FUNDAMENTALS OF NURSING

HISTORY OF NURSING PERIODS OF NURSING INTUITIVE NURSING/ PRIMITIVE NURSING/ INSTINCTIVE NURSING (Primitive times 6th ce t!r"# PRIMITIVE TIMES - Women practice nursing because of low status in society. - Took care of children and sick members of the family. - Personalistic cause of disease. - Sickness is due to active intervention of: a. human caused by witchcraft. b. non human caused by ghosts. c. superhuman beings caused by deities. - Superstitious and believes in magic. - Slave society slave nurses! - Wet nursing" take care of babies#children of their masters - Women also practices midwifery. - $asters#healers are the people who are responsible in decision making when it comes to health. 6th CENTURY - %ounding of religious orders. $ %ttri&!tes '( N!rses &. Self denial '. (evotion to hard work and duty. ). With spiritual calling. M)i G!i*i + Pri ci,-es &. *ove thy neighbor as thy self!. '. Parable of the +ood Samaritan. - .e e(ice ce ,doing good to others-. / T",es '( .e e(ice ce &. .rdinary doing good to others. '. /deal entails sacrifice. %PPRENTICE NURSING PERIOD (6th Ce t!r" 01th Ce t!r"# 6TH CENTURY - founding of religious orders. - women practiced nursing. - (aughters of 0harity#Sisters of 0harity founded by St. 1incent de Paul and 2ugustinian Sisters. CRUS%DES - $en practiced nursing. - 3nights of St. *a4arus a. established a standard among hospitals in 5urope. b. took care of clients with skin problems like leprosy. - 3nights of St. 6ohn of 6erusalem a. also known as 2 i+hts H's,it)-ers. b. founded hospitals. 01TH CENTURY 01$6 - Theodore %leidner reestablished order of (eaconesses. - %ounded school of nursing in 3aisserwerth" +ermany where %lorence 7ightingale was the most known student. 013450136 (CRIME%N 6%R# - %lorence 7ightingale was known as the 7)*" 8ith ) 7)m,. - 0ompiled the 7otes on 7ursing: What it is and What is not! and became the (irst !rse the'rist.

EDUC%TION%7 NURSING PERIOD (01th Ce t!r" /9th Ce t!r"# 01TH CENTURY - %lorence 7ightingale established a nursing school in St. Thomas 8ospital in *ondon which adopted the Ni+hti +)-e S"stem. - $ade %lorence 7ightingale the m'ther '( m'*er !rsi +. Phi-'s',h" '( Ni+hti +)-e S"stem &. +overnment funds should be allotted to nursing education. - earned her the title of being the (irst !rse ,'-itic)- )ctivist. '. Training schools of nursing should be in close affiliation. ). Professional nurses should train nurses. 9. 7ursing students should be provided with residence near their training hospitals. - written orders of doctors insisted. - nurses should go with doctors during rounds. 7%TE /9TH CENTURY - Speciali4ation in medicine. - 0onceptuali4ation of the role of clinical nurse specialist. - /ncrease clinical content of education ,&:;;<s-. CONTEMPOR%RY PERIOD (/0st Ce t!r"# - +lobali4ation of nursing. - Period after world war //. - =orderless nursing or transcultural nursing. - Professionali4ation of nursing. PROFESSION a special calling that re>uires special" skills" knowledge and attitudes. : CRITIC%7 %TTRI.UTES OF PROFESSION &. S,eci)-i4ed education '. Code of ethics ). Research of orientation 9. %utonomy ?. .ody of knowledge @. Service orientation A. Professional Organi4ation SOCI%7I;%TION process where a person learns the ways and means or skills" knowledge" attitudes of the group to which he belongs to. .ENNER 7EVE7 OF PROFICIENCY &. N'vice student nurse entering a clinical setting where he has no eBperience at all. '. %*v) ce nurse who demonstrates a marginally acceptable performance: depends on rules and maBims. ). C'm,ete t ' ) years eBperience demonstrates organi4ational ability but lacks speed and fleBibility of a proficient nurse. 9. Pr'(icie t concerned with long term goals" performance is fluid and fleBible compared to competent nurse - has a wholistic view of the client. ?. E<,ert no longer relies on maBims" performance is highly proficient" fluid fleBible and has a wholistic view. - has high perceptual acuity or a clinical eye. DIMENSIONS OF NURSING &. 7ursing Practice '. 7ursing 5ducation ). 7ursing Cesearch FOCUS OF NURSING &. 8ealth Promotion improve clients well being. '. 8ealth $aintenance ). 8ealth /nstauration help clients with illness to recover. 9. 0are of the (ying clients with cancer. RO7E patterns of behavior eBpected of person assuming a status#position in society or a group. T%S2 specific activities re>uired of a person.

P%TIENT H)s ) *ise)se Ver" *e,e *e t ' he)-th ,r'(essi' )-

C7IENT N't ecess)ri-" sic= He)-th ,r'm'ti' )ct ti-- *ise)se ,reve ti' C-ie t c'--)&'r)tes 8ith he)-th ,r'(essi' )-

7EVE7S OF C7IENTE7E &. /ndividual '. %amily ). 0ommunity 9. Population +roups special groups with special needs attributed to the following: a. 0ultural characteristics indigenous people. b. (evelopmental stage c. .ccupation commercial seB workers are more prone to ST(<s. RO7ES OF NURSE 0> N!rse E*!c)t'r - ) domains of learning a. 0ognitive knowledge aspect b. Psychomotor skills c. 2ffective interest#emotion /> C)re+iver - 2ttends to physical#emotional ,mostly physical- needs of the client. $> N!rses )s 7e)*er - Process of influencing people to work towards the attainment of goals. 4> M) )+er - .rgani4ational goals#works within an organi4ation. PROCESS OF M%N%GEMENT a. Planning ,resourcesb. .rgani4ing ,delegating tasks#taskingc. (irecting ,motivating peopled. 0ontrolling evaluation of output against standards. 3> C-ie t )*v'c)te protects rights of clients. 6> Ch) +e )+e t improvement in organi4ation. :> Rese)rcher research process 1> F)ci-it)t'r THEORIES relationship between concepts 4 CONCEPTS OF NURSING THEORIES &. /ndividual#Person '. 7ursing ). 8ealth 9. 5nvironment

NURSING THEORIES %> GENER%7 THEORIES 0> NIGHTING%7E?S ENVIRONMENT%7 THEORY - What nursing has to do is to put the individual in best position for nature to work on him. - 7ursing 2ction: manipulation of elements in the environment to contribute to reparative process. 09 E7EMENTS FOUND IN ENVIRONMENT &. %ir importance to have moving air in room of patient to contribute in proper ventilation. '. 7i+ht patient should be near windows to be able to see sunlight and give hope. ). He)-th '( h'!ses environmental sanitation. 9. C-e) -i ess ?. .e**i +s change linens#beddings in patients room to promote comfort. @. N!triti' A. V)riet" change in environment for patient. D. Ve ti-)ti' promote warming. :. N'ise due to nurses clothing or roaming around. &;. Ch)tteri + h',es deals with social aspectE nurse should be cautious with words when at bedside" talk about positive things. /> VIRGINI% HENDERSON?S DEFINITION OF NURSING - 2ssisting individuals sick or well in the performance of activity. - Cole of nurse is complimentary. - Supplementary - /ndividual person is a whole" complete and individual being. NURSE5 PERSON INTER%CTION

NURSES

GOALS INDEPENDENCE RESTORATION MAINTENANCE MEANS KNOWLEDGE WILL STRENGTH

PERSON

PEACEFUL DEATH
04 .%SIC COMPONENTS OF NURSING C%RE &. =reathe normally '. 5at" drink ade>uately ). 5liminate body waste 9. $ove and maintain desirable posture ?. Sleep and rest @. Select suitable clothes A. $aintain body temperature D. 3eep body clean and well groomed :. 2void dangers in environment &;. 0ommunicate with others &&. Worship according to ones faith &'. Work for accomplishment &). Participate in recreation &9. *earn to satisfy the curiosity that leads to normal development

05@ PHYSIO7OGIC 09 04 PSYCHO7OGIC%7 0/ 0$ SOCIO7OGIC 00 SPIRITU%7/MOR%7

$> M%RTH% ROGER?S SCIENCE OF UNIT%RY HUM%N .EINGS 2. 7ursing is humanistic science =. Parallel with *udwig von =ertalanffy<s +eneral System Theory 0. ? assumptions about human beings &. $an is a unified whole whole not e>ual to sum of parts. '. /ndividual and environment are continuously eBchanging matter and energy. ). *ifecycle evolves irreversibly and uni-directionally along space and time continuum. 9. *ife patterns identify individuals. ?. 8umans have the capacity for absorption and imagery" language and thought" sensation and emotion. GENER%7 SYSTEM THEORY - 2 set of interacting parts# components with a boundary that filters the input and output from and to the environment. - /nput and output: matter" energy" information. - Whole: physical" psychological" spiritual" intellectual. 4> DOROTHE% OREM?S SE7F C%RE DEFICIT THEORY - $an is an integrated whole" biologically" symbolically and socially. - $an is self reliant and responsible for self care. - $an is re>uisite for all. - 7ursing is a service" art and technology. $ SU. THEORIES &. Self 0are universal self care" developmental. '. Self 0are (eficit demands" capabilities" deficits. ). Theory of 7ursing Systems wholly compensatory" partly supportive-educative. UNIVERS%7 SE7F C%RE REAUISITES &. Sufficient intake of air '. Sufficient intake of water ). Sufficient intake of food 9. Satisfactory eliminative functions ?. 2ctivity balanced with rest @. Time spent alone balanced with time spent with others A. Prevention of danger D. =eing normal DEVE7OPMENT OF SE7F C%RE REAUISITES - Speciali4ed eBpression of universal self-care re>uisites for development process. HE%TH DEVI%TION - 2dditional demands for health care due to illness" disease or inFury. THEORY OF NURSING SYSTEM &. Wholly compensatory nurse acts for patient. '. Partly compensatory both nurse and patient. ). Supportive-5ducative patient able to perform self care. .> SYSTEM THEORIES 3> SISTER C%77IST% ROY?S %D%PT%TION MODE7 - +rounded on humanism. - Person is adaptive system with coping mechanism. - +oal of nursing is to promote persons adaptation. STIMU7I &. %ocal - immediate '. 0onteBtual other internal and eBternal factors ). Cesidual may or may not have effect like attitudes and beliefs.

COPING MECH%NISMS &. Cegulator neural chemical endocrine. '. 0ognator processed through cognition. %D%PTIVE MODES - Physiologic adaptive mode - Self concept mode - /nterdependence mode - Cole function mode - 2daptive#effective response - $aladaptive#ineffective response 6> IMOGENE 2ING?S GO%75%TT%INMENT THEORY - 7ursing is a process of human interaction between the nurse" client" each person perceive the other and situation and eBplore the means to achieve them. - 8umans are ',e s"stems in constant interaction with their environment. - 7ursing focus: human interact with the environment. - 7ursing +oal: humanistic maintenance of individuals and groups. - /nteracting components are personal" interpersonal" social. - 5lements: interaction" communication" transaction role" stress. COMPONENTS PERSON%7 SYSTEM - Perception" self" growth and development" image" space" learning time. - .rgani4ation" authority" power" status" decision making. :> .ETTY NEUM%N?S HE%7TH C%RE SYSTEMS MODE7 - =ased on ' components stress" reaction to stress. - 0lient ,individual" group" community- is an open system in interaction with environment. 4 CONCEPTS %> C7IENT %leBible keeps system free from stressor reaction or symptom-matology. *ine of Cesistance consist of internal defensive processes. 5B. /mmune response. .> ENVIRONMENT - 5nvironment has potential to alter system stability due to internal and eBternal stressors. STRESSORS CAN BE &. 5Btra personal unemployment" microorganisms" peer pressure" radiation. '. /nter personal between ' or more individual ,parent eBpectations-. ). /ntra personal anger" physical abilities" financial condition. - 5nvironment can also be source of resources that may help client cope with stressors. C> HE%7TH D> NURSING - Primary: protection of normal line of defense. - Secondary: protection of basic structure by strengthening internal line of resistance. 5B. Treatment of symptoms" energy conservation - Tertiary: promotion of reconstitution by supporting eBisting strengths and resources. 1> DOROTHY BOHNSON?S .EH%VIOR%7 SYSTEMS MODE7 M) s s!&s"stem - =ehavioral subsystem: addressed by nursing intervention. - =iological subsystem: addressed by medical intervention. G')- '( N!rsi + a. demonstrate behavior commensurate to social demands. b. modify behavior to support biological needs. c. benefit from physicians skill and knowledge. d. demonstrate behavior that does not give evidence of unnecessary trauma. - N!rsi + ('c!sC behavior modification to foster e>uilibrium.

C> INTERPERSON%7/C%RING THEORIES @> HI7DEG%RD PEP7%U?S INTERPERSON%7 RE7%TIONSHIP IN NURSING - purpose of nursing is to educate and to be a nurturing force to a patient for him to get a new view of himself. - interaction is a maturing force. N!rse C'! se-'r identify stressor Res'!rce Pers' health educator S!rr'+)te acts as caregiver C' +r!e t G')-s PH%SE OF NURSE P%TIENT RE7%TIONSHIP &. Orie t)ti' leveling off between nurse and client in term of eBpectation. '. I*e ti(ic)ti' selective response of the client to those who can meet his needsE affected by clients belief. ). E<,-'it)ti' client takes control of the situation by eBtracting help from nurse. 9. Res'-!ti' evaluation of care and discharge of client. 09> M%DE7EINE 7EININGER?S TR%NSCU7TUR%7 C%RE THEORY - C!-t!reC way of life" total of all the material and non material<s produced by the people at their level of social development. - has universalities: same as other culture ,hygiene" nutritional needs-. - diversities: cultural peculiarities ,caring -. 00> ID% BE%N OR7%NDO?S DYN%MIC NURSE5C7IENT RE7%TIONSHIP - Types of nursing response: deliberate action,based on correct identification of patients needs- and automatic action. - nursing function is concerned with providing direct assistance to individuals in whatever setting to avoid" diminish" relieve individual<s sense of helplessness. - 7ursing disciplined professional response. 0/ BE%N 6%TSON?S PHI7OSOPHY %ND SCIENCE OF C%RING - 7ursing is the science of caring. - 0aring is more healthogenic than caring. - $ain focus of nursing is on curative factors that are derived from humanistic perspectives combined with a scientific base. 09 C%R%TIVE F%CTORS &. %ormation of a humanistic-altruistic value system. '. %aith hope ). 0ultivation of sensitivity to self and others. (First $ ()ct'rs )re the ('! *)ti' s ('r c)ri +# 9. 5stablishing a helping trust relation ?. 5Bpression of feelings" both positive and negative. @. Cesearch and systematic problem solving. A. Promotion of interpersonal teaching-learning. D. Provisions for a supportive" protective and corrective mental" physical" sociocultural and spiritual environment. :. 2ssistance with the gratification of human. &;. 2llowance for eBistential phenomenological factors. D> C7IENT CENTERED THEORIES 0$> F%YE G7EN %.DE77%H?S /0 NURSING PRO.7EMS - 7ursing in the use of the problem solving approach - C'vertC psychological problem - OvertC obvious ,physical manifestations of health problemsP)tie t ,with a need-

04> 7YDI% H%77?S THEORY OF CORED C%RED CURE - Patient is composed of ) elements: body" pathology" person - 7ursing is helping clients move in the direction of self awareness - 7ursing operates in all ) elements - C'reC the person" therapeutic use of self - C)reC the body" intimate body care ,nurturing component- C!reC the disease" medical care ,client advocate03> MYR% ESTRINE 7EVINE?S FOUR CONSERV%TION PRINCIP7ES OF NURSING - Promotion of the wholeness of the person - =y improving the clients patterns of adaptive response
0.7S5C12T/.7 .% 5nergy Structural /ntegrity Personal /ntegrity Social /ntegrity

Pr'm'ti' '( E8h'-e essF '( the c-ie t t'8)r*s he)-th m)i te ) ce 'r he)-th rest'r)ti' >

CONSERV%TION - (efends wholeness of living systems by ensuring their ability to confront change 06> NO7% B> PENDER?S HE%7TH PROMOTION MODE7 - (irected towards increasing the level of well being and self actuali4ation of a given individual or group - 5Bample: @ D hours of sleep - Dise)se ,reve ti' /He)-th ,r'tecti' C action directed towards decreasing the probability of eBperiencing illness by active protection of the body against pathological stressors. - 5Bample: =0+ vaccination COGNITIVE PERCEPTU%7 F%CTORS
Importance of hea th

MODIFYING F%CTORS

Demo(raph!c character

Perce!"e# contro of hea th

)!o o(!c

Perce!"e# $e f eff!cac%

Interper$ona !nf &ence$

Depth of hea th

S!t&at!ona factor$

*/35*/8..( /7 57+2+/7+ /7 852*T8 PC.$.T/7+ =5821/.CS

Perce!"e# hea th $tat&$

)eha"!ora factor

5B. $ass media

C&e$ to act!on

Perce!"e# 'arr!er$ of hea th promot!n( 'eha"!or$

HE%7THY 7IFESTY7E - 2de>uate nutrition ) times a day - Cegular eBercise ) times a week - 7ot smoking - $oderate intake of alcohol CONCEPT OF M%N %t'mistic whole or sum of parts H'-istic the whole is not e>ual to the sum of parts Ph"si'-'+ic genetic character" organs and functioning Ps"ch'-'+ic)- emotions" affect" rationality" merciful S'ci'5c!-t!r)- sociali4ation" family" language I te--ect!)- perception" cognition S,irit!)- faith ,un>uestioning belief in someone" serves to unite humans-" hope" charity Ch)rit" outward eBpression of love for others .%SIC HUM%N NEEDS &. Gniversal '. $et in different ways ). Stimulated by eBternal and internal factors 9. $aybe differed ?. /nterrelated @. Priorities maybe altered M%S7O6?S HEIR%RCHY OF NEEDS - Nee*: anything that is essential to the survival of man - Fr)me8'r=: basic need is something whose - %&se ce: may cause illness - Prese ce: prevent illness#signal health - $eeting unmet needs restore health Ph"si'-'+ic - seB" nutrition" shelter" clothing" water" elimination" rest and sleep S)(et" ) * Sec!rit" - physical freedom from harm" psychological knowing what to eBpect from others and what others eBpect from you. 7've ) * .e-' +i + ess - nurturance with affection Se-( Esteem - persons sense of achievement and independence" competence" confidence and strength Se-( %ct!)-iG)ti' - not all people attain self actuali4ation ,attained by only &?H- 2ccepts himself - =alance between rest and activity - .pen mind - Positive outlook in life HE%7TH - 8ealth is a state of complete physical" mental and social well-being and not merely the absence of disease or infirmity. 6E77NESS - State of well being - SubFective perception of balance" harmony and vitality engaging in attitudes and behaviors that enhance the >uality of life and maBimi4es personal potential.

DIMENSION OF 6E77NESS - Physical: 2(*" fitness of organ structures and functioning - Spiritual: faith and hope - /ntellectual: use knowledge for personal" family" social" career development - 5motional: able to manage stress" eBpress feelings and emotions appropriately - Social: interact successfully with others" tolerant of people with different beliefs MODE7S OF HE%7TH %ND 6E77NESS 7E%VE77 %ND C7%R2S %GENT HOST ENVIRONMENT MODE7 OR ECO7OGIC%7 MODE7/EPIDEMIO7OGIC %+e t

H'st

E vir' me t

DUNN?S HIGH 7EVE7 6E77NESS GRID 1ery %avorable 5nvironment Protected poor health , in favorable environment8igh level wellness ,in favorable environment-

HE%7TH %HIS (eath Poor health ,in an unfavorable environmentPeak Wellness 5nergetic" 8igh level wellness ,in an unfavorable environment5nvironmental aBis 1ery Gnfavorable 5nvironment .'th ,h"sic)- ) * s'ci)- c!-t!r)- e vir' me t

TR%VIS I77NESS 6E77NESS CONTINUUM

6e-- ess m'*e-

> Premature (eath

>

>

>

>

>
8igh *evel Wellness

2wareness# 5ducation# +rowth

Tre)tme t M'*e-s

Ne!tr)- P'i t ( ' *iscer )&-e i-- ess 'r 8e-- ess# - $ovement to the right of the neutral point indicates high level of health and well being for an individual and this may be achieved through awareness and education and growth. /n contrast" movement to the left of the neutral point indicates a progressively decrease state of health HE%7TH .E7IEF MODE7 - /ntended to predict whether individuals would or would not use preventive measure - =ased on the motivational theory - 2ssumption: +ood health is a motivation common to all people I77NESS - 8ighly personal state in which the person feels unhealthy or ill" may or may not be related to disease DISE%SE - 2lteration in body function resulting in a reduction of capacities or a shortening of the normal lifespan C%USES OF DISE%SE &. +enetic inherited" genetic defects '. (evelopmental resulting to eBposure to virus or chemicals during pregnancy ). =iologic microorganisms ,virus" bacteria" proto4oa" fungi- and their toBins and helminthes 9. Physical temperature eBtremes" electricity" radiation ?. 0hemical alcohol" strong acid and base" drugs @. $echanical generali4ed tissue response to inFury or irritation ,trauma shearing force" frictionA. Physiologic and 5motional reaction to stress D. %aulty 0hemical or $etabolic Processes eBcessive or insufficient production of hormones" en4ymes IGUN?S 00 ST%GES OF HE%7TH SEE2ING - 2ny activity undertaken by a person who feels ill in order to define his state of health and seek a suitable remedy St)+e 0C Symptom eBperience St)+e /C Self treatment or self medication St)+e $C 0ommunication to others St)+e 4C 2ssessment of symptoms St)+e 3C Sick-role assumption Ch)r)cteristics '( Sic= R'-e a. 5Bpected to seek competent help b. 5Bpected to get well in the shortest possible time

c. Person is not blamed for his disease d. 5Bempted from usual task St)+e 6C 0oncern St)+e :C 5fficacy of treatment St)+e 1C Selection of treatment St)+e @C Treatment St)+e 09C 2ssessment of effectiveness of treatment St)+e 00C Cecovery and rehabilitation SUCHM%N?S 3 ST%GES OF I77NESS St)+e IC S"m,t'm E<,erie ce - Person believes that something is wrong - Physical eBperience of the symptoms - 0ognitive aspect: interpretation of the symptoms - 5motional response: fear or anBiety St)+e IIC %ss!m,ti' '( Sic= R'-e - People are eBcused from normal duties and role eBpectations - 0lients are not held responsible for their condition - 0lients are obliged to get well and resume normal activity - 0lients are obliged to seek competent help St)+e IIIC Me*ic)- C)re C' t)ct - Seeking medical advice to ask for the following o 1alidation of real illness o 5Bplanation of symptoms in understandable terms o Ceassurance that they will be fine or for a prediction of what the outcome would be - 0lient may accept or deny diagnosis St)+e IVC De,e *e t C-ie t R'-e - The client is dependent on the professional for help and give up their independence - 0lient accepts treatment plan St)+e VC rec'ver" 'r Reh)&i-it)ti' - 0lient relin>uishes role and resumes former role and responsibilities - %or permanent disability" this may re>uire therapy to learn how to make maFor adFustments in functioning.

CH%R%CTERISTICS OF NURSING PROCESS &. 0yclic and dynamic rather than static '. 0lient centered nurse organi4es plan of care according to client problems rather that nursing goals ). /nterpersonal and collaborative depends on open and meaningful communication between client and the nurse 9. Gniversally applicable can be used with clients of any age at any point of the wellness illness continuum and useful in a variety of settings ?. 2daptation of problem solving techni>ues and system theory based on the scientific method @. /t can be viewed as parallel to but separate from the medical process %SSESSMENT - .bFective ,physical eBam- and subFective ,nursing historySOURCES OF D%T% &. Primary client '. Secondary relatives" members of health team FOR NURSING HISTORY USE GORDON?S TYPO7OGY OF 00 FUNCTION%7 P%TTERN &. 8ealth perception health management pattern describes clients perceived pattern of health and well being and how health is managed. '. 7utritional metabolic pattern describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply. ). 5limination describes pattern of eBcretory function ,bowel" bladder and skin-. 9. 2ctivity eBercise describes pattern of eBercise" activity" leisure and recreation ?. 0ognitive perceptual describes sensory perceptual and cognitive system @. Sleep rest describes pattern of sleep" rest and recreation. A. Self perception self concept self concept pattern and perceptions of self ,body comfort" body image" feeling state-. D. Cole relationship describes pattern of role engagements and relationships :. SeBual reproductive client patterns of satisfaction and dissatisfaction with seBuality: describes reproductive pattern &;. 0oping stress tolerance general coping pattern and effectiveness of the pattern in terms of stress tolerance. &&. 1alue belief patterns of values" beliefs ,including spiritual- or goals that guide choices of decisions. NURSING DI%GNOSIS - 0linical Fudgment about an individual" family or community responses to actual and potential health problems - Professional nurses are responsible for making nursing diagnosis. - 7ursing diagnosis describe a continuum of health states. %ct!)P'te ti)- He)-th Pr'&-em NURSING DI%GNOSIS - %ocus on identifying human responses to health and illness - (escribe problems treated by nurses within the scope of independent nursing practice - 0hanges from day to day as client responses change He)-th" Res,' ses

MEDIC%7 DI%GNOSIS - /dentifies disease - (escribe problems for which the physician directs the primary treatment - Cemains the same for as long as the disease is present

6 TYPES OF NURSING DI%GNOSIS &. %ct!)- !rsi + *i)+ 'sis Fudgment about a clients response to a health problem at the time of assessment and is signified by the presence of associated signs and symptoms. %ormat: ' part ,problem related to etiology) part ,problem" etiology and signs and symptoms format-

'. Ris= !rsi + *i)+ 'sis clinical Fudgment about a clients vulnerability to develop a problem %ormat: ' part statement ,diagnostic label related to risk factors). P'ssi&-e !rsi + *i)+ 'sis evidence about a certain problem is unclear and need to gather more data to support it %ormat: ' part statement 9. 6e-- ess !rsi + *i)+ 'sis clinical Fudgment about an individual" family and community in transition from a specific level of wellness to a higher level of wellness %ormat: potential I desired higher level of wellness Ceadiness for I higher level of wellness ?. S" *r'me !rsi + *i)+ 'sis comprises of a cluster of problems %ormat: & part statement ,rape trauma syndrome@. %-()r'?s r!-e ('r ) c'--)&'r)tive ,r'&-em focus on potential complications %ormat: potential problem I related to I list of complications that may occur First Pri'rit" is any threat to the vital functions of breathing" heart beat" blood pressure. Me*i!m Pri'rit" health-threatening problems that may result in delayed development or cause destructive physical or emotional changes. 7'8 Pri'rit" problems that arise from normal development needs or those that re>uire minimal nursing support. O.BECTIVES - Should be S$2CT" client centered" statement of a single human response EV%7U%TION - 0onclusion and supporting data - +oal met - +oal partially met - +oal not met GRO6TH - Physical change - /ncrease in si4e - Periods of very rapid growth rate: pre natal" neonatal" infancy" adolescence DEVE7OPMENT - /ncrease in compleBity of function and skill progression - The behavioral aspect of growth PRINCIP7ES OF DEVE7OPMENT & +rowth and development are continuous orderly" se>uential process influenced by maturational environment and genetic factors '. 2ll humans follow the same pattern of growth ). The se>uence of each stage is predictable although the time of onset" the length of the stage and the effects of each stage vary with the person. 9. +rowth and development occur in cephalocaudal direction. ?. +rowth and development occur in a proBimal to distal direction @. (evelopment occurs from simple to compleB or from single acts to integrated acts. A. (evelopment becomes increasingly differentiated" begins with generali4ed response and progresses to a skilled specific response. D. The pace of growth and development is asynchronous or uneven.

2OH7.ERG?S ST%GES OF MOR%7 DEVE7OPMENT 7EVE7 %ND ST%GE 7eve- IC Pre C' ve ti' )- (E+'ce tric F'c!s# St)+e 0 Punishment and obedience orientation - 2ctivity is wrong if one is punished" ,toddler A yearsactivity is right if one is not punished. St)+e / /nstrumental Celativist .rientation ,9 &' years- 2ction is taken to satisfy ones needs. 7eve- IIC C' ve ti' )- (S'ciet)- F'c!s# St)+e $ /nterpersonal concordance" good boy" nice girl ,@ years thru adult yearsSt)+e 4 *aw and order orientation ,adolescent adult7eve- IIIC P'st C' ve ti' )- 'r Pri ci,-e* 7eve(U ivers)- F'c!s# St)+e 3 Social contract" legalistic orientation ,middle age or older adult-

- 2ction is taken to please another and gain approvals. - Cight behavior is obeying the law and follow the rules

- Standard of behavior is based on adhering laws that protect the welfare and rights of others: violating the rights of others is avoided: personal values and opinions are recogni4ed. - Gniversal moral principles are internali4ed" person respects other humans and believes that relationship are based on mutual trust.

St)+e 6 Gniversal ethical principles ,middles age or older adult-

TYPES OF O7DER %DU7T &. Y'! + '-* (63 :4# adaptation to retirement and changing physical abilities" chronic illness may develop. '. Mi**-e '-* (:3 14# adaptation to decline in speed of movement" reaction time and sensory abilities: increasing dependence in others. ). O-* '-* (13 'ver# increase physical problems.

DEVE7OPMENT%7 T%S2 %ND 6HO7ISTIC %PRO%CH .Y RO.ERT H%VIGHURST %GE PERIOD I () c" ) * E)r-" Chi-*h''* DEVE7OPMENT%7 T%S2 - *earning to walk" to taste solid foods" to talk" to control elimination of body wastes" seB differences and seBual modes - *earning to relate emotionally to parents" siblings and others - *earning to distinguish right from wrong and developing a conscience - *earning to form concepts of social and physical reality - *earning physical skills for ordinary games - =uilding wholesome attitude towards oneself - *earning to get along with age mates - *earning an appropriate masculine or feminine social role - (eveloping fundamental skills in reading" writing and calculating - (evelop concepts necessary for everyday living - 2chieving personal independence - 2chieving new and more mature relations with age mates of both seBes - 2chieving masculine#feminine social role - 2ccepting ones physi>ue and using the body effectively - 2chieving emotional independence from parents - Selecting and preparing for an occupation - Preparing for marriage and family life - (eveloping intellectual skills necessary for civic competence - 2c>uiring a set of values and an ethical system as a guide to behavior - Selecting a mate - *earning to live with a partner - Starting a family and rearing children - $anaging a home - +etting started in an occupation - Taking on civic responsibility - %inding a congenial social group - 2chieving adult civic and social responsibility - 5stablishing and maintaining an economic standard of living - 2ssisting teenage children to become responsible and happy adults - (eveloping adult leisure time activity - 2ccepting and adFusting the physiologic changes of middle age - 2dFusting to aging parent - 2dFusting to decrease physical strength - 2dFusting to retirement and reduced income - 2dFusting to death of a spouse - $eeting social and civic obligations - 5stablishing satisfactory living arrangements

Mi**-e Chi-*h''*

%*'-esce ce

E)r-" %*!-th''* (/9 49 "rs#

Mi**-e %+e (Em,ti ess St)+e#

7)te M)t!rit"

NURSE C7IENT RE7%TIONSHIP - 8elping relationship for growth PH%SES OF NURSE C7IENT RE7%TIONSHIP Ph)se IC Pre I ter)cti' - 7o face-to-face interaction with client Ph)se IIC I tr'*!ct'r"/Orie t)ti' - Capport setting" contract setting" sets tone for rest of relationship - Testing behavior ,orientation- resisting behavior ,non compliancePh)se IIIC 6'r=i + - /mplementation of nursing care plans - 1iew as uni>ue individuals - 5mploy decision-making and technical skills and communication skills Ph)se IVC Termi )ti' - 0haracteri4ed by ambivalence on both nurse and client - (ischarge phase - 5valuation of care given by nurse COMMUNIC%TION - 8uman function that enables people to relate with each other MODES Ver&) spoken language N' 5Ver&)- symbols" sign language E7EMENTS OF COMMUNIC%TION &. Stim!-!s reason why people communicate" motivation with each other ,obFect" ideas" feeling- re(ere t '. Mess)+e idea" feelings and emotions ). Se *er also known as encoder" one that sends the message 9. Ch) e-s kinesthetic: tactile stimulus" visual: symbols" auditory: spoken language ?. Receiver decoder @. Fee*&)c= answer to >uestions" whether receiver understood or not F%CTORS TH%T %FFECT COMMUNIC%TION PROCESS &. %&i-it" '( c'mm! ic)t'r ability to speak" hear" see and comprehend stimulus '. Perce,ti' s each has a uni>ue trait" values" life eBperiences ). Pers' )- s,)ce distance people prefer in interactions with one another F'!r *ist) ces a. I tim)te - Physical contact to & J feet characteri4ed by body contact heightened sensation of body heat and smell" low vocali4ation - Threatening to client b. Pers' )- & J feet to 9 feet - *ess overwhelming than intimate distance - Gsual distance between nurse and client - =est distance c. S'ci)- 9 feet to &' feet - 0ommunication is non-formal - 2llows more activity and movement back and forth - .ften misused by nurse d. P!&-ic - &' feet and beyond - /ndividuality is lost - $ass health education 9. Territ'ri)-it" concept of space and things that an individual considers as belonging to the self

?. R'-es ) * Re-)ti' shi,s @. Time events that precede and follow interactions A. E vir' me t environment is comfortable" communication is more effective D. %ttit!*es THER%PEUTIC COMMUNIC%TION Usi + si-e ce R%TION%7E 2ccepting pauses or silences without interFecting any verbal response Gsing statements or >uestions that a. encourage client to verbali4e b. choose a topic of conversation Statements that are specific rather than general and tentative rather than absolute Specify only topic to be discussed and invite answers longer than one or two words Touch reinforces caring feelings" however" nurse should be sensitive to difference in attitude<s practice of clients self 2ctively listening for the client<s basic message then repeats those thoughts and#or feelings in similar words. Gsed when communication is rambling or when paraphrasing is difficult 8elping the client clarify an event situation or happening with respect to time Suggesting ones presence" interest or wish to understand the client without making any demands that could make client comply to suggestion 2 simple and information direct manner" specific factual

Pr'vi*i + +e er)- -e)*s

.ei + s,eci(ic ) * te t)tive

Usi + ',e e *e* I!esti' s Usi + t'!ch

Rest)ti +/Re,hr)si +

See=i + c-)ri(ic)ti'

C-)ri("i + time 'r SeI!e ce O((eri + se-(

Givi + i ('rm)ti' %c= '8-e*+i +

+iving recognition in a non Fudgmental way of a. change in behavior b. effort the client has made c. contribution to a communicator 8elping client differentiate real from unreal 8elping the client eBpand on and develop a topic of importance The focus may be an idea or a feeling.(irecting ideas" feelings" >uestions or content back to clients to enable them to eBplore their own feelings

Prese ti + re)-it" F'c!si + Re(-ecti +

S!mm)riGi + ) * P-) Perce,ti' chec=i +

i +

Stating the main points of discussion to clarify relevant parts discussed 1erifies meaning of specific words than overall meaning of a message

NON THER%PEUTIC COMMUNIC%TION Stere't",i + %+reei + ) * Dis)+reei + .ei + *e(e sive Ch)--e +i + Pr'&i + Testi + Ch) +i + t',ic U 8)rr) te* re)ss!r) ce P)ssi + J!*+me t Givi + c'mm' )*vice

R%TION%7E .ffering generali4ed and over simplified beliefs about groups of people 2kin to Fudgmental responses implies client is either right or wrong 2ttempting to protect a person +iving response that makes client prove their statement or point of view 2sking information chiefly out of curiosity rather than intent Kuestion than make a client admit something (irecting communication into areas of self intent Gsing clichLs or comforting statements of advice as a means to reassure the client +iving opinions and approving or disapproving response Telling client what to do

VIT%7 SIGNS TEMPER%TURE 0> Or)- $ost accessible and convenient - 7ormal value: )A o 0 :D.@ o % - ' ) minutes /> Rect)- $ost reliable - 7ormal value: )A.A o 0 ::.@ o % - ) ? minutes $> %<i-) - *ess accurate - 7ormal value: )@.9 o 0 :A.? o % - ? &; minutes 4> T"m,) ic mem&r) e - (irectly reflects core temperature - 7ormal value: )A.A o 0 ::.: o % - 2utomatic results

CONVERSION - %ahrenheit to 0elsius M ,%-)'- B ?#: - 0elsius to %ahrenheit M ,0 B :#?- I )' PU7SE SITE &. Temporal @. %emoral '. 0arotid A. Popliteal ). 2pical D. Posterior tibial 9. =rachial :. (orsalis pedis ?. Cadial When palpating for pulse use ' ) fingers eBcept when taking the apical pulse use stethoscope 2pical pulse is in the ?th intercostals space *andmark is the angle of *ouie 9th intercostals space left mid clavicular line child apical pulse When using the stethoscope use the flat part when looking for high pitch sounds like ,lung and bowel sounds- and use the bell for vascular or heart sounds RESPIR%TION - 2dult: &' '; c#min - 7ewborn ); @; c#min ERRORS IN T%2ING RESPIR%TORY R%TE P)tie t F)ct'r /nsufficient rest before assessing 2ssessing immediately after a meal or while client smokes or has pain EI!i,me t F)ct'r Stethoscope fits poorly or hearing impaired =ladder or cuff too wide =ladder or cuff too narrow Err'rs i tech iI!e 2rm unsupported 2rm above heart level and not perpendicular to the body 0uff wrapped to loosely (eflating cuff to slowly (eflating cuff to >uick %ailure to identify auscultatory gap %!sc!-t)t'r" +), Temporary cessation of sounds after initiation +ap of &; 9; mm8g 0ommon among hypertensive Cepeating assessment too >uickly ,wait for ' ) minutes after taking again the bp" and maBimum of ) takes same arm and if still inaudible rest arm for ? &? minutes $ultiple eBaminer using different 3ortkoff sounds for diastolic readings %ailure to use the same arm consistently 5ffects 5rroneously high readings

F)-se -'8 s"st'-ic ) * ()-se hi+h *i)st'-ic - %alse low reading - %alse high reading - 5rroneously high readings - 5rroneously low readings - %alse high readings - %alse low diastolic reading - %alse high diastolic reading - %alse low systolic bp and diastolic bp - %alse high systolic blood pressure" false low diastolic blood pressure

 /naccurate interpretation /nconsistent measurements F'r ) c-ie t 8h'?s &-''* ,ress!re is t' &e t)=e ('r the (irst timeD t)=e the &-''* ,ress!re '( &'th )rms (ifference of blood pressure for both arms should only be &; mm 8g Gse higher value as baseline P%7P%TORY SYSTO7IC PRESSURE Point of pulsation stops with the use of stethoscope $aBimum pressure I ); mm8g that is you limit when taking the blood pressure 2OROT2OFF SOUNDS Ph)ses &. 0haracteri4ed by a thud" thump and tapping sound '. Swooshing" whoosing sound ). Sound decrease in intensity when compared to 3orotkoff one 9. $uffling sound ?. (isappearance of sound - in adults record 3orotkoff & and 3orotkoff ? of able to hear 3orotkoff 9 record also - in children record 3orotkoff & and 3orotkoff 9 HYPERTENSION 2verage of ' or more diastolic reading on at least ' subse>uent visits is :; mm8g or higher or when an average of ' or more systolic readings on at least ' visits is higher than &9; mm8g .ptimal# 7ormal 2bove 7ormal 8ypertension +rade & ,$ild+rade ' ,$oderate+rade ) ,SevereSNST.*/0 &'; &': &); &): &9; &?: &@; &A: +reater than &D; +reater than &9;*ess D; (/2ST.*/0 D; D9 D? D: :; :: &;; &;: +reater than &&; *ess :;