness of breath if contrast medium is j. Local anesthetic is injected
used during the procedure k. The procedure takes about 45 minutes
Tattoo pigments (body arts), eyeliner, l. Monitor urine output for 24 hours as watch
eyebrow or lip liner may contain metals out for hematuria which may indicate
which create an electrical current that can bladder trauma.
cause redness and swelling to a first degree 16. Lumbar Puncture
burn at the site of the tattoo. a. obtain consent
12.UGIS Barium Swallow b. instruct client to empty the bladder and
instruct client on low-residue diet 1-3 days bowel
before the procedure c. position the client in lateral recumbent
administer laxative evening before the with back at the edge of the examining
procedure table
NPO after midnight d. instruct client to remain still
instruct client to drink a cup of flavored barium e. Spinal needle in inserted in the midline
x-rays are taken every 30 minutes until barium between the spinous process between the
advances through the small bowel 3rd and 4th lumbar vertebrae
film can be taken as long as 24 hours later f. Using 18G or 20G in adult, 22G in children
force fluid after the test to prevent g. obtain specimen per MDs order
constipation/barium impaction Post procedure
13.LGIS Barium Enema instruct client to remain still during needle
instruct client on low-residue diet 1-3 days insertion to prevent trauma on the spinal cord
before the procedure Instruct the client to remain in flat position for
administer laxative evening before the 8 hours to prevent spinal headache
procedure obtain specimen per MDs order
NPO after midnight Headache is the most common adverse
administer suppository in AM effects of a lumbar puncture..
Enema until clear Mgt. for spinal headache
force fluid after the test to prevent Bed rest
constipation/barium impaction Place patient in dark and quiet room
14. Liver Biopsy Administer analgesics
a. Secure consent, Fluids
b. NPO 2-4 hrs before the test note:
c. Monitor PT, Vit K at bedside If the headache continues, epidural patch maybe
d. Place the client in supine at the right side of required. Blood is withdrawn from the clients
the bed vein and injected into the epidural space, usually
e. Instruct client to inhale and exhale deeply at the LP site.
for several times and then exhale and hold 17.Queckenstedts Test
breath while the MD insert the needle Lumbar manometric test
f. Right lateral post procedure for 4 hours to Compressing the jugular vein on each side
apply pressure and prevent bleeding of the neck during the lumbar puncture.
g. Bed rest for 24 hours The increase in pressure caused by the
h. Observe for S/S of peritonitis compression is noted; then pressure is
15. Paracentesis released and pressure reading are made
a. Secure consent at a 10-seconds intervals.
b. check V/S Normally CSF pressure rises rapidly in
c. Weigh the client before and after the response to compression of the jugular
procedure vein and returns quickly to normal when
d. Measure abdominal girth before the the compression is released.
procedure A slow rise and fall in pressure indicates a
e. Let the patient void before the procedure to partial block due to a lesion compressing
prevent puncture of the bladder the spinal subarachnoid pathways.
f. Use gauge 18 trochar or cannula If there is no pressure change, a complete
g. Check for serum protein. Excessive loss of bloc is indicated.
plasma protein may lead to hypovolemic This test is not performed if an intracranial
shock. lesion is suspected.
 May skew fluid & electrolyte balance,
NURSING PROCEDURES especially potassium & sodium
1. Steam Inhalation Digestive enzymes in stool irritate skin
a. It is dependent nursing function. Do NOT give laxatives
b. Heat application requires physicians order. Ileostomy lavage may be done if needed
c. Place the spout 12-18 inches away from the to clear food blockage
clients nose or adjust the distance as May not require appliance set; if continent
necessary. ileal reservoir or Koch pouch
2. Suctioning b. Colostomy
a. Assess the lungs before the procedure for Ascending-must wear appliance--semi-
baseline information. liquid stool
b. Position: conscious semi-Fowlers Transverse-wear appliance--semi-formed
c. Unconscious lateral position stool
d. Size of suction catheter- adult- fr 12-18 Loop stoma
e. Hyper oxygenate before and after procedure Proximal end-functioning stoma
f. Observe sterile technique Distal end-drains mucous
g. Apply suction during withdrawal of the Plastic rod used to keep loop out
catheter Usually temporary
h. Maximum time per suctioning 15 sec
3. Nasogastric Feeding (gastric gavage)
Double barrel
Two stomas
Insertion:
Similar to loop but bowel is surgically
a. Fowlers position
severed
b. Tip of the nose to tip of the earlobe to the
xyphoid Sigmoid
Tube Feeding Formed stool
a. Semi-Fowlers position Bowel can be regulated so appliance not
b. Assess tube placement needed
c. Assess residual feeding May be irrigated
d. Height of feeding is 12 inches above the
tubes point of insertion Stoma assessment
e. Ask client to remain upright position for at a. Color-should be same color as mucous
least 30 min. membranes
f. Most common problem of tube feeding is (Normal stoma color- Red not dusky or pale: sign
Diarrhea due to lactose intolerance of infection)
4. Enema b. Edema-common after surgery. Bleeding-slight
a. Check MDs order bleeding common after surgery
b. Provide privacy
c. Position left lateral 6. COLOSTOMY IRRIGATION
d. Size of tube Fr. 22-32 Initial colostomy irrigation is done to stimulate
e. Insert 3-4 inches of rectal tube peristalsis; subsequent irrigations are done to
f. If abdominal cramps occur, temporarily stop promote evacuation of feces at a regular and
the flow until cramps are gone. convenient time
g. Height of enema can 18 inches Recommended with sigmoid colostomy
5. Urinary Catheterization Initiated 5 to 7 days postop
a. Verify MDs order
b. Practice strict asepsis Done in semi Fowlers position; then sitting
c. Perineal care before the procedure on a toilet bowl once ambulatory.
d. Catheter size: male-14-16 , female 12 14 Use warm normal saline solution
e. Length of catheter insertion Initially, introduce 200 mls. of NSS then 500 to
male 6-9 inches ,female 3-4 inches 1,000 mls. Subsequently
For retention catheter: Dilate stoma with lubricated gloved finger
Male anchor laterally or upward over the before insertion of catheter
lower abdomen to prevent penoscrotal Lubricate catheter before insertion.
pressure Insert 3 to 4 inches of the catheter into the
Female- inner aspect of the thigh stoma
Height of solution 12 inches above the
Types of ostomies stoma
a. Ileostomy If abdominal cramps occur during
Liquid to semi-formed stool, dependent introduction of solution, temporarily stop
upon amount of bowel removed the flow of solution until peristalsis
relaxes.
 Allow the catheter to remain in place for 5 The nurse does this 3 times:
to 10 minutes for better cleansing effect; a. Before removing the container from the
then remove catheter to drain for 15 to 20 drawer or shelf
minutes. b. As the amount of medication ordered is
Clean the stoma, apply new pouch removed from the container
c. Before returning the container to the
7 . Bed Bath storage
a. Provide privacy 2. Right Dose when performing medication
b. Expose, wash and dry one body part a time calculation or conversions, the nurse should have
c. Use warm water (110-115 F) another
d. Wash from cleanest to dirtiest qualified nurse check the
e. Wash, rinse, and dry the arms and leg using calculated dose
Long, firm strokes from distal to proximal 3. Right Client an important step in
area to increase venous return. administering medication safely is being sure the
8. Foot Care medication is given to the right client.
a. Soaking the feet of diabetic client is no a. To identify the client correctly:
longer recommended b. The nurse check the medication
b. Cut nail straight across administration form against the clients
9. Mouth Care identification bracelet and asks the
a. Eat coarse, fibrous foods (cleansing foods) client to state his or her name to
such as fresh fruits and raw vegetables ensure the clients identification bracelet
b. Dental check every 6 mounts has the correct information.
10. Oral care for unconscious client 4. RIGHT ROUTE if a prescribers order does
a. Place in side lying position not designate a route of administration, the nurse
b. Have the suction apparatus readily available consult the prescriber. Likewise, if the specified
11. Hair Shampoo route is not recommended, the nurse should alert
c. Place client diagonally in bed the prescriber immediately.
d. Cover the eyes with wash cloth 5. RIGHT TIME
e. Plug the ears with cotton balls a. the nurse must know why a medication is
f. Massage the scalp with the fatpads of the ordered for certain times of the day and whether
fingers to promote circulation in the scalp. time schedule can be altered
11. Restraints b. each institution has are commended time
Secure MDs order for each episode of schedule for medications ordered at frequent
restraints application. interval
Check circulation every 15 min c. Medication that must act at certain times are
Remove restraints at least every 2 hours for given priority (e.g insulin should be given at a
30 minutes precise interval before a meal )
Types of Restraints
Chemical sedating antipsychotic drugs to 6. RIGHT DOCUMENTATION Documentation is
manage or control behavior an important part of safe medication
Physical direct application of physical force administration
to a client, with or without the clients a. The documentation for the medication
permission. should clearly reflect the clients name,
Seclusion involuntary confinement of a the name of the ordered medication, the
client in a locked room time, dose, route and frequency
b. Sign medication sheet immediately after
Procedure: administration of the drug
Ensure that face-to face assessment is CLIENTS RIGHT RELATED TO MEDICATION
completed on the client ADMINISTRATION
Ensure that the restraint orders are renewed A client has the following rights:
every 24 hours or sooner according to a. To be informed of the medications name,
hospital policy. purpose, action, and potential undesired
Tie the restraints using clove hitch effects.
Secure the tie in a non-movable part of the b. To refuse a medication regardless of the
bed consequences
c. To have a qualified nurses or physicians
PRINCIPLES OF MEDICATION ADMINISTRATION assess medication history, including
I - Six Rights of drug administration allergies
1. The Right Medication when administering d. To be properly advised of the experimental
medications, the nurse compares the label of the nature of medication therapy and to give
medication container with medication form. written consent for its use
 e. To received labeled medications safely b. Inappropriate for client with nausea and
without discomfort in accordance with the vomiting
six rights of medication administration c. Drug may have unpleasant taste
f. To receive appropriate supportive therapy in d. Drug may discolor the teeth
relation to medication therapy e. Drug may irritate the gastric mucosa
g. To not receive unnecessary medications f. Drug may be aspirated by seriously ill
patient.
II Practice Asepsis wash hand before and Drug Forms for Oral Administration
after preparing the medication to reduce transfer of a. Solid: tablet, capsule, pill, powder
microorganisms. b. Liquid: syrup, suspension, emulsion, elixir,
III Nurse who administer the medications are milk, or other alkaline substances.
responsible for their own action. Question any order c. Syrup: sugar-based liquid medication
that you considered incorrect (may be unclear or d. Suspension: water-based liquid
appropriate) medication. Shake bottle before use of
IV Be knowledgeable about the medication that medication to properly mix it.
you administer e. Emulsion: oil-based liquid medication
f. Elixir: alcohol-based liquid medication.
A FUNDAMENTAL RULE OF SAFE DRUG After administration of elixir, allow 30
ADMINISTRATION IS: NEVER ADMINISTER AN minutes to elapse before giving water.
UNFAMILIAR MEDICATION This allows maximum absorption of the
medication.
V Keep the Narcotics in locked place.
VI Use only medications that are in clearly labeled NEVER CRUSH ENTERIC-COATED OR
containers. Relabelling of drugs are the SUSTAINED RELEASE TABLET
responsibility of the pharmacist. Crushing enteric-coated tablets
VII Return liquid that are cloudy in color to the allows the irrigating medication to come in
pharmacy. contact with the oral or gastric mucosa,
VIII Before administering medication, identify the resulting in mucositis or gastric irritation.
client correctly Crushing sustained-released
IX Do not leave the medication at the bedside. medication allows all the medication to
Stay with the client until he actually takes the be absorbed at the same time, resulting in
medications. a higher than expected initial level of
X The nurse who prepares the drug administers medication and a shorter than expected
it.. Only the nurse prepares the drug knows what duration of action
the drug is. Do not accept endorsement of 2. SUBLINGUAL
medication. a. A drug that is placed under the tongue, where
it dissolves.
XI If the client vomits after taking the medication, b. When the medication is in capsule and
report this to the nurse in-charge or physician. ordered sublingually, the fluid must be
XII Preoperative medications are usually aspirated from the capsule and placed under
discontinued during the postoperative period the tongue.
unless ordered to be continued. c. A medication given by the sublingual route
XIII- When a medication is omitted for any reason, should not be swallowed, or desire effects will
record the fact together with the reason. not be achieved
XIV When the medication error is made, report it Advantages:
immediately to the nurse in-charge or physician. To a. Same as oral
implement necessary measures immediately. This b. Drug is rapidly absorbed in the
may prevent any adverse effects of the drug. bloodstream
Disadvantages
Medication Administration a. If swallowed, drug may be inactivated by
1. Oral administration gastric juices.
Advantages b. Drug must remain under the tongue until
a. The easiest and most desirable way to dissolved and absorbed
administer medication 3. BUCCAL
b. Most convenient a. A medication is held in the mouth against the
c. Safe, does nor break skin barrier mucous membranes of the cheek until the
d. Usually less expensive drug dissolves.
Disadvantages b. The medication should not be chewed,
a. Inappropriate if client cannot swallow and if swallowed, or placed under the tongue (e.g
GIT has reduced motility sustained release nitroglycerine,
opiates,antiemetics, tranquilizer, sedatives)
c. Client should be taught to alternate the cheeks b. Have the client assume a side-lying
with each subsequent dose to avoid mucosal position ( if not contraindicated) with ear
irritation to be treated facing up.
Advantages: c. Perform hand hygiene. Apply gloves if
a. Same as oral drainage is present.
b. Drug can be administered for local effect d. Straighten the ear canal:
c. Ensures greater potency because drug 0-3 years old: pull the pinna downward
directly enters the blood and bypass the and backward
liver Older than 3 years old: pull the pinna
Disadvantages: upward and backward
If swallowed, drug may be inactivated by e. Instill eardrops on the side of the auditory
gastric juice canal to allow the drops to flow in and
4. TOPICAL Application of medication to a continue to adjust to body temperature
circumscribed area of the body. f. Press gently bur firmly a few times on the
1. Dermatologic includes lotions, liniment and tragus of the ear to assist the flow of
ointments, powder. medication into the ear canal.
a. Before application, clean the skin thoroughly by g. Ask the client to remain in side lying
washing the area gently with soap and water, position for about 5 minutes
soaking an involved site, or locally debriding h. At times the MD will order insertion of
tissue. cotton puff into outermost part of the
b. Use surgical asepsis when open wound is canal. Do not press cotton into the canal.
present Remove cotton after 15 minutes.
c. Remove previous application before the next 1. Nasal
application Nasal instillations usually are
d. Use gloves when applying the medication over instilled for their astringent effects
a large surface. (e.g large area of burns) (to shrink swollen mucous
e. Apply only thin layer of medication to prevent membrane),
systemic absorption. to loosen secretions and facilitate
2. Opthalmic - includes instillation and irrigation drainage or to treat infections of
a. Instillation to provide an eye medication the nasal cavity or sinuses.
that the client requires. Decongestants, steroids, calcitonin.
b. Irrigation To clear the eye of noxious or a. Have the client blow the nose prior to
other foreign materials. nasal instillation
c. Position the client either sitting or lying. b. Assume a back lying position, or sit up and
d. Use sterile technique lean head back.
e. Clean the eyelid and eyelashes with sterile c. Elevate the nares slightly by pressing the
cotton balls moistened with sterile normal thumb against the clients tip of the nose.
saline from the inner to the outer canthus While the client inhales, squeeze the
f. Instill eye drops into lower conjunctival sac. bottle.
g. Instill a maximum of 2 drops at a time. Wait d. Keep head tilted backward for 5 minutes
for 5 minutes if additional drops need to be after instillation of nasal drops.
administered. This is for proper absorption e. When the medication is used on a daily
of the medication. basis, alternate nares to prevent irritations
h. Avoid dropping a solution onto the cornea 5. Inhalation use of nebulizer, metered-dose
directly, because it causes discomfort. inhaler
i. Instruct the client to close the eyes gently. a. Semi or high-fowlers position or standing
Shutting the eyes tightly causes spillage of position. To enhance full chest expansion
the medication. allowing deeper inhalation of the
j. For liquid eye medication, press firmly on medication
the nasolacrimal duct (inner cantus) for at b. Shake the canister several times. To mix
least 30 seconds to prevent systemic the medication and ensure uniform
absorption of the medication. dosage delivery
3. Otic c. Position the mouthpiece 1 to 2 inches from
Instillation to remove cerumen or pus or to the clients open mouth. As the client
remove foreign body starts inhaling, press the canister down to
a. Warm the solution at room temperature or release one dose of the medication. This
body temperature, failure to do so may allows delivery of the medication more
cause vertigo, dizziness, nausea and pain. accurately into the bronchial tree rather
than being trapped in the oropharynx then
swallowed
 d. Instruct the client to hold breath for 10 b. Indicated for allergy and tuberculin testing
seconds. To enhance complete absorption of and for vaccinations.
the medication. c. Use the needle gauge 25, 26, 27: needle
e. If bronchodilator, administer a maximum of length 3/8, 5/8 or
2 puffs, for at least 30 second interval. d. Needle at 1015 degree angle; bevel up.
Administer bronchodilator before other e. Inject a small amount of drug slowly over
inhaled medication. This opens airway and 3 to 5 seconds to form a wheal or bleb.
promotes greater absorption of the f. Do not massage the site of injection. To
medication. prevent irritation of the site, and to
f. Wait at least 1 minute before administration prevent absorption of the drug into the
of the second dose or inhalation of a subcutaneous.
different medication by MDI Subcutaneous vaccines, heparin, preoperative
g. Instruct client to rinse mouth, if steroid had medication, insulin, narcotics.
been administered. This is to prevent fungal The site:
infection. outer aspect of the upper arms
6. Vaginal drug forms: tablet liquid (douches). anterior aspect of the thighs
Jelly, foam and suppository. Abdomen
a. Close room or curtain to provide privacy. Scapular areas of the upper back
b. Assist client to lie in dorsal recumbent Ventrogluteal
position to provide easy access and good Dorsogluteal
exposure of vaginal canal, also allows a. Only small doses of medication should be
suppository to dissolve without escaping injected via SC route.
through orifice. b. Rotate site of injection to minimize tissue
c. Use applicator or sterile gloves for vaginal damage.
administration of medications. c. Needle length and gauge are the same as
Vaginal Irrigation is the washing of the vagina for ID injections
by a liquid at low pressure. It is also called douche. d. Use 5/8 needle for adults when the
a. Empty the bladder before the procedure injection is to administer at 45 degree
b. Position the client on her back with the hips angle; is use at a 90 degree angle.
higher than the shoulder (use bedpan) e. For thin patients: 45 degree angle of
c. Irrigating container should be 30 cm (12 needle
inches) above f. For obese patient: 90 degree angle of
d. Ask the client to remain in bed for 5-10 needle
minute following administration of vaginal g. For heparin injection:
suppository, cream, foam, jelly or irrigation. h. do not aspirate.
7. RECTAL can be use when the drug has i. Do not massage the injection site to
objectionable taste or odor. prevent hematoma formation
a. Need to be refrigerated so as not to soften. j. For insulin injection:
b. Apply disposable gloves. k. Do not massage to prevent rapid
c. Have the client lie on left side and ask to absorption which may result to
take slow deep breaths through mouth and hypoglycemic reaction.
relax anal sphincter. l. Always inject insulin at 90 degrees angle
d. Retract buttocks gently through the anus, to administer the medication in the pocket
past internal sphincter and against rectal between the subcutaneous and muscle
wall, 10 cm (4 inches) in adults, 5 cm (2 in) layer. Adjust the length of the needle
in children and infants. May need to apply depending on the size of the client.
gentle pressure to hold buttocks together m. For other medications, aspirate before
momentarily. injection of medication to check if the
e. Discard gloves to proper receptacle and blood vessel had been hit. If blood appears
perform hand washing. on pulling back of the plunger of the
f. Client must remain on side for 20 minute syringe, remove the needle and discard
after insertion to promote adequate the medication and equipment.
absorption of the medication. Intramuscular
a. Needle length is 1, 1 , 2 to reach the
muscle layer
8. PARENTERAL- administration of medication by b. Clean the injection site with alcoholized
needle. cotton ball to reduce microorganisms in
Intradermal under the epidermis. the area.
a. The site are the inner lower arm, upper c. Inject the medication slowly to allow the
chest and back, and beneath the scapula. tissue to accommodate volume.
Sites:
Ventrogluteal site c. Do not massage the site of injection to
a. The area contains no large nerves, or blood prevent leakage into the subcutaneous.
vessels and less fat. It is farther from the GENERAL PRINCIPLES IN PARENTERAL
rectal area, so it less contaminated. ADMINISTRATION OF MEDICATIONS
b. Position the client in prone or side-lying. 1. Check doctors order.
c. When in prone position, curl the toes 2. Check the expiration for medication drug
inward. potency may increase or decrease if outdated.
d. When side-lying position, flex the knee and 3. Observe verbal and non-verbal responses
hip. These ensure relaxation of gluteus toward receiving injection. Injection can be
muscles and minimize discomfort during painful. Client may have anxiety, which can
injection. increase the pain.
e. To locate the site, place the heel of the hand 4. Practice asepsis to prevent infection. Apply
over the greater trochanter, point the index disposable gloves.
finger toward the anterior superior iliac 5. Use appropriate needle size. To minimize
spine, and then abduct the middle (third) tissue injury.
finger. The triangle formed by the index 6. Plot the site of injection properly. To prevent
finger, the third finger and the crest of the hitting nerves, blood vessels, bones.
ilium is the site. 7. Use separate needles for aspiration and
Dorsogluteal site injection of medications to prevent tissue
a. Position the client similar to the irritation.
ventrogluteal site 8. Introduce air into the vial before aspiration. To
b. The site should not be use in infant under 3 create a positive pressure within the vial and
years because the gluteal muscles are not allow easy withdrawal of the medication.
well developed yet. 9. Allow a small air bubble (0.2 ml) in the syringe
c. To locate the site, the nurse draws an to push the medication that may remain.
imaginary line from the greater trochanter 10. Introduce the needle in quick thrust to lessen
to the posterior superior iliac spine. The discomfort.
injection site id lateral and superior to this 11. Either spread or pinch muscle when
line. introducing the medication. Depending on the
d. Another method of locating this site is to size of the client.
imaginary divide the buttock into four 12. Minimized discomfort by applying cold
quadrants. The upper most quadrant is the compress over the injection site before
site of injection. Palpate the crest of the introduction of medicati0n to numb nerve
ilium to ensure that the site is high enough. endings.
e. Avoid hitting the sciatic nerve, major blood 13. Aspirate before the introduction of
vessel or bone by locating the site properly. medication. To check if blood vessel had been
Vastus Lateralis hit.
a. Recommended site of injection for infant 14. Support the tissue with cotton swabs before
b. Located at the middle third of the anterior withdrawal of needle. To prevent discomfort of
lateral aspect of the thigh. pulling tissues as needle is withdrawn.
c. Assume back-lying or sitting position. 15. Massage the site of injection to haste
Rectus femoris site located at the middle third, absorption.
anterior aspect of thigh. 16. Apply pressure at the site for few minutes. To
Deltoid site prevent bleeding.
a. Not used often for IM injection because it is 17. Evaluate effectiveness of the procedure and
relatively small muscle and is very close to make relevant documentation.
the radial nerve and radial artery. Intravenous
b. To locate the site, palpate the lower edge of The nurse administers medication intravenously
the acromion process and the midpoint on by the following method:
the lateral aspect of the arm that is in line 1. As mixture within large volumes of IV
with the axilla. This is approximately 5 cm (2 fluids.
in) or 2 to 3 fingerbreadths below the 2. By injection of a bolus, or small volume, or
acromion process. medication through an existing
IM injection Z tract injection intravenous infusion line or intermittent
a. Used for parenteral iron preparation. To seal venous access (heparin or saline lock)
the drug deep into the muscles and prevent 3. By piggyback infusion of solution
permanent staining of the skin. containing the prescribed medication and
b. Retract the skin laterally, inject the a small volume of IV fluid through an
medication slowly. Hold retraction of skin existing IV line.
until the needle is withdrawn a. Most rapid route of absorption of medications.
b. Predictable, therapeutic blood levels of Nursing Intervention:
medication can be obtained. Change the site of needle
c. The route can be used for clients with Apply warm compress. This will absorb edema
compromised gastrointestinal function or fluids and reduce swelling.
peripheral circulation. 2. Circulatory Overload -Results from
d. Large dose of medications can be administered administration of excessive volume of IV fluids.
by this route. Assessment:
e. The nurse must closely observe the client for Headache
symptoms of adverse reactions. Flushed skin
f. The nurse should double-check the six rights of Rapid pulse
safe medication. Increase BP
g. If the medication has an antidote, it must be Weight gain
available during administration. Syncope and faintness
h. When administering potent medications, the Pulmonary edema
nurse assesses vital signs before, during and Increase volume pressure
after infusion. SOB
Coughing
Nursing Interventions in IV Infusion Tachypnea
a. Verify the doctors order shock
b. Know the type, amount, and indication of IV
therapy. Nursing Interventions:
c. Practice strict asepsis. Slow infusion to KVO
d. Inform the client and explain the purpose of Place patient in high fowlers position. To
IV therapy to alleviate clients anxiety. enhance breathing
e. Prime IV tubing to expel air. This will prevent Administer diuretic, bronchodilator as
air embolism. ordered
f. Clean the insertion site of IV needle from 3. Drug Overload the patient receives an
center to the periphery with alcoholized excessive amount of fluid containing drugs.
cotton ball to prevent infection. Assessment:
g. Shave the area of needle insertion if hairy. Dizziness
h. Change the IV tubing every 72 hours. To Shock
prevent contamination. Fainting
i. Change IV needle insertion site every 72 Nursing Intervention
hours to prevent thrombophlebitis. Slow infusion to KVO.
j. Regulate IV every 15-20 minutes. To ensure Take vital signs
administration of proper volume of IV fluid as Notify physician
ordered. 4. Superficial Thrombophlebitis it is due to
k. Observe for potential complications. o0veruse of a vein, irritating solution or drugs,
clot formation, large bore catheters.
Types of IV Fluids Assessment:
Isotonic solution has the same concentration as Pain along the course of vein
the body fluid Vein may feel hard and cordlike
a. D5 W Edema and redness at needle insertion
b. Na Cl 0.9% site.
c. plainRingers lactate Arm feels warmer than the other arm
d. Plain Normosol M Nursing Intervention:
Hypotonic has lower concentration than the body Change IV site every 72 hours
fluids. Use large veins for irritating fluids.
a. NaCl 0.3% Stabilize venipuncture at area of flexion.
Hypertonic has higher concentration than the Apply cold compress immediately to
body fluids. relieve pain and inflammation; later with
a. D10W warm compress to stimulate circulation
b. D50W and promotion absorption.
c. D5LR Do not irrigate the IV because this could
d. D5NM push clot into the systemic circulation
Complication of IV Infusion 5. Air Embolism Air manages to get into the
1. Infiltration the needle is out of nein, and circulatory system; 5 ml of air or more causes air
fluids accumulate in the subcutaneous tissues. embolism.
Assessment: Assessment:
Pain, swelling, skin is cold at needle site, pallor Chest, shoulder, or backpain
of the site, flow rate has decreases or stops. Hypotension
 Dyspnea g. Identify client properly. Two Nurses check
Cyanosis the clients identification.
Tachycardia h. Use needle gauge 18 to 19. This allows
Increase venous pressure easy flow of blood.
Loss of consciousness i. j. Use BT set with special micron mesh
Nursing Intervention filter. To prevent administration of blood
Do not allow IV bottle to run dry clots and particles.
Prime IV tubing before starting infusion. j. Start infusion slowly at 10 gtts/min.
Turn patient to left side in the Trendelenburg Remain at bedside for 15 to 30 minutes.
position. To allow air to rise in the right side Adverse reaction usually occurs during the
of the heart. This prevent pulmonary first 15 to 20 minutes.
embolism. k. Monitor vital signs. Altered vital signs
6. Nerve Damage may result from tying the arm indicate adverse reaction.
too tightly to the splint. Do not mixed medications with blood
Assessment transfusion. To prevent adverse
Numbness of fingers and hands efects
Nursing Interventions Do not incorporate medication into
Massage the are and move shoulder through the blood transfusion
its ROM Do not use blood transfusion line for
Instruct the patient to open and close hand IV push of medication.
several times each hour. l. . Administer 0.9% NaCl before, during or after
Physical therapy may be required BT. Never administer IV fluids with dextrose.
Note: apply splint with the fingers free to move. Dextrose causes hemolysis.
7. Speed Shock may result from administration m. . Administer BT for 4 hours (whole blood,
of IV push medication rapidly. packed rbc). For plasma, platelets,
To avoid speed shock, and possible cardiac cryoprecipitate, transfuse quickly (20 minutes)
arrest, give most IV push medication over 3 clotting factor can easily be destroyed.
to 5 minutes.
BLOOD TRANSFUSION THERAPY Complications of Blood Transfusion
Objectives: 1. Allergic Reaction it is caused by sensitivity
1. To increase circulating blood volume after to plasma protein of donor antibody, which reacts
surgery, trauma, or hemorrhage with recipient antigen.
2. To increase the number of RBCs and to Assessments
maintain hemoglobin levels in clients with Flushing
severe anemia Rush, hives
3. To provide selected cellular components as Pruritus
replacements therapy (e.g. clotting factors,
platelets, albumin)
Laryngeal edema, difficulty of breathing
2. Febrile, Non-Hemolytic it is caused by
Nursing Interventions:
hypersensitivity to donor white cells, platelets or
a. Verify doctors order. Inform the client and
plasma proteins. This is the most symptomatic
explain the purpose of the procedure.
complication of blood transfusion
b. Check for cross matching and typing. To
Assessments:
ensure compatibility
c. Obtain and record baseline vital signs Sudden chills and fever
d. Practice strict Asepsis Flushing
e. At least 2 licensed nurse check the label of Headache
the blood transfusion Anxiety
Check the following: 3. Septic Reaction it is caused by the
Serial number transfusion of blood or components contaminated
Blood component with bacteria.
Blood type Assessment:
Rh factor Rapid onset of chills
Expiration date Vomiting
Screening test (VDRL, HBsAg, malarial Marked Hypotension
smear)- this is to ensure that the blood is free from High fever
blood-carried diseases and therefore, safe from 4. Circulatory Overload it is caused by
transfusion. administration of blood volume at a rate greater
f. Warm blood at room temperature before than the circulatory system can accommodate.
transfusion to prevent chills. Assessment
Rise in venous pressure
 Dyspnea PaCo2 35-45
Crackles or rales HCO3 22-26 mEq/L
Distended neck vein Pa O2 80-100 mmHg
SaO2 94-100%
Cough
Sodium 135- 145
Elevated BP mEq/L
5. Hemolytic reaction. It is caused by infusion of Potassium 3.5- 5.0 mEq/L
incompatible blood products. Calcium 4.2- 5.5 mg/dL
Assessment Chloride 98-108 mEq/L
Low back pain (first sign). This is due to Magnesium 1.5-2.5 mg/dl
inflammatory response of the kidneys to BUN 10-20 mg/dl
incompatible blood. Creatinine 0.4- 1.2
Chills CPK-MB male 50 325 mu/ml
Feeling of fullness female 50-250 mu/ml
Tachycardia Fibrinogen 200-400 mg/dl
Flushing FBS 80-120 mg/dl
Glycosylated Hgb 4.0-7.0%
Tachypnea
(HbA1c)
Hypotension Uric Acid 2.5 8 mg/dl
Bleeding ESR male 15-20 mm/hr
Vascular collapse Female 20-30 mm/hr
Acute renal failure
Nursing Interventions when complications Cholesterol 150- 200 mg/dl
occurs in Blood transfusion Triglyceride 140-200 mg/dl
1. If blood transfusion reaction occurs. STOP
THE TRANSFUSION. Lactic Dehydrogenase 100-225 mu/ml
2. Start IV line (0.9% Na Cl) Alkaline phospokinase 32-92 U/L
3. Place the client in Fowlers position if with Albumin 3.2- 5.5 mg/dl
SOB and administer O2 therapy.
4. The nurse remains with the client, observing COMMON THERAPEUTIC DIETS
signs and symptoms and monitoring vital 1. CLEAR-LIQUID DIET
signs as often as every 5 minutes. Purpose:
5. Notify the physician immediately. relieve thirst and help maintain fluid
6. The nurse prepares to administer balance.
emergency drugs such as antihistamines, Use:
vasopressor, fluids, and steroids as per post-surgically and following acute
physicians order or protocol. vomiting or diarrhea.
7. Obtain a urine specimen and send to the Foods Allowed:
laboratory to determine presence of carbonated beverages; coffee (caffeinated
hemoglobin as a result of RBC hemolysis. and decaff.); tea; fruit-flavored drinks;
8. Blood container, tubing, attached label, and strained fruit juices; clear, flavored
transfusion record are saved and returned to gelatins; broth, consomme; sugar;
the laboratory for analysis. popsicles; commercially prepared clear
liquids; and hard candy.
Foods Avoided:
Normal Values milk and milk products, fruit juices with
Bleeding time 1-9 min pulp, and fruit.
Prothrombin time 10-13 sec 2. FULL-LIQUID DIET
Hematocrit Male 42-52% Purpose:
Female 36-48% Provide an adequately nutritious diet for
Hemoglobin male 13.5-16 g/dl patients who cannot chew or who are too
female 12-14 g/dl ill to do so.
Platelet 150,00- 400,000 Use:
RBC male 4.5-6.2 million/L acute infection with fever, GI upsets, after
Female 4.2-5.4 million/L surgery as a progression from clear
Amylase 80-180 IU/L liquids.
Bilirubin(serum)direct 0-0.4 mg/dl Foods Allowed:
indirect 0.2-0.8 mg/dl clear liquids, milk drinks, cooked cereals,
total 0.3-1.0 mg/dl custards, ice cream, sherbets, eggnog, all
pH 7.35- 7.45 strained fruit juices, creamed vegetable
soups, puddings, mashed potatoes, instant
 breakfast drinks, yogurt, mild cheese sauce popcorn; fresh or canned shellfish; all
or pureed meat, and seasoning. cheeses
Foods Avoided: smoked or commercially prepared meats;
nuts, seeds, coconut, fruit, jam, and salted butter or margarine;
marmalade bacon, olives; and commercially prepared
SOFT DIET salad dressings.
Purpose: RENAL DIET
provide adequate nutrition for those who Purpose:
have troubled chewing. control protein, potassium, sodium, and fluid
Use: levels in the body.
patient with no teeth or ill-fitting dentures; Use:
transition from full-liquid to general diet; acute and chronic renal failure, hemodialysis.
and for those Foods Allowed:
who cannot tolerate highly seasoned, fried high-biological proteins such as meat,
or raw foods following acute infections or fowl, fish, cheese, and dairy products-
gastrointestinal range between 20 and 60 mg/day.
disturbances such as gastric ulcer or Potassium is usually limited to 1500
cholelithiasis. mg/day.
Foods Allowed: Vegetables such as cabbage, cucumber,
very tender minced, ground, baked broiled, and peas are lowest in potassium.
roasted, stewed, or creamed beef, lamb, Sodium is restricted to 500 mg/day.
veal, liver, Fluid intake is restricted to the daily
poultry, or fish; crisp bacon or sweet bread; volume plus 500 mL, which represents
cooked vegetables; pasta; all fruit juices; insensible water loss.
soft raw fruits; Fluid intake measures water in fruit,
soft bread and cereals; all desserts that are vegetables, milk and meat.
soft; and cheeses. Foods Avoided:
Foods Avoided: Cereals, bread, macaroni, noodles, spaghetti,
coarse whole-grain cereals and bread; nuts; avocados, kidney beans, potato chips
raisins; coconut; raw fruit, yams
fruits with small seeds; fried foods; soybeans, nuts, gingerbread
high fat gravies or sauces; apricots, bananas, figs, grapefruit, oranges,
spicy salad dressings; pickled meat, fish, or percolated coffee
poultry; Coca-Cola, orange crush, sport drinks, and
strong cheeses; breakfast drinks such as Tang or Awake
brown or wild rice;
raw vegetables, as well as lima beans and corn; HIGH-PROTEIN, HIGH CARBOHYDRATE DIET
spices such as horseradish, Purpose:
mustard, and catsup; and popcorn. To correct large protein losses and raises the
SODIUM-RESTRICTED DIET level of blood albumin. May be modified to
Purpose: include low-fat, low-sodium, and low-
reduce sodium content in the tissue and cholesterol diets.
promote excretion of water. Use:
Use: Burns
heart failure, hypertension, renal disease, Hepatitis
cirrhosis, toxemia of pregnancy, and Cirrhosis
cortisone therapy. Pregnancy
Modifications: Hyperthyroidism
mildly restrictive 2 g sodium diet to Mononucleosis
extremely restricted 200 mg sodium diet. protein deficiency due to poor
Foods Avoided: eating habits
table salt; all commercial soups, including geriatric patient with poor intake
bouillon; gravy, catsup, mustard, meat nephritis, nephrosis,
sauces, and soy sauce; liver and gall bladder disorder.
buttermilk, ice cream, and sherbet; sodas; Foods Allowed:
beet greens, carrots, celery, chard, general diet with added protein.
sauerkraut, and Foods Avoided:
spinach; all canned vegetables; frozen peas; restrictions depend on modifications added to
all baked products containing salt, baking the diet. The modifications are determined by
powder, or baking soda; potato chips and the patients condition.
PURINE-RESTRICTED DIET
Purpose: Hyperlipedimia
designed to reduce intake of uric acid- Atherosclerosis
producing foods. Pancreatitis
Use: scystic fibrosis
high uric acid retention, uric acid renal stones, sprue (disease of intestinal tract
and gout. characterized by malabsorption)
Foods Allowed: gastrectomy
general diet plus 2-3 quarts of liquid daily. massive resection of small intestine
Foods Avoided: cholecystitis.
cheese containing spices or nuts Foods Allowed:
fried eggs, meat nonfat milk
liver, seafood low-carbohydrate
lentils, dried peas and beans low-fat vegetables; most fruits; breads;
broth, bouillon, gravies pastas; cornmeal
oatmeal and whole wheat lean meat
pasta, noodles unsaturated fats
alcoholic beverages Foods Avoided:
Limited quantities of meat, fish, and seafood remember to avoid the five Cs of
allowed. cholesterol- cookies, cream, cake,
BLAND DIET coconut, chocolate
Purpose: whole milk and whole-milk or cream
Provision of a diet low in fiber, roughage, products
mechanical irritants, and chemical stimulants. avocados, olives
Use: commercially prepared baked goods such
Gastritis as
hyperchlorhydria (excess hydrochloric acid) donuts and muffins
functional GI disorders poultry skin, highly marbled meats
gastric atony butter, ordinary margarines, olive oil, lard
diarrhea pudding made with whole milk, ice cream,
spastic constipation candies with chocolate, cream, sauces,
biliary indigestion gravies and commercially fried foods.
hiatus hernia. DIABETIC DIET
Foods Allowed: Purpose:
Varied to meet individual needs and food maintain blood glucose as near as normal as
tolerances. possible; prevent or delay onset of diabetic
Foods Avoided: complications.
fried foods, including eggs, meat, fish, and Use:
sea food diabetes mellitus
cheese with added nuts or spices Foods Allowed:
commercially prepared luncheon meats choose foods with low glycemic index
cured meats such as ham compose of:
gravies and sauces a. 45-55% carbohydrates
raw vegetables; b. 30-35% fats
potato skins c. 10-25% protein
fruit juices with pulp coffee, tea, broth, spices and flavoring can be
figs, raisins used as desired.
fresh fruits exchange groups include: milk, vegetable,
whole wheat; rye bread; bran cereals fruits, starch/bread, meat (divided in lean,
rich pastries; pies medium fat, and high fat), and fat exchanges.
chocolate the number of exchanges allowed from each
jams with seeds; nuts group is dependent on the total number of
seasoned dressings calories allowed.
caffeinated coffee; strong tea; cocoa; non-nutritive sweeteners (sorbitol) in
alcoholic and carbonated beverages moderation with controlled, normal weight
pepper. diabetics.
LOW-FAT, CHOLESTEROL-RESTRICTED DIET Foods Avoided:
Purpose: concentrated sweets or regular soft drinks.
reduce hyperlipedimia, provide dietary ACID AND ALKALINE DIET
treatment for malabsorption syndromes and Purpose:
patients having acute intolerance for fats.
Use:
 Furnish a well balance diet in which the total recommended intake about 6 g crude fiber
acid ash is greater than the total alkaline ash daily
each day. All bran cereal
Use: Watermelon, prunes, dried peaches, apple
Retard the formation of renal calculi. The type with skin; parsnip, peas, brussels sprout,
of diet chosen depends on laboratory analysis sunflower seeds.
of the stone. LOW RESIDUE DIET
Acid and alkaline ash food groups: Purpose:
Acid ash: meat, whole grains, eggs, cheese, Reduce stool bulk and slow transit time
cranberries, prunes, plums Use:
Alkaline ash: milk, vegetables, fruits (except Bowel inflammation during acute diverticulitis,
cranberries, prunes and plums.) or ulcerative colitis, preparation for bowel
Neutral: sugar, fats, beverages (coffee, tea) surgery, esophageal and intestinal stenosis.
Foods allowed: Food Allowed:
Breads: any, preferably whole grain; crackers; eggs; ground or well-cooked tender meat,
rolls fish, poultry; milk, cheeses; strained fruit juice
Cereals: any, preferable whole grains (except prune): cooked or canned apples,
Desserts: angel food or sunshine cake; cookies apricots, peaches, pears; ripe banana; strained
made without baking powder or soda; vegetable juice: canned, cooked, or strained
cornstarch, asparagus, beets, green beans, pumpkin, squash,
pudding, cranberry desserts, ice cream, spinach; white bread;
sherbet, plum or prune desserts; rice or tapioca refined cereals (Cream of Wheat)
pudding.
Fats: any, such as butter, margarine, salad
dressings, Crisco, Spry, lard, salad oil, olive oil,
ect.
fruits: cranberry, plums, prunes
Meat, eggs, cheese: any meat, fish or fowl, two
serving daily; at least one egg daily
Potato substitutes: corn, hominy, lentils,
macaroni, noodles, rice, spaghetti, vermicelli.
Soup: broth as desired; other soups from food
allowed
Sweets: cranberry and plum jelly; plain sugar
candy
Miscellaneous: cream sauce, gravy, peanut
butter, peanuts, popcorn, salt, spices, vinegar,
walnuts.
Restricted foods:
no more than the amount allowed each day
1. Milk: 1 pint daily (may be used in other ways
than as beverage)
2. Cream: 1/3 cup or less daily
3. Fruits: one serving of fruits daily( in addition to
the prunes, plums and cranberries)
4. Vegetable: including potatoes: two servings daily
5. Sweets: Chocolate or candies, syrups.
6. Miscellaneous: other nuts, olives, pickles.
HIGH-FIBER DIET
Purpose:
Soften the stool
exercise digestive tract muscles
speed passage of food through digestive
tract to prevent exposure to cancer-causing agents
in food
lower blood lipids
Prevent sharp rise in glucose after eating.
Use: diabetes, hyperlipedemia, constipation,
diverticulitis, anticarcinogenics (colon)
Foods Allowed: