c.

Dona Hilaria de Aguinaldo– Wife of Emilio

NP1 - FUNDAMENTALS Aguinaldo; Organized the Filipino Red Cross
under the inspiration of Apolinario Mabini.
OF NURSING d. Dona Maria de Aguinaldo- second wife of
Emilio Aguinaldo. Provided nursing care for
The Earliest Hospitals established were the the Filipino soldier during the revolution.
following: President of the Filipino Red Cross branch in
Batangas.
a.Hospital Real de Manila (1577). It was e. Melchora Aquino (Tandang Sora) – Nurse
established mainly to care for theSpanish the wounded Filipino soldiers and gave
King’ssoldiers, but also admitted Spanish civilians. them shelter and food.
Founded by Gov. Franciscode Sande f. Captain Salome – A revolutionary leader in
b.San Lazaro Hospital (1578) – built exclusively for Nueva Ecija; provided nursing care to the
patients with leprosy.Founded by Brother Juan wounded when not in combat.
Clemente g. Agueda Kahabagan– Revolutionary leader
in Laguna, also provided nursing services to
The Earliest Hospitals Established her troop.
a. Hospital de Indio (1586) –Established by the h. Trinidad Tecson– “Ina ng Biac na Bato”,
Franciscan Order; stayed in the hospital at Biac na Bato to
Service was in general supported by alms and care for the wounded soldier.
contribution from charitable persons.
b. Hospital de Aguas Santas (1590). Established in Hospitals and Nursing Schools
Laguna, near a medicinal spring, Founded by 1. Iloilo Mission Hospital School of Nursing (Iloilo
Brother J. Bautista of the Franciscan Order. City, 1906)- It was ran by the Baptist Foreign
c. San Juan de Dios Hospital (1596) Founded by the Mission Society of America.
Brotherhood de Misericordia and support was
derived from alms and rents. Rendered general  Miss Rose Nicolet- a graduate of New
health service to the public. England Hospital for woman and children in
Boston, Massachusetts, was the first
Nursing During the Philippine Revolution superintendent.
 Miss Flora Ernst- an American nurse, took
The prominent persons involved in the nursing charge of the school in 1942
works were:
a. Josephine Bracken – wife of Jose Rizal. 2. St. Paul’s Hospital School of Nursing (Manila,
Installed a field hospital in anestate house 1907)- The hospital was established by the
in Tejeros. Provided nursing care to the Archbishop of Manila, The Most Reverend
wounded night and day. Jeremiah Harty, under the supervision of the
b. Rosa Sevilla De Alvero – converted their Sisters of St. Paul de Chartres. It was located in
house into quarters for the Filipino soldier, Intramuros and it provided general hospital
during the Philippine-American war that services.
broke out in 1899.
3. Philippine General Hospital School of Nursing the Bureau of Health with Anastacia Giron-Tupas as
(1907)- In 1907, with the support of the Governor the organizer.
General Forbes and the Director of Health and
among others, she opened classes in nursing under The First Colleges of Nursing in the
the auspices of the Bureau of Education.
 Anastacia Giron-Tupas- was the first
Philippines
Filipino to occupy the position of chief 1. University of Santo Tomas .College of
nurse and superintendent in the Nursing (1946)
Philippines, succeded her. 2. Manila Central University College of Nursing
(1948)
4. St. Luke’s Hospital School of Nursing (Quezon 3. University of the Philippines College of
City, 1907)- The Hospital is an Episcopalian Nursing (1948)
Institution. It began as a small dispensary in 1903.  Ms.Julita Sotejo was its first Dean
In 1907, the school opened with three Filipino girls
admitted.
 Mrs. Vitiliana Beltran- was the first Filipino
superintendent of nurses. The Basic Human Needs
 Each individual has unique characteristics,
5. Mary Johnston Hospital and School of Nursing but certain needs are common to all
(Manila, 1907)- It started as a small dispensary on people.
Calle Cervantes (now Avenida). It was called  A need is something that is desirable, useful
Bethany Dispensary and was founded by the or necessary.
Methodist Mission.  Human needs are physiologic and
 Miss Librada Javelera- the first Filipino psychologic conditions that an individual
director of the school. must meet to achieve a state of health or
well-being.
6. Philippine Christian mission Institute School of
Nursing.
Maslow’s Hierarchy of Basic Human Needs
The United Christian Missionary of Indianapolis,
operated three schools of Nursing:
A. Physiologic
1. Sallie Long Read Memorial Hospital
1. Oxygen
School of Nursing (Laoag, IlocosNorte,1903)
2. Fluids
2. Mary Chiles Hospital school of Nursing
3. Nutrition
(Manila, 1911)
4. Body temperature
3. Frank Dunn Memorial hospital
5. Elimination
6. Rest and sleep
7. San Juan de Dios hospital School of Nursing
7. Sex
(Manila, 1913)
B. Safety and Security
8. Emmanuel Hospital School of Nursing
1. Physical safety
(Capiz,1913)
2. Psychological safety
9. Southern Island Hospital School of Nursing
3. The need for shelter and freedom from
(Cebu,1918)- The hospital was established under
harm and danger
 C. Love and belonging 4. is the ability to maintain the internal
1. The need to love and be loved milieu. Illness is the result of failure to
2. The need to care and to be cared for maintain the internal environment.
3. The need for affection: to associate or (Claude Bernard)
to belong 5. is the ability to maintain homeostasis or
4. The need to establish fruitful and dynamic equilibrium. Homeostasis is
meaningful relationships with people, regulated by the negative feedback
institution, or organization mechanism.(WalterCannon)
D. Self-Esteem Needs 6. is being well and using ones’s power to
1. Self-worth the fullest extent. Health is maintained
2. Self-identity through prevention of diseases via
3. Self-respect environmental health factors.(Florence
4. Body image Nightingale)
E. Self-Actualization Needs 7. is viewed in terms of the individual’s
1. The need to learn, create and ability to perform 14 components of
understand or comprehend nursing care unaided. (Henderson)
2. The need for harmonious relationships 8. Positive Health- symbolizes wellness. It
3. The need for beauty or aesthetics is value term defined by the culture or
4. The need for spiritual fulfillment individual. (Rogers)
9. Health is a state of a process of being
Characteristics of Basic Human Needs becoming an integrated and whole as a
1.Needs are universal. person.(Roy)
2.Needs may be met in different ways 10. Health is a state the characterized by
3.Needs may be stimulated by external and soundness or wholeness of developed
internal factor human structures and of bodily and
4.Priorities may be deferred mental functioning.(Orem)
5.Needs are interrelated 11. Health -is a dynamic state in the life
cycle; illness is an interference in the life
Concepts of health and Illness
cycle. (King)
12. Wellness – is the condition in which all
HEALTH parts and subparts of an individual are
1. is the fundamental right of every human in harmony with the whole system.
being. It is the state of integration of the (Neuman)
body and mind 13. Health – is an elusive, dynamic state
2. 2.Health and illness are highly influenced by biologic, psychologic, and
individualized perception. Meanings and social factors. Health is reflected by the
descriptions of health and illness vary organization, interaction,
among people in relation to geography interdependence and integration of the
and to culture. subsystems of the behavioral system.
3. HEALTH is the state of complete (Johnson)
physical, mental, and social well-
being,and not merely the absence of
Illness and Disease
disease or infirmity. (WHO)
Illness help. Accepts/rejects health professional’s
 is a personal state in which the person feels suggestions. Becomes more passive and accepting.
unhealthy. 5.Recovery/Rehabilitation- Gives up the sick role
 Illness is a state in which a person’s and returns to former roles and functions.
physical, emotional, intellectual, social,
developmental, or spiritual functioning is Risk Factors of a Disease
diminished or impaired compared with 1. Genetic and Physiological Factors
previous experience.  For example, a person with a family history
 Illness is not synonymous with disease. of diabetes mellitus, is at risk in developing
Disease the disease later in life.
 An alteration in body function resulting in 2. Age
reduction of capacities or a shortening of  Age increases and decreases susceptibility
the normal life span. (risk of heart diseases increases with age for
both sexes)
Common Causes of Disease 3. Environment
1.Biologic agent – e.g. microorganism  The physical environment in which a person
2.Inherited genetic defects – e.g. cleft palate works or lives can increase the likelihood
3.Developmental defects – e.g. imperforate anus that certain illnesses will occur.
4.Physical agents – e.g. radiation, hot and cold 4. Lifestyle
substances, ultraviolet rays  Lifestyle practices and behaviors can also
5.Chemical agents – e.g. lead, asbestos, carbon have positive or negative effects on health.
monoxide
6.Tissue response to irritations/injury – e.g. Classification of Diseases
inflammation, fever 1. According to Etiologic Factors.
7.Faulty chemical/metabolic process – e.g. a. Hereditary – due to defect in the
inadequate insulin in diabetes genes of one or other parent which
8.Emotional/physical reaction to stress – e.g. fear, istransmitted to their offspring
anxiety b. Congenital – due to a defect in the
development, hereditary factors, or
Stages of Illness prenatal infection
1.Symptoms Experience- experience some c. Metabolic – due to disturbances or
symptoms, person believes something is wrong abnormality in the intricate
 3 aspects –physical, cognitive, emotional processes of metabolism.
2.Assumption of Sick Role – acceptance of illness, d. Deficiency – results from
seeks advice inadequate intake or absorption of
3.Medical Care Contact- Seeks advice to essential dietary factor.
professionals for validation of real illness, e. Traumatic- due to injury
explanation of symptoms, reassurance or predict of f. Allergic – due to abnormal response
outcome of the body to chemical and protein
4.Dependent Patient Role - The person becomes a substances or to physical stimuli.
client dependent on the health professional for g. Neoplastic– due to abnormal or
uncontrolled growth of cell.
 h. Idiopathic –Cause is unknown; self- b. Functional – no anatomical changes are
originated; of spontaneous origin observed to account from the symptoms present,
i. Degenerative –Results from the may result from abnormal response to stimuli.
degenerative changes that occur in c.Occupational – Results from factors associated
the tissue and organs. with the occupation engage in by the patient.
j. Iatrogenic –result from the d. Venereal– usually acquired through sexual
treatment of the disease relation
e. Familial – occurs in several individuals of the
2. According to Duration or Onset same family
a. Acute Illness – An acute illness f. Epidemic – attacks a large number of individuals
usually has a short duration and is in the community at the same time. (e.g. SARS)
severe. Signs and symptoms g. Endemic– Presents more or less continuously or
appears abruptly, intense and often recurs in a community.(e.g. malaria, goiter)
subside after a relatively short h. Pandemic–An epidemic which is extremely
period. widespread involving anentire country or
b. Chronic Illness – chronic illness continent.
usually longer than 6 months, and i. Sporadic –a disease in which only occasional
can also affects functioning in any cases occur. (e.g. dengue,leptospirosis)
dimension. The client may fluctuate
between maximal functioning and
serious relapses and may be life
threatening. Is characterized by
remission and exacerbation.
1. Remission - periods Leavell and Clark’s Three Levels of
during which the disease
is controlled and
Prevention
symptoms are not
obvious. a. Primary Prevention – seeks to prevent a
2. Exacerbations – The disease or condition at a prepathologic
disease becomes more state ; to stop something from ever
active given again at a happening.
future time, with  Health Promotion
recurrence of - health education
pronounced symptoms. -marriage counseling
c. Sub-Acute– Symptoms are -genetic screening
pronounced but more prolonged -good standard of nutrition adjusted to
than the acute disease. developmental phase of life
3. Disease may also be described as:  Specific Protection
a. Organic –results from changes in the normal -use of specific immunization
structure, from recognizable anatomical changes in -attention to personal hygiene
an organ or tissue of the body. -use of environmental sanitation
-protection against occupational hazards
-protection from accidents
 -use of specific nutrients  Help the client gain independence as
-protections from carcinogens rapidly as possible.
-avoidance to allergens

b. Secondary Prevention– also known as CONCEPTUAL AND THEORETICAL

“Health Maintenance”. Seeks to identify
MODELS OF NURSING PRACTICE
specific illnesses or conditions at an early stage
with prompt intervention to prevent or limit A. NIGHTANGLE’S THEORY ( mid-1800)
disability; to prevent catastrophic effects that could  Focuses on the patient and his
occur if proper attention and treatment are not environment.
provided  Developed the described the first
 Early Diagnosis and Prompt Treatment -case theory of nursing.
finding measures-individual and mass screening  Notes on Nursing: What It Is, What It Is
survey-prevent spread of communicable disease- Not. She focused on changing and
prevent complication and sequelae-shorten period manipulating the environment in order
of disability to put the patient in the best possible
 Disability Limitations- adequate treatment to conditions for nature to act.
arrest disease process and prevent further  She believed that in the nurturing
complication and sequelae.-provision of facilities to environment, the body could repair
itself. Client’s environment is
limit disability and prevent death.
manipulated to include appropriate
c. Tertiary Prevention – occurs after a disease or noise, nutrition, hygiene, socialization
disability has occurred and the recovery process has and hope.
begun; Intent is to halt the disease or injury process B. PEPLAU, HILDEGARD (1951)
and assist the person in obtaining an optimal health  Defined nursing as a therapeutic,
status. To establish a high-level wellness.“To interpersonal process which strives
maximize use of remaining capacities” to develop a nurse- patient
 Restoration and Rehabilitation relationship in which the nurse
-work therapy in hospital serves as a resource person,
- use of shelter colony counselor and surrogate.
 Introduced the Interpersonal
NURSING Model. She defined nursing as an
interpersonal process of therapeutic
As defined by then INTERNATIONAL COUNCIL OF between an individual who is sick or
NURSES as written by Virginia Henderson. in need of health services and a
 the unique function of the nurse is to assist nurse especially educated to
the individual, sick or well, in the recognize and respond to the need
performance of those activities for help.
contributing to health, it’s recovery, or to a  She identified four phases of the
peaceful death the client would perform nurse-client relationship namely:
unaided if he had the necessary strength, 1. Orientation: the nurse and the
client initially do not know each
will or knowledge.
other’s goals and testing the role
 each will assume. The client
attempts to identify difficulties and
D. ORLANDO, IDA
the amount of nursing help that is
needed;  She conceptualized The Dynamic
2. Identification: the client Nurse – Patient Relationship Model.
responds to help professionals E. LEVINE, MYRA (1973)
or the significant others who can  Believes nursing intervention is a
meet the identified needs. Both conservation activity, with
the client and the nurse plan conservation of energy as a primary
together an appropriate concern, four conservation
program to foster health; principles of nursing: conservation
3. Exploitation: the clients utilize of client energy, conservation of
all available resources to move structured integrity, conservation of
toward a goal of maximum personal integrity, conservation of
health functionality; social integrity.
4. Resolution: refers to the  Described the Four Conservation
termination phase of the nurse- Principles. She Advocated that
clientrelationship. it occurs nursing is a human interaction and
when the client’s needs are met proposed four conservation
and he/she can move toward a principle sof nursing which are
new goal. Peplau further concerned with the unity and
assumed that nurse- integrity of the individual.
clientrelationship fosters growth The four conservation principles are as
in both the client and the nurse. follows
1. Conservation of energy . The human
body functions by utilizing energy.
C. ABDELLAH, FAYE G. (1960) The human body needs energy
 Defined nursing as having a problem-solving producing input (food, oxygen,
approach, with key nursing problems fluids) to allow energy utilization
related to health needs of people; output.
developed list of 21nursing-problem areas. 2. Conservation of Structural Integrity.
 Introduced Patient – Centered Approaches The human body has physical
to Nursing Model. She defined nursing as boundaries (skin and mucous
service to individual and families; therefore membrane) that must be
the society. Furthermore, she maintained to facilitate health and
conceptualized nursing as an art and a prevent harmful agents from
science that molds the attitudes, entering the body.
intellectual competencies and technical 3. Conservation of Personal Integrity.
skills of the individual nurse into the desire The nursing interventions are based
and ability to help people, sick or well, and on the conservation of the individual
cope with their health needs. client’s personality. Every individual
has sense of identity, self worth and
 self esteem, which must be 7. Sexual role identity
preserved and enhanced by nurses. behavior
4. Conservation of Social integrity. The G. ROGERS, MARTHA
social integrity of the client reflects
 Considers man as a unitary human
the family and the community in
being co-existing within the
which the client functions.
universe,views nursing primarily as a
Healthcare institutions may separate
science and is committed to nursing
individuals from their family. It is
research.
important for nurses to consider the
H. OREM, DOROTHEA (1970, 1985)
individual in the context of the
family.
 Emphasizes the client’s self-care
needs, nursing care becomes
F. JOHNSON, DOROTHY (1960, 1980)
necessary when client is unable to
 Focuses on how the client adapts to fulfill biological, psychological,
illness; the goal of nursing is to
developmental or social needs.
reduce stress so that the client can
 Developed the Self-Care Deficit
move more easily through recovery.
Theory. She defined self-care as “the
 Viewed the patient’s behavior as a practice of activities that individuals
system, which is a whole with
initiate to perform on their own
interacting parts.
behalf in maintaining life, health
 The nursing process is viewed as a well-being.” She conceptualized
major tool. Conceptualized the three systems asfollows:
Behavioral System Model. According 1. Wholly Compensatory: when
to Johnson, each personas a the nurse is expected to
behavioral system is composed of accomplish all the patient’s
seven subsystems namely: therapeutic self-care or to
1. Ingestive. Taking in nourishment compensate for the patient’s
in socially and culturally inability to engage in self care or
acceptable ways. when the patient needs
2. Eliminated. Riddling the body of continuous guidance in self care;
waste in socially and culturally 2. Partially Compensatory: when
acceptable ways both nurse patient engage in
3. Affiliative. Security seeking meeting self care needs;
behavior 3. Supportive-Educative : the
4. Aggressive.Self –protective system that requires assistance
behavior decision
5. Dependence. Nurturance – I. IMOGENE KING (1971, 1981)
seeking behavior.  Nursing process is defined as
6. Achievement. Master of oneself dynamic interpersonal process
and one’s environment between nurse, client and health
according tointernalized care system.
standards of excellence.
  Postulated the Goal Attainment  Introduced the model of Nursing:
Theory. She described nursing as a What Is It?, focusing on the notion
helping profession that assists that centers around three
individuals and groups in society components of CARE, CORE and
toattain, maintain, and restore CURE. Care represents nurturance
health. If is this not possible, nurses and is exclusive to nursing. Core
help individuals die with dignity. involves the therapeutic use of self
 In addition, King viewed nursing as and emphasizes the use of
an interaction process between reflection. Cure focuses on nursing
client and nurse whereby during related to the physician’s orders.
perceiving, setting goals, and acting Core and cure are shared with the
on them transactions occurred and other health care providers.
goals are achieved. M. Virginia Henderson (1955)
J. BETTY NEUMAN  Introduced The Nature of Nursing
 Stress reduction is a goal of system Model. She identified fourteen basic
model of nursing practice. Nursing needs.
actions are in primary, secondary or  She postulated that the unique
tertiary level of prevention. function of the nurse is to assist the
K. SIS CALLISTA ROY (Adaptation clients, sick or well, in the
Theory) (1979, 1984) performance of those activities
contributing to health or its
 Views the client as an adaptive
recovery, the clients would perform
system. The goal of nursing is to
unaided if they had the necessary
help the person adapt to changes in
strength, will or knowledge.
physiological needs, self-concept,
role function and interdependent  She further believed that nursing
relations during health and illness. involves assisting the client in
gaining independence as rapidly as
 Presented the Adaptation Model.
possible, or assisting him achieves
She viewed each person as a unified
peaceful death if recovery is no
bio psychosocial system in constant
longer possible.
interaction with a changing
N. Madaleine Leininger (1978, 1984)
environment. She contented that
the person as an adaptive system,  Developed the Transcultural
functions as a whole through Nursing Model. She advocated that
interdependence of its part. The nursing is a humanistic and scientific
system consists of input, control mode of helping a client through
processes, output feedback. specific cultural caring processes
(cultural values, beliefs and
L. LYDIA HALL (1962)
practices) to improve or maintain a
 The client is composed of the ff.
health condition.
overlapping parts: person
O. Ida Jean Orlando (1961)
(core),pathologic state and
treatment (cure) and body (care).  Conceptualized The Dynamic Nurse
– Patient Relationship Model.
  She believed that the nurse helps maintaining maximal degree of
patients meet a perceived need that health.
the patient cannot meet for  She further viewed that
themselves. Orlando observed that interpersonal process is a human-to-
the nurse provides direct assistance human relationship formed during
to meet an immediate need for help illness and “experience of suffering”
in order to avoid or to alleviate  She believed that a person is a
distress or helplessness. unique, irreplaceable individual who
 She emphasized the importance of is in a continuous process of
validating the need and evaluating becoming, evolving and changing.
care based on observable outcomes. S. Josephine Peterson and Loretta
P. Ernestine Weidanbach (1964) Zderad (1976)
 Developed the Clinical Nursing – A  Provided the Humanistic Nursing
Helping Art Model Practice Theory. This is based on
 She advocated that the nurse’s their belief that nursing is an
individual philosophy or central existential experience.
purpose lends credence to nursing  Nursing is viewed as a lived dialogue
care. that involves the coming together of
 She believed that nurses meet the the nurse and the person to be
individual’s need for help through nursed.
the identification of the needs,  The essential characteristic of
administration of help, and nursing is nurturance. Humanistic
validation that actions were helpful. care cannot take place without the
Components of clinical practice: authentic commitment of the nurse
Philosophy, purpose, practice and an to being with and the doing with the
art. client. Humanistic nursing also
Q. Jean Watson (1979-1992) presupposes responsible choices.
 Introduced the Theory of Human T. Helen Erickson, Evelyn Tomlin, and
Becoming. She emphasized free
Mary Ann Swain (1983)
choice of personal meaning in
 Developed Modeling and Role
relating value priorities, co –
Modeling Theory. The focus of this
creating the rhythmical patterns, in
exchange with the environment, and theory is on the person. The nurse
co transcending in many dimensions models (assesses), role models
as possibilities unfold. (plans), and intervenes in this
interpersonal and interactive theory.
R. Joyce Travelbee (1966,1971)
 They asserted that each individual
 She postulated the Interpersonal
unique, has some self-care
Aspects of Nursing Model.She
knowledge, needs simultaneously to
advocated that the goal of nursing
be attached to the separate from
individual or family in preventing or
others, and has adaptive potential.
coping with illness, regaining health
Nurses in this theory, facilitate,
finding meaning in illness, or
 nurture and accept the person Moral Theories
unconditionally.
1.Freud (1961)
U. Margaret Newman  Believed that the mechanism for right and
 Focused on health as expanding wrong within the individual is the superego,
consciousness. She believed that or conscience. He hypnotized that a child
human are unitary in whom disease internalizes and adopts the moral standards
is a manifestation of the pattern of and character or character traits of the
health. model parent through the process of
 She defined consciousness as the identification.
information capability of the system  The strength of the superego depends on
which is influenced by time, space the intensity of the child’s feeling of
movement and is ever – expanding. aggression or attachment toward the model
V. Patricia Benner and Judith Wrudel parent rather than on the actual standards
(1989) of the parent.
 Proposed the Primacy and Caring 2.Erikson (1964)
 Erikson’s theory on the development of
Model. They believed that caring
virtues or unifying strengths of the “good
central to the essence of nursing.
man” suggest that moral development
Caring creates the possibilities for
continuous throughout life. He believed
coping and creates the possibilities
that if the conflicts of each psychosocial
for connecting with and concern for
developmental stages favorably resolved,
others.
then an ‘ego-strength” or virtue emerges.
W. Anne Boykin and Savina 3.Kohlberg
Schoenhofer  Suggested three levels of moral
 Presented the Grand theory of development. He focused on the reason for
Nursing as Caring . They believed the making of a decision, not on the
that all person are caring, and morality of the decision itself.
nursing is a response to a unique 1. At first level called the premolar or the pre
social call. The focus of nursing is on conventional level, children are responsive
nurturing person living and growing to cultural rules and labels of good and bad,
in caring in a manner that is specific rightand wrong. However children interpret
to each nurse-nursed relationship or these in terms of the physicalconsequences
nursing situation. Each nursing of the actions, i.e., punishment or reward.
situation is original. 2. At the second level, the conventional level,
 They support that caring is a moral the individual is concerned about
imperative. Nursing as Caring is not maintaining the expectations of the family,
based on need or deficit but is groups or nation and sees this as right.
egalitarian model helping. 3. At the third level, people make
postconventional, autonomous, or principal
level. At this level, people make an effort to
define valid values and principles without
regard to outside authority or to the
 expectations of others. These involve  He used the term “faith” as a form of
respect for other human and belief that knowing a way of being in relation “to an
relationship are based on mutual trust. ultimate environment.” To Fowler, faith is a
relational phenomenon: it is “an active
Peter (1981) made-of-being-in-relation to others in
 Proposed a concept of rational morality which we invest commitment, belief, love,
based on principles. Moral development is risk and hope.”
usually considered to involve three separate
components: moral emotion (what one
feels), moral judgment (how one reasons), ROLES AND FUNCTIONS OF THE
and moral behavior (how one acts).
NURSE
 In addition, Peters believed that the
 Care giver
development of character traits or virtues is
 Decision-maker
an essential aspect or moral development.
 Protector
And that virtues or character traits can be
 Client Advocate
learned from others and encouraged by the
 Manager
example of others.
 Rehabilitator
 Also, Peters believed that some can be
 Comforter
described as habits because they are in
 Communicator
some sense automatic and therefore are
 Teacher
performed habitually, such as politeness,
 Counselor
chastity, tidiness, thrift and honesty.
 Coordinator
Gilligan (1982)
 Leader
 Included the concepts of caring and
 Role Model
responsibility. She described three stages in
 Administrator
the process of developing an “Ethic of Care”
which are as follows.1.Caring for
oneself.2.Caring for others.3.Caring for self Selected Expanded Career Roles of Nurses
and others. 1. Nurse Practitioner
 She believed the human see morality in the  A nurse who has an advanced
integrity of relationships and caring. For education and is a graduate of a
women, what is right is taking responsibility nurse practitioner program.
for others as self-chosen decision. On the  These nurses are in areas as adult
other hand, men consider what is right to nurse practitioner, family nurse
be what is just. practitioner, school nurse
practitioner, pediatric nurse
practitioner, or gerontology nurse
Spiritual Theories
practitioner.
Fowler (1979)
 They are employed in health care
 Described the development of faith. He
agencies or community based
believed that faith, or the spiritual
settings. They usually deal with non-
dimension is a force that gives meaning to a
emergency acute or chronic illness
person’s life.
 and provide primary ambulatory  Nurse educator is employed in
care. nursing programs, at educational
2. Clinical Nurse Specialist institutions, and in hospital staff
 A nurse who has an advanced education.
degree or expertise and is  The nurse educator usually ha a
considered to be an expert in a baccalaureate degree or more
specialized area of practice (e.g., advanced preparation and
gerontology, oncology). frequently has expertise in a
 The nurse provides direct client particular area of practice. The nurse
care, educates others, consults, educator is responsible for
conducts research, and manages classroom and of ten clinicalteaching
care. 6. Nurse Entrepreneur
 The American Nurses Credentialing  A nurse who usually has an
Center provides national advanced degree and manages a
certification of clinical specialists. health-related business.
3. Nurse Anesthetist  The nurse may be involved in
 A nurse who has completed education, consultation, or research,
advanced education in an accredited for example.
program in anesthesiology.
 The nurse anesthetist carries out COMMUNICATION IN NURSING
pre-operative visits and
assessments, and Administers
COMMUNICATION
general anesthetics for surgery
1. Is the means to establish a helping-healing
under the supervision of a physician
relationships. All behaviorcommunication
prepared in anesthesiology.
influences behavior
 The nurse anesthetist also assesses
2. Communication is essential to the nurse-
the postoperative of clients
patient relationship for the following
4. Nurse Midwife
reasons
 An RN who has completed a
3. Is the vehicle for establishing a therapeutic
program in midwifery.
relationship.
 The nurse gives pre-natal and post-
4. It the means by which an individual influen
natal care and manages deliveries in
ces the behavior of another,which leads to
normal pregnancies.
the successful outcome of nursing
 The midwife practices the
intervention.
association with a health care
agency and can obtain medical
Basic Elements of the Communication Process
services if complication occurs.
1. SENDER – is the person who encodes and
 The nurse midwife may also conduct
delivers the message
routine Papanicolaou smears, family
2. MESSAGES – is the content of the
planning, and routine breast
communication. It may contain verbal, nonverbal,
examination.
and symbolic language.
5. Nurse Educator
3. RECEIVER – is the person who receives the 1. Listen attentively, be patient, and do
decodes the message. not interrupt.
4. FEEDBACK – is the message returned by the 2. Ask simple question that require “yes” and
receiver. It indicates whether the meaning of the “no” answers.
sender’s message was understood. 3. Allow time for understanding and
response.
Modes of Communication 4. Use visual cues (e.g., words, pictures,
1.Verbal Communication – use of spoken or written and objects)
words. 5. Allow only one person to speak at a
2.Nonverbal Communication– use of gestures, time.
facial expressions, posture/gait, body movements, 6. Do not shout or speak too loudly.
physical appearance and body language 7. U s e c o m m u n i c a t i o n a i d : -pad and
felt-tipped pen, magic slate, pictures
Characteristics of Good Communication denoting basic needs, callbells or alarm.
1. Simplicity – includes uses of commonly 2. Clients who are cognitively impaired
understood, brevity, and completeness. 1. Reduce environmental distractions
2. Clarity– involves saying what is meant. The while conversing.
nurse should also need to speak slowly and 2. Get client’s attention prior to
enunciate words well. speaking
3. Timing and Relevance – requires choice of 3. Use simple sentences and avoid long
appropriate time and consideration of the explanation.
client’s interest and concerns. Ask one 4. A s k o n e q u e s t i o n a t a t i m e
question at atime and wait for an answer 5. Allow time for client to respond
before making another comment. 6. B e a n a t t e n t i v e l i s t e n e r
4. Characteristics of Good 7. Include family and friends in conversations,
Communication especially in subjects known toclient.
5. Adaptability – Involves adjustments on 3.Client who are unresponsive
what the nurse says and how it is said 1. Call client by name during interactions
depending on the moods and behavior of 2. Communicate both verbally and by
the client. touch
6. Credibility – Means worthiness of belief. To 3. Speak to client as though he or she
become credible, the nurse requires could hear
adequate knowledge about the topic being 4. Explain all procedures and sensations
discussed. The nurse should be able to 5. Provide orientation to person,
provide accurate information, to convey place, and time
confidence and certainly in what she says. 6. Avoid talking about client to others in his or
her presence
Communicating With Clients Who 7. Avoid saying things client should not hear
Have Special Needs 4.Communicating with hearing impaired client
1.Clients who cannot speak clearly (aphasia, 1. Establish a method of
dysarthria, muteness) communication (pen/pencil and paper, sign-
language)
 2. Pay attention to client’s non-verbal 5.flexible enough to retrieve critical data, maintain
cues continuity of care, track client outcomes, and
3. Decrease background noise such as reflects current standards of nursing practice
television 6.Effective documentation ensures continuity of
4. Always face the client when speaking care, saves time and minimizes the risk of error.
5. It is also important to check the family as to 7.As members of the health care team, nurses
how to communicate with the client need to communicate information about clients
6. It may be necessary to contact the accurately and in timely manner
appropriate department resource person 8.If the care plan is not communicated to all
for this type of disability members of the health care team, care can
5. Client who do not speak English become fragmented, repetition of tasks occurs, and
1. Speak to client in normal tone of voice therapies may be delayed or omitted.
(shouting may be interpreted as anger) 9.Data recorded, reported, or c0mmunicated to
2. Establish method for client o signal desire other health care professionals are CONFIDENTIAL
to communicate (call light or bell) and must be protected.
3. Provide an interpreter (translator)
as needed CONFIDENTIALITY
4. Avoid using family members, especially 1. nurses are legally and ethically obligated to keep
children, as interpreters. information about clients confidential.
5. Develop communication board, pictures or 2.Nurses may not discuss a client’s examination,
cards. observation, conversation, or treatment with other
6. Have dictionary (English/Spanish) available clients or staff not involved in the client’s care.
if client can read. 3. Only staff directly involved in a specific client’s
care have legitimate access to the record.
Reports 4.CONFIDENTIALITY
 Are oral ,written, or audio taped exchanges 5. Clients frequently request copies of their medical
of information between caregivers. record, and they have the right to read those
records.
Common reports: 6.Nurses are responsible for protecting records
1.Change-in-shift report from all unauthorized readers.
2.Telephone report 7. when nurses and other health care professionals
3.Telephone or verbal order – only RN’s are have a legitimate reason to use records for data
allowed to accept telephone orders. gathering, research, or continuing education,
4.Transfer report appropriate authorization must be obtained
5.Incident report according to agency policy.
8.Confidentiality
Documentation 9.Maintaining confidentiality is an important aspect
1.Is anything written or printed that is relied on as of profession behavior.
record or proof for authorized person. 10.It is essential that the nurse safe-guard the
2.Nursing documentation must be: client’ right to privacy by carefully protecting
3.accurate information of a sensitive, private nature.
4.comprehensive
11.Sharing personal information or gossiping about accuracy and decrease unnecessary
others violates nursing ethical codes and practice duplication, many healthcare agencies
standards. use records kept near the client’s
12.It sends the message that the nurse cannot be bedside, which facilitate immediate
trusted and damages the interpersonal documentation of information as it is
relationships. collected from a client
5. Organized
Guidelines of Quality Documentation and 1. .The nurse communicates information in a
Reporting. logical order.
1.Factual  For example, an organized note describes
1. a record must contain descriptive, objective the client’s pain, nurse’s assessment,
information about what a nurse sees, nurse’s interventions, and the client’s
hears, feels, and smells. response
2. The use of vague terms, such as appears,
seems, and apparently, is not acceptable Legal Guidelines for recording
because these words suggests that the 1. Draw single line through error, write word error
nurse is stating an opinion. above it and sign your name or initials. Then record
 Example: “ the client seems anxious” (the note correctly.
phrase seems anxious is a conclusion 2.Do not write retaliatory or critical comments
without supported facts.) about the client or care by other health care
2.Accurate professionals.
1. .The use of exact measurements establishes  Enter only objective descriptions of client’s
accuracy. (example: “Intake of 350 ml of behavior; client’s comments should be
water” is more accurate than “ the client quoted.
drank an adequate amount of fluid” 3.Correct all errors promptly
2. Documentation of concise data is clear and  errors in recording can lead to errors in
easy to understand. treatment
3. It is essential to avoid the use of  Avoid rushing to complete charting, be sure
unnecessary words and irrelevant details information is accurate.
3. Complete 4.Do not leave blank spaces in nurse’s notes.
1. The information within a recorded entry or  Chart consecutively, line by line; if space is
a report needs to be complete, containing left, draw line horizontally through it and
appropriate and essential information. sign your name at end.
Example: 5.Record all entries legibly and in blank ink
 The client verbalizes sharp, throbbing pain  Never use pencil, felt pen.
localized along lateral side of right ankle,  Blank ink is more legible when records are
beginning approximately 15 minutes ago photocopied or transferred to microfilm.
after twisting his foot on the stair. Client  Legal Guidelines for Recording
rates pain as 8 on a scale of 0-10. 6.If order is questioned, record that clarification
4. Current was sought.
1. Timely entries are essential in the
clients ongoing care. To increase
  If you perform orders known to be Normal Adult Temperature Ranges
incorrect, you are just as liable for A. Oral 36.5 –37.5 ºC
prosecution as the physician is. B. Axillary 35.8 – 37.0 ºC
7.Chart only for yourself C. Rectal 37.0 – 38.1 ºC
 Never chart for someone else. D. Tympanic 36.8 – 37.9ºC
 You are accountable for information you
enter into chart. Methods of Temperature-Taking
8.Avoid using generalized, empty phrases such as 1. Oral – most accessible and convenient
“status unchanged” or “had good day”. method.
 Begin each entry with time, and end with a. Put on gloves, and position the tip of the
your signature and title. thermometer under the patients tongue on
 Do not wait until end of shift to record either of the frenulun as far back as
important changes that occurred several possible. Itpromotes contact to the
hours earlier. Be sure to sign each entry. superficial blood vessels and ensure a more
9.For computer documentation keep your accurate reading.
password to yourself. b. Wash thermometer before use
 maintain security and confidentiality. c. Take oral temp 2-3 minutes.
 Once logged into the computer do not leave d. Allow 15 min to elapse between client’s
the computer screen unattended. food intakes of hot or cold food, smoking.
e. Instruct the patient to close his lips but not
Assessing Vital Signs to bite down with his teeth to avoid
Vital Signs or Cardinal Signs are: breaking the thermometer in his mouth.
 Body temperature Contraindications
 Pulse  Young children an infants
 Respiration Patients who are unconscious or disoriented
 Blood pressure Who must breath through the mouth
 Pain Seizure prone
Patient with N/V
I.Body Temperature Patients with oral lesions/surgeries
 The balance between the heat produced by
the body and the heat loss from the body.
Types of Body Temperature 2. Rectal- most accurate measurement of
 Core temperature –temperature of the temperature
deep tissues of the body. a. Position- lateral position with his top legs flexed
 Surface body temperature and drape him to provide privacy
Alteration in body Temperature b. Squeeze the lubricant onto a facial tissue to
 Pyrexia – Body temperature above avoid contaminating the lubricant supply
normal range( hyperthermia) c. Insert thermometer by 0.5 – 1.5 inches
 Hyperpyrexia– Very high fever, d.Hold in place in 2minutese. Do not force to insert
41ºC(105.8 F) and above the thermometer
 Hypothermia– Subnormal temperature. Contraindications
Patient with diarrhea
Recent rectal or prostatic surgery or injury h.Provide dry clothing and linens
because it may injure inflamed tissue i.Give antipyretic as ordered by MD
Recent myocardial infarction
Patient post head injury
3. Axillary – safest and non-invasive
a. Pat the axilla dry
b.Ask the patient to reach across his chest and II. Pulse – It’s the wave of blood created by
grasp his opposite shoulder. This promote skin contractions of the left ventricles of the heart.
contact with the thermometer Normal Pulse rate
c.Hold it in place for 9 minutes because the  1 year 80-140 beats/min
thermometer isn’t close in a body cavity  2 years 80- 130 beats/min
Note:  6 years 75- 120 beats/min
Use the same thermometer for repeat  10 years 60-90 beats/min
temperature taking to ensure more consistent  Adult 60-100 beats/min
result
Store chemical-dot thermometer in a cool area Tachycardia – pulse rate of above 100 beats/min
because exposure to heat activates the dye dots. Bradycardia- pulse rate below 60 beats/min
4. Tympanic thermometer Irregular – uneven time interval between beats.
a.Make sure the lens under the probe is clean and
shiny What you need:
b.Stabilized the patient’s head; gently pull the ear a.Watch with second hand
straight back (for children up to age 1) or up and b.Stethoscope (for apical pulse)
back (for children 1 and older to adults) c.Doppler ultrasound blood flow detector if
c.Insert the thermometer until the entire ear canal necessary
is sealed
d.Place the activation button, and hold it in place A. Radial Pulse
for 1 second 1. Wash your hand and tell your client that
5. Chemical-dot thermometer you are going to take his pulse
a.Leave the chemical-dot thermometer in place for 2. Place the client in sitting or supine
45 seconds position with his arm on his side or
b.Read the temperature as the last dye dot that acrosshischest
has change color, or fired. 3. Gently press your index, middle, and
ring fingers on the radial artery, inside
Nursing Interventions in Clients with Fever the patient’s wrist.
a.Monitor V.S 4. Excessive pressure may obstruct blood
b.Assess skin color and temperature flow distal to the pulse site
c.Monitor WBC, Hct and other pertinent lab 5. Counting for a full minute provides a
records more accurate picture of irregularities
d.Provide adequate foods and fluids. B. Doppler device
e.Promote rest 1. Apply small amount of transmission gel
f.Monitor I & O to the ultrasound probe
g.Provide TSB
 2. Position the probe on the skin directly h. If the client is crying or anxious, delay
over a selected artery measuring his blood pressure to avoid false-
3. Set the volume to the lowest setting high BP
4. To obtain best signals, put gel between
the skin and the probe and tilt theprobe V. Pain
45 degrees from the artery. How to assess Pain
5. After you have measure the pulse rate, a. You must consider both the patient’s
clean the probe with soft cloth soaked description and your observations on his
in antiseptic. Do not immerse the probe behavioral responses.
b. First, ask the client to rank his pain on a
III. Respiration - is the exchange of oxygen and scale of 0-10, with 0 denoting lack of pain
carbon dioxide between the atmosphere and the and 10 denoting the worst pain imaginable.
body c. Ask:
Assessing Respiration d. Where is the pain located?
 Rate – Normal 14-20/ min in adult e. How long does the pain last?
 The best time to assess respiration is f. How often does it occur?
immediately after taking client’s pulse g. Can you describe the pain?
 Count respiration for 60 second h. What makes the pain worse
 As you count the respiration, assess and i. Observe the patient’s behavioral response
record breath sound as stridor, wheezing, to pain (body language, moaning,
or stertor. grimacing, withdrawal, crying, restlessness
 Respiratory rates of less than 10 or more muscle twitching andimmobility)
than 40 are usually considered abnormal j. Also note physiological response, which
and should be reported immediately to the may be sympathetic or parasympathetic
physician. Managing Pain
IV. Blood Pressure 1. Giving medication as per MD’s order
 Adult – 90- 132 systolic 2. Giving emotional support
60- 85 diastolic 3. Performing comfort measures
 Elderly 140-160 systolic 4. Use cognitive therapy
70-90 diastolic
a. Ensure that the client is rested Height and weight
b. Use appropriate size of BP cuff. a. Height and weight are routinely measured
c. If too tight and narrow- false high BP when a patient is admitted to a health care
d. If too lose and wide-false low BP facility.
e. Position the patient on sitting or supine b. It is essential in calculating drug dosage,
position contrast agents, assessing nutritional status
f. Position the arm at the level of the heart, if and determining the height-weight ratio.
the artery is below the heart level, you may c. Weight is the best overall indicator of fluid
get a false high reading. status, daily monitoring is important for
g. Use the bell of the stethoscope since the clients receiving a diuretics or a medication
blood pressure is a low frequency sound. that causes sodium retention.
 d. Weight can be measured with a standing c. Soak the specimen in a container
scale, chair scale and bed scale. with ice
e. Height can be measured with the measuring d. Add preservative as ordered
bar, standing scale or tape measure if the according to hospital policy
client is confine in a supine position. 3. Second-Voided urine – required to
Pointers: assess glucose level and for the
a. Reassure and steady patient who are at risk presence of albumen in the urine.
for losing their balance on a scale. a. Discard the first urine
b. Weight the patient at the same time each b. Give the patient a glass of water to
day. (usually before breakfast), ins imilar drink
clothing and using the same scale. c. After few minutes, ask the patient to
c. If the patient uses crutches, weigh the client void
with the crutches or heavy clothing and 4. Catheterized urine specimen
subtract their weight from the total a. Clamp the catheter for 30 min to 1
determined patient’ weight. hour to allow urine to accumulate in
the bladder and adequate specimen
can be collected.
Laboratory and Diagnostic b. Clamping the drainage tube and
emptying the urine into a container
examination are contraindicated after a
A. Urine Specimen genitourinary surgery.
1. Clean-Catch mid-stream - urine
specimen for routine urinalysis, culture B. Stool Specimen
and sensitivity test 1. Fecalysis – to assess gross appearance of
a. Best time to collect is in the stool and presence of ova or parasite
morning, first voided urine a. Secure a sterile specimen container
b. Provide sterile container b. Ask the pt. to defecate into a clean , dry
c. Do perineal care before collection of bed pan or a portable commode.
the urine c. Instruct client not to contaminate the
d. Discard the first flow of urine specimen with urine or toilet paper(urine
e. Label the specimen properly inhibits bacterial growth and paper towel
f. Send the specimen immediately to contain bismuth which interfere with the
the laboratory test result.
g. Document the time of specimen 2. Stool culture and sensitivity test - To
collection and transport to the lab. assess specific etiologic agent causing
h. Document the appearance, odor, gastroenteritis and bacterial sensitivity to
and usual characteristics of the various antibiotics.
specimen. 3. Fecal Occult blood test -are valuable test
2. 24-hour urine specimen for detecting occult blood (hidden) which
a. Discard the first voided urine. may be present incolo-rectal cancer,
b. Collect all specimen thereafter until detecting melena stool
the following day
 a. Hematest- (an Orthotolidin reagent a. Before arterial puncture, perform Allen’s
tablet) test first.
b. Hemoccult slide- (filter paper b. If the patient is receiving oxygen, make sure
impregnated with guaiac) that the patient’s therapy has been
Both test produces blue reaction id occult underway for at least 15 min before
blood lost exceeds 5 ml in 24hours. collecting arterial sample
c. Colocare – a newer test, requires no c. Be sure to indicate on the laboratory
smear request slip the amount and type of oxygen
therapy the patient is having.
Instructions: d. If the patient has just receive a nebulizer
a. Advise client to avoid ingestion of red treatment, wait about 20 minutes before
meat for 3 days collecting the sample.
b. Patient is advise on a high residue diet
c. avoid dark food and bismuth compound
d. .If client is on iron therapy, inform the IV. Blood specimen
MD a. No fasting for the following tests:- CBC,
e. Make sure the stool in not Hgb, Hct, clotting studies, enzyme studies,
contaminated with urine, soap solution serum electrolytesb.
or toilet paper b. Fasting is required:- FBS, BUN, Creatinine,
f. Test sample from several portion of the serum lipid ( cholesterol, triglyceride)
stool.
Venipuncture V. Sputum Specimen
Pointers 1.Gross appearance of the sputum
a. Never collect a venous sample from the arm a. Collect early in the morning
or a leg that is already being used for I.V b. Use sterile container
therapy or blood administration because it c.Rinse the mount with plain water before
mat affect the result. collection of the specimen
b. Never collect venous sample from an d.Instruct the patient to hack-up sputum
infectious site because it may introduce 2. Sputum culture and sensitivity test
pathogens into the vascular system a. Use sterile container
c. Never collect blood from an edematous b.Collect specimen before the first dose of
area, AV shunt, site of previous hematoma, antibiotic
or vascular injury. 3. Acid-Fast Bacilli
d. Don’t wipe off the povidine-iodine with a.To assess presence of active pulmonary
alcohol because alcohol cancels the effect tuberculosis
of povidine iodine. b.Collect sputum in three consecutive morning
e. If the patient has a clotting disorder or is 4. Cytologic sputum exam--to assess for presence
receiving anticoagulant therapy, maintain of abnormal or cancer cells.
pressure on the site for at least 5 min after
withdrawing the needle.
Diagnostic Test
Arterial puncture for ABG test 1. PPD test
a. read result 48 – 72 hours after injection.
b. For HIV positive clients, induration of 5 mm is d.Have client void before the procedur
considered positive e.Monitor PT, PTT, ECG prior to test
2. Bronchography f.NPO for 4-6 hours before the test
a. Secure consent g.Shave the groin or brachial area
b. Check for allergies to seafood or iodine or h.After the procedure : bed rest to prevent
anesthesia bleeding on the site, do not flexextremity
c. NPO 6-8 hours before the testd. NPO until gag i.Elevate the affected extremities on extended
reflex return to prevent aspiration position to promote bloodsupply back to the heart
3. Thoracentesis – aspiration of fluid in the pleural and prevent thrombplebities
space. j.Monitor V/S especially peripheral pulses
a. Secure consent, take V/S k.Apply pressure dressing over the puncture site
b.Position upright leaning on overbed table l.Monitor extremity for color, temperature, tingling
c.Avoid cough during insertion to prevent pleural to assess for impaired circulation.
perforation 8. MRI
d.Turn to unaffected side after the procedure to m. secure consent,
prevent leakage of fluid in thethoracic cavity n. the procedure will last 45-60 minute
e.Check for expectoration of blood. This indicate o. Assess client for claustrophobia
trauma and should be reported to MD p. Remove all metal items
immediately. q. Client should remain still
4.Holter Monitor r. Tell client that he will feel nothing but may hear
a. it is continuous ECG monitoring, over 24 hours noises
period s. Client with pacemaker, prosthetic valves,
b. The portable monitoring is called telemetry unit implanted clips, wires are not eligible for MRI.
5. Echocardiogram t. Client with cardiac and respiratory complication
a. ultrasound to assess cardiac structure and may be excluded
mobility u. Instruct client on feeling of warmth or shortness
b. Client should remain still, in supine position of breath if contrast medium is used during the
slightly turned to the leftside, with HOB elevated procedure
15-20 degrees 9.UGIS – Barium Swallow
a. instruct client on low-residue diet 1-3 days
before the procedure
6. Electrocardiography- b. administer laxative evening before the
a.If the patient’s skin is oily, scaly, or diaphoretic, procedure
rub the electrode with a dry 4x4 gauze to enhance c. NPO after midnight
electrode contact. d. instruct client to drink a cup of flavored barium
b.If the area is excessively hairy, clip it e. x-rays are taken every 30 minutes until barium
c.Remove client`s jewelry, coins, belt or any metal advances through the small bowel
d.Tell client to remain still during the procedure f. film can be taken as long as 24 hours later
7. Cardiac Catheterization g. force fluid after the test to prevent
a.Secure consent constipation/barium impaction
b.Assess allergy to iodine, shelfish 10.LGIS – Barium Enema
c.V/S, weight for baseline information
a. instruct client on low-residue diet 1-3 days c. Place the spout 12-18 inches away from
before the procedure the client’s nose or adjust the distance
b. administer laxative evening before the as necessary.
procedure 2. Suctioning
c. NPO after midnight a. Assess the lungs before the procedure
d. administer suppository in AM for baseline information.
e. Enema until clear b. Position: conscious – semi-Fowler’s
f. force fluid after the test to prevent c. Unconscious – lateral position
constipation/barium impaction d. Size of suction catheter- adult- fr 12-18
11. Liver Biopsy e. Hyper oxygenate before and after
a.Secure consent, procedure
b.NPO 2-4 hrs before the test f. Observe sterile technique
c.Monitor PT, Vit K at bedside g. Apply suction during withdrawal of the
d.Place the client in supine at the right side of the catheter
bed h. Maximum time per suctioning –15 sec
e.Instruct client to inhale and exhale deeply for 3. Nasogastric Feeding (gastric gavage)
several times and then exhale and hold breath Insertion:
while the MD insert the needle a. Fowler’s position
f.Right lateral post procedure for 4 hours to apply b. Tip of the nose to tip of the earlobe to the
pressure and prevent bleeding xyphoid
g.Bed rest for 24 hours Tube Feeding:
h.Observe for S/S of peritonitis a. Semi-Fowler’s position
12. Paracentesis b. Assess tube placement
a.Secure consent, check V/S c. Assess residual feeding
b.Let the patient void before the procedure to d. Height of feeding is 12 inches above the
prevent puncture of the bladder tube’s point of insertion
c.Check for serum protein. excessive loss of plasma e. Ask client to remain upright position for at
protein may lead to hypovolemic shock. least 30 min.
13. Lumbar Puncture f. Most common problem of tube feeding is
a.obtain consent Diarrhea due to lactose intolerance
b.instruct client to empty the bladder and bowel
c.position the client in lateral recumbemt with back 4. Enema
at the edge of the examining table a. Check MD’s order
d.instruct client to remain still b. Provide privacy
e.obtain specimen per MDs order c. Position left lateral
d. Size of tube Fr. 22-32
e. Insert 3-4 inches of rectal tube
f. If abdominal cramps occur, temporarily stop the
NURSING PROCEDURES flow until cramps are gone.
1. Steam Inhalation g. Height of enema can – 18 inches
a. It is dependent nursing function. 5. Urinary Catheterization
b. Heat application requires physician’s a. Verify MD’s order
order.
b. Practice strict asepsis
c. Perineal care before the procedure
COMMON THERAPEUTIC
d. Catheter size: male-14-16 , female – 12 – 14 DIETS
e. Length of catheter insertion male – 6-9 1. CLEAR-LIQUID DIET
inches ,female – 3-4 inches Purpose:
*For retention catheter:  relieve thirst and help maintain fluid
Male –anchor laterally or upward over the lower balance. Use:
abdomen to prevent penoscrotal pressure  post-surgically and following acute vomiting
Female- inner aspect of the thigh or diarrhea.
6. Bed Bath  Foods Allowed: carbonated beverages;
a. Provide privacy coffee (caffeinated and decaff.); tea; fruit-
b. Expose, wash and dry one body part a time flavoreddrinks; strained fruit juices; clear,
c. Use warm water (110-115 F) flavored gelatins; broth, consomme;sugar;
d. Wash from cleanest to dirtiest popsicles; commercially prepared clear
e. Wash, rinse, and dry the arms and leg using liquids; and hard candy.
Long, firm strokes from distal toproximal area – to  Foods Avoided: milk and milk products, fruit
increase venous return. juices with pulp, and fruit.
7. Foot Care 2. FULL-LIQUID DIET
a. Soaking the feet of diabetic client is no longer Purpose:
recommended  provide an adequately nutritious diet for
b. Cut nail straight across patients who cannot chew or who are too ill
8. Mouth Care to do so.
a. Eat coarse, fibrous foods (cleansing foods) such  Use: acute infection with fever, GI upsets,
as fresh fruits and raw vegetables after surgery as a progression from clear
b.Dental check every 6 mounts liquids.
9. Oral care for unconscious client  Foods Allowed: clear liquids, milk drinks,
a.Place in side lying position cooked cereals, custards, ice cream,
b. Have the suction apparatus readily available sherbets,eggnog, all strained fruit juices,
10. Hair Shampoo creamed vegetable soups,
c. Place client diagonally in bed puddings,mashed potatoes, instant
d. Cover the eyes with wash cloth breakfast drinks, yogurt, mild cheese sauce
e. Plug the ears with cotton balls orpureed meat, and seasoning.
f. Massage the scalp with the fatpads of the fingers  Foods Avoided: nuts, seeds, coconut, fruit,
to promote circulation in the scalp. jam, and marmalade
11. Restraints SOFT DIET
g. Secure MD’s order for each episode of restraints Purpose:
application.  provide adequate nutrition for those who
h. Check circulation every 15 min have troubled chewing.
i. Remove restraints at least every 2 hours for 30  Use: patient with no teeth or ill-fitting
minutes dentures; transition from full-liquid to
generaldiet; and for those who cannot
tolerate highly seasoned, fried or raw foods
 following acute infections or RENAL DIET
gastrointestinal disturbances such as gastric Purpose:
ulcer or cholelithiasis.  control protein, potassium, sodium, and
 Foods Allowed: very tender minced, fluid levels in the body.
ground, baked broiled, roasted, stewed, or  Use: acute and chronic renal failure,
creamed beef,lamb, veal, liver,poultry, or hemodialysis.
fish; crisp bacon or sweet bread; cooked  Foods Allowed: high-biological proteins
vegetables; pasta; all fruit juices; soft raw such as meat, fowl, fish, cheese, and dairy
fruits;soft bread and cereals; all desserts products-range between 20 and60 mg/day.
that are soft; and cheeses.  Potassium is usually limited to 1500
 Foods Avoided: coarse whole-grain cereals mg/day.
and bread; nuts; raisins; coconut; fruits with  Vegetables such as cabbage, cucumber, and
smallseeds; fried foods; highfat gravies or peas are lowest in potassium.
sauces; spicy salad dressings; pickled meat,  Sodium is restricted to 500 mg/day.
fish, or poultry;strong cheeses; brown  Fluid intake is restricted to the daily volume
orwild rice; raw vegetables, as well as lima plus 500 mL, which represents insensible
beans and corn; spices such as horse radish, water loss.
mustard, andcatsup; and popcorn.  Fluid intake measures water in fruit,
vegetables, milk and meat.
SODIUM-RESTRICTED DIET  Foods Avoided: Cereals, bread, macaroni,
Purpose: noodles, spaghetti, avocados, kidney beans,
 reduce sodium content in the tissue and potatochips, raw fruit, yams, soybeans,
promote excretion of water. nuts, gingerbread, apricots, bananas,
 Use: heart failure, hypertension, renal figs,grapefruit, oranges, percolated coffee,
disease, cirrhosis, toxemia of pregnancy, Coca-Cola, orange crush, sport drinks, and
and cortisone therapy. breakfast drinks such as Tang or Awake
 Modifications: mildly restrictive 2 g sodium
diet to extremely restricted 200 mg sodium HIGH-PROTEIN, HIGH CARBOHYDRATE DIET
diet. Purpose:
 Foods Avoided: table salt; all commercial  to correct large protein losses and raises
soups, including bouillon; gravy, catsup, the level of blood albumin. May be
mustard,meat sauces, and soysauce; modified to include low-fat, low-sodium,
buttermilk, ice cream, and sherbet; sodas; and low-cholesterol diets.
beet greens, carrots, celery,chard,  Use: burns, hepatitis, cirrhosis, pregnancy,
sauerkraut, andspinach; all canned hyperthyroidism, mononucleosis, protein
vegetables; frozen peas; all baked products deficiency due to poor eating habits,
containing salt, baking powder, or baking geriatric patient with poor intake; nephritis,
soda; potato chipsand popcorn; fresh nephrosis, and liverand gall bladder
orcanned shellfish; all cheeses; smoked or disorder.
commercially prepared meats; saltedbutter  Foods Allowed: general diet with added
or margarine;bacon, olives; and protein.
commercially prepared salad dressings.
  Foods Avoided: restrictions depend on cereals;rich pastries; pies; chocolate; jams
modifications added to the diet. The with seeds; nuts; seasoned
modifications are determined by the dressings;caffeinated coffee; strong
patient’s condition. tea;cocoa; alcoholic and carbonated
beverages; and pepper.

LOW-FAT, CHOLESTEROL-RESTRICTED DIET

PURINE-RESTRICTED DIET Purpose:
Purpose:  reduce hyperlipedimia, provide dietary
 designed to reduce intake of uric acid- treatment for malabsorption syndromesand
producing foods. patients havingacute intolerance for fats.
 Use: high uric acid retention, uric acid renal  Use: hyperlipedimia, atherosclerosis,
stones, and gout. pancreatitis, cystic fibrosis, sprue (disease
 Foods Allowed: general diet plus 2-3 quarts of intestinal tractcharacterized by
of liquid daily. malabsorption), gastrectomy, massive
 Foods Avoided: cheese containing spices or resection of smallintestine, and
nuts, fried eggs, meat, liver, seafood, lentils, cholecystitis.
dried peas and beans, broth,bouillon,  Foods Allowed: nonfat milk; low-
gravies, oatmeal and whole wheat, pasta, carbohydrate, low-fat vegetables; most
noodles, and alcoholicbeverages. Limited fruits; breads; pastas;cornmeal; lean
quantities of meat, fish, and seafood meats;nsaturated fats
allowed.  Foods Avoided: remember to avoid the five
C’s of cholesterol- cookies, cream, cake,
BLAND DIET coconut, chocolate; whole milk and whole-
Purpose: milk or cream products, avocados, olives,
 provision of a diet low in fiber, roughage, commercially prepared baked goods such as
mechanical irritants, and chemical donuts and muffins, poultry skin, highly
stimulants. marbled meats, butter, ordinary
 Use: Gastritis, hyperchlorhydria (excess margarines, olive oil, lard, pudding made
hydrochloric acid), functional GI with whole milk, icecream, candies with
disorders,gastric atony, diarhhea, spastic chocolate, cream, sauces, gravies and
constipation, biliary indigestion, and hiatus commercially fried foods.
hernia.
 Foods Allowed: varied to meet individual DIABETIC DIET
needs and food tolerances. Purpose:
 Foods Avoided: fried foods, including eggs,  maintain blood glucose as near as normal as
meat, fish, and sea food; cheese with added possible; prevent or delay onset of diabetic
nuts orspices; commercially prepared complications.
luncheon meats; cured meats such as ham;  Use: diabetes mellitus
gravies and sauces; raw vegetables; potato  Foods Allowed: choose foods with low
skins; fruit juices with pulp; figs; raisins; glycemic index compose of:
fresh fruits; whole wheats; ryebread; bran a. 45-55% carbohydrates
 b. 30-35% fats d. Fats: any, such as butter, margarine,
c. 10-25% protein salad dressings, Crisco, Spry, lard, salad
 coffee, tea, broth, spices and flavoring can oil, olive oil, ect.
be used as desired. e. fruits: cranberry, plums, prunes
 exchange groups include: milk, vegetable, f. Meat, eggs, cheese: any meat, fish or
fruits, starch/bread, meat (divided inlean, fowl, two serving daily; at least one egg
medium fat, andhigh fat), and fat daily
exchanges. g. Potato substitutes: corn, hominy, lentils,
 the number of exchanges allowed from macaroni, noodles, rice, spaghetti,
each group is dependent on the total vermicelli.
number of calories allowed. h. Soup: broth as desired; other soups
 non-nutritive sweeteners (sorbitol) in from food allowed
moderation with controlled, normal weight i. Sweets: cranberry and plum jelly; plain
diabetics. sugar candy
 Foods Avoided: concentrated sweets or j. Miscellaneous: cream sauce, gravy,
regular soft drinks. peanut butter, peanuts, popcorn, salt,
spices, vinegar, walnuts.
ACID AND ALKALINE DIET  Restricted foods:
Purpose: a. no more than the amount allowed each
 Furnish a well balance diet in which the day
total acid ash is greater than the total 1. Milk: 1 pint daily (may be used in
alkaline ash each day. other ways than as beverage)
 Use: Retard the formation of renal calculi. 2. Cream: 1/3 cup or less daily
The type of diet chosen depends on 3. Fruits: one serving of fruits daily( in
laboratory analysis of the stone. addition to the prunes, plums
 Acid and alkaline ash food groups: andcranberries
a. Acid ash: meat, whole grains, eggs, 4. Vegetable: including potatoes: two
cheese, cranberries, prunes, plums servings daily
b. Alkaline ash: milk, vegetables, fruits 5. Sweets: Chocolate or candies,
(except cranberries, prunes and plums.) syrups.
c. Neutral: sugar, fats, beverages (coffee, 6. Miscellaneous: other nuts, olives,
tea) pickles.
 Foods allowed
a. Breads: any, preferably whole grain; HIGH-FIBER DIET
crackers; rolls Purpose:
b. Cereals: any, preferable whole grains  Soften the stool, exercise digestive tract
c. Desserts: angel food or sunshine cake; muscles, speed passage of food through
cookies made without baking powderor digestive tract to prevent exposure to
soda; cornstarch, pudding, cranberry cancer-causing agents in food, lower blood
desserts, ice cream, sherbet, plum or lipids, prevent sharp rise in glucose after
prune desserts; riceor tapioca pudding. eating.
  Use: diabetes, hyperlipedemia, c. Before returning the container
constipation, diverticulitis, to the storage
anticarcinogenics (colon) 2. Right Dose –when performing
 Foods Allowed: recommended intake about medication calculation or
6 g crude fiber daily, All bran cereal, conversions, the nurse should have
Watermelon, prunes, dried peaches, apple another qualified nurse check the
with skin; parsnip, peas, Brussels sprout, calculated dose.
sunflower seeds. 3. Right Client – an important step in
administering medication safely is
LOW RESIDUE DIET being sure the medication is given to
Purpose: the right client.
 Reduce stool bulk and slow transit time a. To identify the client correctly
 Use: Bowel inflammation during acute b. The nurse check the medication
diverticulitis, or ulcerative colitis, administration form against the
preparation for bowel surgery, esophageal client’s identification bracelet
and intestinal stenosis. and asks the client to state his or
 Food Allowed: eggs; ground or well-cooked her name to ensure the client’s
tender meat, fish, poultry; milk, cheeses; identification bracelet has the
strainedfruit juice (exceptprune): cooked or correct information.
canned apples, apricots, peaches, pears; 4. RIGHT ROUTE – if a prescriber’s
ripe banana;strained vegetable order does nor designate a route of
juice:canned, cooked, or strained administration, the nurse consult
asparagus, beets, green beans, pumpkin, the prescriber. Likewise, if the
squash,spinach; white bread;refined cereals specified route is not recommended,
(Cream of Wheat) the nurse should alert the prescriber
immediately.
5. RIGHT TIME
PRINCIPLES OF MEDICATION a. the nurse must know why a
medication is ordered for certain
ADMINISTRATION times of the day and whether the
I. “Six Rights” of drug administration time schedule can be altered
1. The Right Medication – when b. each institution has are
administering medications, the commended time schedule for
nurse compares the label of the medications ordered at frequent
medication container with interval
medication form. The nurse does c. Medication that must act at
this 3 times: certain times are given priority (e.g
a. Before removing the container insulin should be given at a precise
from the drawer or shelf interval before a meal )
b. As the amount of medication 6. RIGHT DOCUMENTATION –
ordered is removed from the Documentation is an important part
container of safe medication administration
 a. The documentation for the
medication should clearly reflect “A FUNDAMENTAL RULE OF SAFE
the client’s name, the name of
DRUG ADMINISTRATION IS: “NEVER
the ordered medication, the
time, dose, route and frequency ADMINISTER AN UNFAMILIAR
b. Sign medication sheet MEDICATION ”
immediately after administration
of the drug V. Keep the Narcotics in locked place.
VI. Use only medications that are in clearly
labeled containers. Relabelling of drugs
CLIENT’S RIGHT RELATED TO MEDICATION are the responsibility of the pharmacist.
ADMINISTRATION VII. Return liquid that are cloudy in color to
A client has the following rights: the pharmacy.
a. To be informed of the medication’s name, VIII. Before administering medication,
purpose, action, and potential undesired identify the client correctly
effects. IX. Do not leave the medication at the
b. To refuse a medication regardless of the bedside. Stay with the client until he
consequences actually takes the medications.
c. To have a qualified nurses or physicians X. The nurse who prepares the drug
assess medication history, including administers it.. Only the nurse prepares
allergies the drug knows what the drug is. Do not
d. To be properly advised of the experimental accept endorsement of medication.
nature of medication therapy and to give XI. If the client vomits after taking the
written consent for its use medication, report this to the nurse in-
e. To received labeled medications safely charge or physician.
without discomfort in accordance with the XII. Preoperative medications are usually
six rights of medication administration discontinued during the postoperative
f. To receive appropriate supportive therapy period unless ordered to be continued.
in relation to medication therapy XIII. When a medication is omitted for any
g. To not receive unnecessary medications reason, record the fact together with
the reason.
II. Practice Asepsis- wash hand before and XIV. When the medication error is made,
after preparing the medication toreduce report it immediately to the nurse in-
transfer of microorganisms. charge or physician. To implement
III. Nurse who administer the medications necessary measures immediately. This
are responsible for their own action. may prevent any adverse effects of the
Question any order that you considered drug.
incorrect (may be unclear or
appropriate) Medication Administration
IV. Be knowledgeable about the 1. Oral administration
medication that you administer *Advantages
 a. The easiest and most desirable way to 2. SUBLINGUAL
administer medication a. A drug that is placed under the tongue, where it
b. Most convenient dissolves.
c. Safe, does not break skin barrier b. When the medication is in capsule and ordered
d. Usually less expensive sublingually, the fluid must be aspirated from the
*Disadvantages capsule and placed under the tongue.
a. Inappropriate if client cannot swallow c. A medication given by the sublingual route
and if GIT has reduced motility should not be swallowed, or desire effects will not
b. Inappropriate for client with nausea and be achieved
vomiting *Advantages:
c. Drug may have unpleasant tasted. Drug a. Same as oral
may discolor the teeth b. Drug is rapidly absorbed in the bloodstream
e. Drug may irritate the gastric mucosa *Disadvantages:
f. Drug may be aspirated by seriously ill a. If swallowed, drug may be inactivated by gastric
patient. juices.
b. Drug must remain under the tongue until
Drug Forms for Oral Administration dissolved and absorbed
a. Solid: tablet, capsule, pill, powder
b. Liquid: syrup, suspension, emulsion, elixir, milk, 3. BUCCAL
or other alkaline substances. a. A medication is held in the mouth against the
c. Syrup: sugar-based liquid medication mucous membranes of the cheek until the drug
d. Suspension : water-based liquid medication. dissolves.
Shake bottle before use of medication to properly b. The medication should not be chewed,
mix it. swallowed, or placed under the tongue (e.g
e. Emulsion: oil-based liquid medication sustained release nitroglycerine,
f. Elixir: alcohol-based liquid medication. After opiates,antiemetics,tranquilizer, sedatives)
administration of elixir, allow 30minutes to elapse c. Client should be taught to alternate the cheeks
before giving water. This allows maximum with each subsequent dose to avoid mucosal
absorption of the medication. irritation
*Advantages:
“NEVER CRUSH ENTERIC-COATED OR a.Same as oral
b. Drug can be administered for local effect
SUSTAINED RELEASE TABLET”-
c. Ensures greater potency because drug directly
Crushing enteric-coated tablets:
enters the blood and bypass the liver
– allows the irrigating medication to come in
*Disadvantages:
contact with the oral or gastric mucosa, resulting in
a. If swallowed, drug may be inactivated by gastric
mucositis or gastric irritation.
juice
Crushing sustained-released medication
– allows all the medication to be absorbed at the
4. TOPICAL
same time, resulting in a higher than expected
– Application of medication to a circumscribed area
initial level of medication and a shorter than
of the body.
expected duration of action
A. Dermatologic – includes lotions, liniment
and ointments, powder.
 a. Before application, clean the skin C. Otic Instillation – to remove cerumen or
thoroughly by washing the area gently pus or to remove foreign body
with soap and water, soaking an a. Warm the solution at room temperature
involved site, or locally debriding tissue. or body temperature, failure to dos o
b. Use surgical asepsis when open wound may cause vertigo, dizziness, nausea
is present and pain
c. Remove previous application before the b. Have the client assume a side-lying
next application position (if not contraindicated) with ear
d. Use gloves when applying the to be treated facing up.
medication over a large surface. (e.g c. Perform hand hygiene. Apply gloves if
large area of burns) drainage is present
e. Apply only thin layer of medication to d. Straighten the ear canal:
prevent systemic absorption.  0-3 years old: pull the pinna
B. Opthalmic - includes instillation and downward and backward
irrigation  Older than 3 years old: pull the
a. Instillation – to provide an eye pinna upward and backward
medication that the client requires. e. Instill eardrops on the side of the
b. Irrigation – To clear the eye of noxious auditory canal to allow the drops to flow
or other foreign materials. in and continue to adjust to body
c. Position the client either sitting or lying. temperature
d. Use sterile technique f. Press gently bur firmly a few times on
e. Clean the eyelid and eyelashes with the tragus of the ear to assist the flow of
sterile cotton balls moistened with medication into the ear canal
sterile normal saline from the inner to g. Ask the client to remain in side lying
the outer canthus position for about 5 minutes
f. Instill eye drops into lower conjunctival h. At times the MD will order insertion of
sac. cotton puff into outermost part of the
g. Instill a maximum of 2 drops at a time. canal. Do not press cotton into the
Wait for 5 minutes if additional drops canal. Remove cotton after 15 minutes.
need to be administered. This is for
proper absorption of the medication. 4. Nasal – Nasal instillations usually are instilled for
h. Avoid dropping a solution onto the their astringent effects (to shrink swollen mucous
cornea directly, because it causes membrane), to loosen secretions and facilitate
discomfort. drainage or to treat infections of the nasal cavity or
i. Instruct the client to close the eyes sinuses. Decongestants, steroids, calcitonin.
gently. Shutting the eyes tightly causes a. Have the client blow the nose prior to nasal
spillage of the medication. instillation
j. For liquid eye medication, press firmly b. Assume a back lying position, or sit up and lean
on the nasolacrimal duct (inner cantus) head back.
for at least 30 seconds to prevent c.Elevate the nares slightly by pressing the thumb
systemic absorption of the medication. against the client’s tip of the nose. While the client
inhales, squeeze the bottle.
d.Keep head tilted backward for 5 minutes after c. Use applicator or sterile gloves for vaginal
instillation of nasal drops. administration of medications.
e.When the medication is used on a daily basis, Vaginal Irrigation – is the washing of the vagina by
alternate nares to prevent irritations a liquid at low pressure. It is also called douche.
a. Empty the bladder before the procedure
b. Position the client on her back with the hips
5. Inhalation– use of nebulizer, metered-dose higher than the shoulder (usebedpan)
inhaler c. Irrigating container should be 30 cm (12 inches)
a. Simi or high-fowler’s position or standing above
position. To enhance full chest expansion allowing d. Ask the client to remain in bed for 5-10 minute
deeper inhalation of the medication following administration of vaginal suppository,
b. Shake the canister several times. To mix the cream, foam, jelly or irrigation.
medication and ensure uniform dosage delivery
c. Position the mouthpiece 1 to 2 inches from the 7. RECTAL– can be use when the drug has
client’s open mouth. As theclient starts inhaling, objectionable taste or odor.
press the canister down to release one dose of the a. Need to be refrigerated so as not to soften.
medication. This allows delivery of the medication b. Apply disposable gloves.
more accurately into the bronchial tree rather than c. Have the client lie on left side and ask to take
being trapped in the oropharynx then swallowed slow deep breaths through mouth and relax anal
d. Instruct the client to hold breath for 10 seconds. sphincter.
To enhance complete absorption of the d. Retract buttocks gently through the anus, past
medication. internal sphincter and against rectal wall, 10 cm (4
e. If bronchodilator, administer a maximum of 2 inches) in adults, 5 cm (2 in) in children and infants.
puffs, for at least 30 second interval. Administer May need to apply gentle pressure to hold buttocks
bronchodilator before other inhaled medication. together momentarily.
This opens airway and promotes greater e. Discard gloves to proper receptacle and perform
absorption of the medication. hand washing.
f. Wait at least 1 minute before administration of f. Client must remain on side for 20 minute after
the second dose or inhalation of a different insertion to promote adequate absorption of the
medication by MDI medication.
g. Instruct client to rinse mouth, if steroid had been
administered. This is to prevent fungal infection. 8. PARENTERAL- administration of medication by
needle.
6. Vaginal– A. Intradermal – under the epidermis.
Drug forms: tablet liquid (douches), Jelly, foam and 1. The site are the inner lower arm, upper chest
suppository. and back, and beneath the
a. Close room or curtain to provide privacy. capula
b. Assist client to lie in dorsal recumbent 2. Indicated for allergy and tuberculin testing
position to provide easy access and good and for vaccinations.
exposure of vaginal canal, also allows 3. Use the needle gauge 25, 26, 27: needle
suppository to dissolve without escaping length 3/8”, 5/8” or ½”
through orifice. 4. Needle at 10–15 degree angle; bevel up.
 5. Inject a small amount of drug slowly over 3 vessel had been hit. If blood appears on
to 5 seconds to form a wheal orbleb. pulling back of the plunger of the syringe,
6. Do not massage the site of injection. To remove the needle and discard the
prevent irritation of the site, and to prevent medication and equipment.
absorption of the drug into the
subcutaneous. C. Intramuscular
a. Needle length is 1”, 1 ½”, 2” to reach the muscle
B.Subcutaneous– vaccines, heparin, preoperative layer
medication, insulin, narcotics. b. Clean the injection site with alcoholized cotton
The site: ball to reduce microorganisms in the area.
outer aspect of the upper arms c.Inject the medication slowly to allow the tissue to
anterior aspect of the thighs accommodate volume.
Abdomen Sites:
Scapular areas of the upper back Ventrogluteal site
Ventrogluteal a.The area contains no large nerves, or blood
Dorsogluteal vessels and less fat. It is farther from the rectal
area, so it less contaminated.
a. Only small doses of medication should be b.Position the client in prone or side-lying.
injected via SC route. c.When in prone position, curl the toes inward.
b. Rotate site of injection to minimize tissue d.When side-lying position, flex the knee and hip.
damage. These ensure relaxation of gluteus muscles and
c. Needle length and gauge are the same as for ID minimize discomfort during injection.
injections e.To locate the site, place the heel of the hand over
d. Use 5/8 needle for adults when the injection is the greater trochanter,point the index finger
to administer at 45 degree angle; ½ is use at a 90 toward the anterior superior iliac spine, then
degree angle. abduct the middle (third) finger. The triangle
e. For thin patients: 45 degree angle of needle formed by the index finger, the third finger and the
f. For obese patient: 90 degree angle of needle crest of the ilium is the site.
g. For heparin injection:
 do not aspirate Dorsogluteal site
 Do not massage the injection site to a.Position the client similar to the ventrogluteal
prevent hematoma formation site
h.For insulin injection: b.The site should not be use in infant under 3 years
 Do not massage to prevent rapid absorption because the gluteal muscles are not well developed
which may result to hypoglycemic reaction. yet.
 Always inject insulin at 90 degrees angle to c.To locate the site, the nurse draw an imaginary
administer the medication in the pocket line from the greater trochanter to the posterior
between the subcutaneous and muscle superior iliac spine. The injection site id lateral and
layer. Adjust the length of the needle superior to this line.
depending on the size of the client. d.Another method of locating this site is to
 For other medications, aspirate before imaginary divide the buttock intof our quadrants.
injection of medication to check if the blood The upper most quadrant is the site of injection.
Palpate the crest of the ilium to ensure that the painful. Client may have anxiety, which can
site is high enough increase the pain.
e.Avoid hitting the sciatic nerve, major blood vessel 4. Practice asepsis to prevent infection. Apply
or bone by locating the site properly. disposable gloves.
5. Use appropriate needle size. To minimize
Vastus Lateralis tissue injury.
a.Recommended site of injection for infant 6. Plot the site of injection properly. To
b.Located at the middle third of the anterior lateral prevent hitting nerves, blood vessels,bones.
aspect of the thigh. 7. Use separate needles for aspiration and
c.Assume back-lying or sitting position. injection of medications to prevent tissue
irritation.
Rectus femoris site –located at the middle third, 8. Introduce air into the vial before aspiration.
anterior aspect of thigh. To create a positive pressure within the vial
and allow easy withdrawal of the
Deltoid site medication.
a.Not used often for IM injection because it is 9. Allow a small air bubble (0.2 ml) in the
relatively small muscle and is very close to the syringe to push the medication that may
radial nerve and radial artery. remain.
b.To locate the site, palpate the lower edge of the 10. Introduce the needle in quick thrust to
acromion process and the midpoint on the lateral lessen discomfort.
aspect of the arm that is in line with the axilla. This 11. Either spread or pinch muscle when
is approximately 5 cm (2 in) or 2 to 3 introducing the medication. Depending on
fingerbreadths below the acromion process. the size of the client.
12. Minimized discomfort by applying cold
IM injection – Z tract injection compress over the injection site before
a. Used for parenteral iron preparation. To introduction of medicati0n to numb nerve
seal the drug deep into the muscles and endings.
prevent permanent staining of the skin. 13. Aspirate before the introduction of
b. Retract the skin laterally, inject the medication. To check if blood vessel had
medication slowly. Hold retraction of skinu been hit.
ntil the needle is withdrawn 14. Support the tissue with cotton swabs before
c. Do not massage the site of injection to withdrawal of needle. To prevent
prevent leakage into the subcutaneous. discomfort of pulling tissues as needle is
withdrawn.
15. Massage the site of injection to haste
GENERAL PRINCIPLES IN PARENTERAL
absorption.
ADMINISTRATION OF MEDICATIONS 16. Apply pressure at the site for few minutes.
1. Check doctor’s order. To prevent bleeding.
2. Check the expiration for medication – drug 17. Evaluate effectiveness of the procedure and
potency may increase or decrease if make relevant documentation.
outdated.
3. Observe verbal and non-verbal responses
toward receiving injection. Injection can be
Intravenous f. Clean the insertion site of IV needle from
The nurse administers medication intravenously by center to the periphery with alcoholized
the following method: cotton ball to prevent infection.
1. As mixture within large volumes of IV fluids. g. Shave the area of needle insertion if hairy.
2. By injection of a bolus, or small volume, or h. Change the IV tubing every 72 hours. To
medication through an existing intravenous prevent contamination.
infusion line or intermittent venous access i. Change IV needle insertion site every 72
(heparin or salinelock) hours to prevent thrombophlebitis.
3. By “piggyback” infusion of solution j. Regulate IV every 15-20 minutes. To ensure
containing the prescribed medication and a administration of propervolume of IV fluid
small volume of IV fluid through an existing asordered.
IV line. k. Observe for potential complications.

a. Most rapid route of absorption of Types of IV Fluids

medications. A. Isotonic solution – has the same
b. Predictable, therapeutic blood levels of concentration as the body fluid
medication can be obtained. a. D5 W
c. The route can be used for clients with b. Na Cl 0.9%
compromised gastrointestinal function c. plainRinger’s lactated.
orperipheral circulation. d. Plain Normosol M
d. Large dose of medications can be B. Hypotonic – has lower concentration than
administered by this route. the body fluids.
e. The nurse must closely observe the client a. NaCl 0.3%
for symptoms of adverse reactions. C. Hypertonic – has higher concentration than
f. The nurse should double-check the six the body fluids.
rights of safe medication. a.D10W
g. If the medication has an antidote, it must b.D50W
be available during administration. c.D5LR
h. When administering potent medications, d.D5NM
the nurse assesses vital signs before, during
and after infusion. Complication of IV Infusion
1. Infiltration – the needle is out of vein, and fluids
Nursing Interventions in IV Infusion accumulate in the subcutaneous tissues.
a. Verify the doctor’s order Assessment:
b. Know the type, amount, and indication of IV  Pain, swelling, skin is cold at needle site,
therapy. pallor of the site, flow rate has decreases or
c. Practice strict asepsis. stops.
d. Inform the client and explain the purpose of  Nursing Intervention:
IV therapy to alleviate client’sanxiety a. Change the site of needle
e. Prime IV tubing to expel air. This will b. Apply warm compress. This will absorb
prevent air embolism. edema fluids and reduce swelling.
2.Circulatory Overload - Results from Nursing Intervention:
administration of excessive volume of IVfluids. Change IV site every 72 hours
Assessment: Use large veins for irritating fluids.
 Headache Stabilize venipuncture at area of flexion.
 Flushed skin Apply cold compress immediately to relieve pain
 Rapid pulse and inflammation; laterwith warm compress to
 Increase BP stimulate circulation and promotion absorption.
 Weight gain “Do not irrigate the IV because this could push
 Syncope and faintness clot into the systemiccirculation’
 Pulmonary edema
 Increase volume pressure
 SOB 5.Air Embolism– Air manages to get into the
 Coughing circulatory system; 5 ml of air or more causes air
 Tachypnea embolism.
 shock Assessment:
Nursing Interventions: Chest, shoulder, or backpain
a. Slow infusion to KVO Hypotension
b. Place patient in high fowler’s position. To Dyspnea
enhance breathing Cyanosis
c. Administer diuretic, bronchodilator as  Tachycardia
ordered Increase venous pressure
Loss of consciousness
3.Drug Overload – the patient receives an
excessive amount of fluid containing drugs. Nursing Intervention
Assessment: Do not allow IV bottle to “run dry”
Dizziness “Prime” IV tubing before starting infusion.
Shock  Turn patient to left side in the trendelenburg
Fainting position. To allow air to rise in the right side of the
Nursing Intervention heart. This prevent pulmonary embolism.
Slow infusion to KVO.
Take vital signs 6.Nerve Damage– may result from tying the arm
Notify physician too tightly to the splint.
Assessment
4.Superficial Thrombophlebitis – it is due to  Numbness of fingers and hands
overuse of a vein, irritating solution or drugs, clot Nursing Interventions
formation, large bore catheters.  Massage the area and move shoulder
Assessment: through its ROM
Pain along the course of vein  Instruct the patient to open and close hand
Vein may feel hard and cordlike several times each hour.
Edema and redness at needle insertion site.  Physical therapy may be required
Arm feels warmer than the other arm  Note: apply splint with the fingers free to
move.
 j. Use BT set with special micron mesh filter.
7.Speed Shock – may result from administration of To prevent administration of blood clots
IV push medication rapidly. and particles.
 To avoid speed shock, and possible cardiac k. Start infusion slowly at 10 gtts/min. Remain
arrest, give most IV push medication over 3 at bedside for 15 to 30 minutes. Adverse
to 5 minutes. reaction usually occurs during the first 15 to
20 minutes.
BLOOD TRANSFUSION THERAPY l. Monitor vital signs. Altered vital signs
indicate adverse reaction.
Objectives:
 Do not mixed medications with
1. To increase circulating blood volume after
blood transfusion. To prevent
surgery, trauma, or hemorrhage
adverse effects
2. To increase the number of RBCs and to
 Do not incorporate medication into
maintain hemoglobin levels in clients with
the blood transfusion
severe anemia
 Do not use blood transfusion line for
3. To provide selected cellular components as
IV push of medication.
replacements therapy (e.gclotting factors,
m. Administer 0.9% NaCl before, during or
platelets, albumin)
after BT. Never administer IV fluids with
Nursing Interventions:
dextrose. Dextrose causes hemolysis.
a. Verify doctor’s order. Inform the client and
n. Administer BT for 4 hours (whole blood,
explain the purpose of theprocedure.
packed rbc). For plasma, platelets,
b. Check for cross matching and typing. To
cryoprecipitate, transfuse quickly (20
ensure compatibility
minutes) clotting factor can easily be
c. Obtain and record baseline vital signs
destroyed.
d. Practice strict Asepsis
e. At least 2 licensed nurse check the label of
Complications of Blood Transfusion
the blood transfusion
1. Allergic Reaction – it is caused by sensitivity
f. Check the following:
to plasma protein of donor antibody, which
 Serial number
reacts with recipient antigen.
 Blood component
Assessments
 Blood type
 Flushing
 Rh factor
 Rush, hives
 Expiration date
 Pruritus
 Screening test (VDRL, HBsAg, malarial
 Laryngeal edema, difficulty of
smear)- this is to ensure that the blood is
breathing
free from blood-carried diseases and
2. Febrile, Non-Hemolytic – it is caused by
therefore,safe from transfusion.
hypersensitivity to donor white cells,
g. Warm blood at room temperature before
platelets or plasma proteins. This is the
transfusion to prevent chills.
most symptomatic complication of blood
h. Identify client properly. Two Nurses check
transfusion
the client’s identification.
Assessments:
i. Use needle gauge 18 to 19. This allows easy
 Sudden chills and fever
flow of blood.
  Flushing 3. Place the client in fowlers position if with
 Headache SOB and administer O2 therapy.
 Anxiety 4. The nurse remains with the client,
3. Septic Reaction – it is caused by the observing signs and symptoms and
transfusion of blood or components monitoring vital signs as often as every 5
contaminated with bacteria. minutes.
Assessment: 5. Notify the physician immediately.
 Rapid onset of chills 6. The nurse prepares to administer
 Vomiting emergency drugs such as antihistamines,
 Marked Hypotension vasopressor, fluids, and steroids as per
 High fever physician’s order or protocol.
4. Circulatory Overload – it is caused by 7. Obtain a urine specimen and send to the
administration of blood volume at a rate laboratory to determine presence of
greater than the circulatory system can hemoglobin as a result of RBC hemolysis
accommodate. 8. Blood container, tubing, attached label, and
Assessment: transfusion record are saved and returned
 Rise in venous pressure to the laboratory for analysis.
 Dyspnea
 Crackles or rales
 Distended neck vein
 Cough
 Elevated BP
5. Hemolytic reaction. - It is caused by
infusion of incompatible blood products.
Normal Values
Assessment: Bleeding time1 9 min
 Low back pain (first sign). This is due Prothrombin time 10-13 sec
to inflammatory response of the Hematocrit Male42-52%
kidneys to incompatible blood. Female36-48%
 Chills Hemoglobin male13.5-16 g/dl
 Feeling of fullness female 12-16 g/dl
 Tachycardia Platelet 150,00- 400,000
 Flushing RBC male4.5-6.2 million/L
 Tachypnea female4.2-5.4 million/L
 Hypotension Amylase 80-180 IU/L
 Bleeding Bilirubin(serum) direct0-0.4 mg/dl
 Vascular collapse indirect0.2-0.8 mg/dl
 Acute renal failure total0.3-1.0 mg/dl
Nursing Interventions when complications pH 7.35- 7.45
occurs in Blood transfusion PaCo2 35-45
1. If blood transfusion reaction occurs. STOP HCO3 22-26 mEq/L
THE TRANSFUSION. Pa O2 80-100 mmHg
2. Start IV line (0.9% Na Cl) SaO2 94-100%
Sodium 135- 145 mEq/L
Potassium 3.5- 5.0 mEq/L
Calcium 4.2- 5.5 mg/dL
Chloride 98-108 mEq/L
Magnesium 1.5-2.5 mg/dl
BUN 10-20 mg/dl
Creatinine 0.4- 1.2
CPK-MB male50 –325 mu/ml
female50-250 mu/ml
Fibrinogen 200-400 mg/dl
FBS 80-120 mg/dl
Glycosylated Hgb 4.0-7.0%(HbA1c)
Uric Acid 2.5 –8 mg/dl
ESR male15-20 mm/hr
Female20-30 mm/hr
Cholesterol 150- 200 mg/dl
Triglyceride 140-200 mg/dl
Lactic 100-225 mu/ml
Dehydrogenase
Alkaline 32-92 U/L
phospokinase
Albumin 3.2- 5.5 mg/dl