Reviewer In Fundamentals of Nursing PDF

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REVIEWER IN FUNDAMENTALS OFNURSING (MIDTERMS)“UNIT 1”NURSIG AS A PROFESSIONNURSING AS AN ARTo Is the art of caring the sick and well individual. Refers to the dynamic skill and methods in assisting sick and well individual in their recovery and promotion and maintenance of health. It involves the cr...

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REVIEWER IN FUNDAMENTALS OF NURSING (MIDTERMS)

VIRGINIA HENDERSON o

“UNIT 1” NURSIG AS A PROFESSION NURSING AS AN ART o

Is the art of caring the sick and well individual. Refers to the dynamic skill and methods in assisting sick and well individual in their recovery and promotion and maintenance of health. It involves the creative application knowledge in the service of people

NURSING AS A SCIENCE o

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It is the “body of abstract knowledge” and through scientific research and logical analysis. Is the scientific knowledge and skills in assisting individual to achieve optimal health. It is the diagnosis and treatment of human response to actual or potential problem

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NURSING AS A PROFESSION o

Profession – a calling in which its members profess to have acquired special knowledge by training or experience, or both so that they may guide, advise or save others in that special field.

FLORENCE NIGHTINGALE o

Nursing is the act of utilizing the environment of the patient to assist his recovery.

Nursing is the act of assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or, knowledge, and to do this is such as to help him gain independence rapidly as possible.

CANADIAN (CAN) o

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NURSES

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ASSOCIATION

Nursing is dynamic, caring, helping relationship in which the nurse assist the client to achieve and obtain optimal health. Themes that are common to these definition:  Nursing is caring  Nursing is an art  Nursing is a science  Nursing is client-centered  Nursing is holistic  Nursing is adaptive  Nursing is concerned with health promotion, health maintenance, and health restoration  Nursing is a helping profession

1980 

1995 

Nursing is the diagnosis and treatment of human responses to actual or potential health problems ANA acknowledges FOUR ESSENTIAL FEAURES OF CONTEMPORARY NURSING PRACTICE:  Attention to the full range of human experiences and responses to health and illness without restriction to a problem-focused orientation  Integration of objective data with knowledge gained from understanding of the client or group’s subjective experience  Application of scientific knowledge to the processes of diagnosis and treatment  Provision of caring relationship that facilitates health and healing

AMERICAN NURSES ASSOCIATION (ANA) NURSE o

1973 

Nursing is direct, goal-oriented, and adaptable to the need of the individual, the family, and community during health and illness.

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Comes from a Latin word “to nourish” or “to cherish” One who cares for the sick, the injured, and the physically, mentally, and emotionally disabled

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One who advise and instruct individuals, families, groups, and communities in the prevention, treatment of illness and diseases and in the promotion of health. An essential member of a health team who cares for individuals, families, and communities in disease and illness prevention and in the promotion of health and health equipment.

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PATIENT o o o

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Comes from a Latin word, “to suffer” or “to Bear” An individual who is in state of physical, mental, and emotional imbalance An individual who seeks for nursing assistance, medical assistance, or for surgery due to illness or a disease Is an individual who is waiting or undergoing medical or surgical care. One who is physically or mentally disabled.

HISTORY SETTING) o

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NURSING

EARLY HOSPITALS o

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(PHILIPPINE

EARLY BELIEFS AND PRACTICES  Caused or Inflicted by other person (enemy or witch)  Evil Spirits Beliefs That Evil Spirits Could Be Driven Off By Powers To Expel Bad Spirits:  Believed in Gods of healing  Word doctors – Priest Physicians  Herbolarios – Herb Doctors EARLY CARE OF THE SICK  Herbicheros – Herbmen who practice witchcraft  Mangkukulam/Mangangawa – a person suffering from disease

within any identified cause and were believed bewitched by such Difficult child birth and some disease attributed to (NONO) midwives. Difficult birth, witches were supposed to be the cause, gunpowder exploded from the bamboo pole close to the heel of the mother to drive evil spirits

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Hospital Real de Manila – 1577  1st Hospital Established  Gov. Francisco de Sande  To give service to the King’s Spaniard soldiers San Lazaro Hospital – 1578  Fray Juan Clemente  Named After the Knights of St. Lazarus  Hospital for the Lepers Hospital de Indios – 1586  Franciscan Orders  Hospital for the poor Filipino people Hospital de Aguas Santas – 1590  Fray Juan Bautista  Named after its location (near spring) because people believed that spring has healing power. San Juan de Dios Hospital – 1596  For Poor People  Located at Roxas Boulevard

PERSONAGES o

Melchora Aquino

Took care of the wounded Katipuneros Anastacia Giron Tupaz  Founder of Filipino Nurses Association  1st Filipino Chief nurse of PGH  1st Filipino Superintendent of nurses in the Philippines Francisco Delgado  1st President of Filipino Nurses Association Cesaria Tan  1st Filipino to receive Masteral Degree in Nursing Abroad Socorro Sirilan  Pioneer In Social Service At San Lazaro Hospital  Also the Chief Nurse Rosa Militar  Pioneer in Nursing Education Socorro Diaz  1st editor of PNA magazine called, “The Massage”. Conchita Ruiz  Full time editor of the PNA newly named magazine, “The Filipino Nurses” 

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EARLY NURSING SCHOOLS o o o o o

PGH School of Nursing – 1907 St. Paul School of Nursing – 1907 St. Luke’s School of Nursing – 1907 UST – 1946 Fatima – 1947

NURSING IN PRIMARY CARE SETTING Nursing In Primary Care Setting

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Primary - initial health care for general complaints Usually the person’s 1st contact with the health care delivery system Managing current heath care needs, and preventing further problems  Public health nursing  Occupational nursing  Clinic nursing  School nursing  Private duty nursing  Military nursing  Ambulatory nursing  Nursing in correctional facilities

NURSING IN SECONDARY CARE SETTING Institutional Nursing: Hospital Nursing o o o o

o o

Director of nursing Clinical coordinator Head Nurse Staff nurse  OB-Gyne nursing  Pediatric nursing  Orthopaedic nursing  OR nursing  Med-Surgical nursing  Psychiatric nursing  ER nursing  Critical nursing Flight nurse Infection-surveillance nurse

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Nurse anesthetist Nurse educator Nurse administrator Nurse researcher

QUALITIES AND ABILITIES PROFESSIONAL NURSE o

ROLE o

A goal directed act or behaviour that is considered acceptable to the culture of given situation

ROLES OF A NURSE o o o o o o o o o o o o o o

Caregiver Communicator Teacher Client Advocate Counselor Change Agent Leader Manager Case Manager Research Consumer Role Model Administrator Expanded Career Roles

PROFESSIONAL NURSING o

Art and science, dominated by an ideal of service in which certain principles are applied in skilful care of the well and ill, and through relationship others and other members of the health team.

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PROFESSIONAL NURSE o Skilled care setting Rehabilitation setting Advanced practice nursing (APN)  Clinical nurse specialist

A person who has completed a basic nursing education program and is licensed in his country or state to practice professional nursing

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Has faith in the fundamental values that underlie the democratic way of life:  Respect for human dignity  Self-sacrifice for the common good  Strong sense of responsibility for sharing in the solution of the problem of the society Has a sense of responsibility for understanding those with whom he works or associates with through the use of Has the basic knowledge, skills and attitudes necessary to address present day social problems, realistic and well organized thoughts through the use of critical thinking Has skills in using written and spoken language, both to develop own thought and to communicate them to others Appreciates and understands importance of good health Has emotional balance Accepts and tries to understand people of all sorts, regardless of race, religion and color.

INTRODUCTION

NURSING IN TERTIARY CARE SETTING o o o

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Communication is the basic element of human interaction that allows people to establish maintain and improve contacts with others Nursing is a communicative intervention and is founded on effective communication

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The word communication originates from “communis”, a Greek word meaning “to make common” It is the transmission and receiving information, feelings and/or attitudes with the overall purpose of having understood producing a response

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THE COMMUNICATION PROCESS o

It has the following main components  Sender (Source)  Message (Content)  Channel (s) (Medium)  Receiver (Audience)  Feedback (Effect)

SENDER o o

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The sender (communicator) is the originator of the message Sender formulated, encodes and transmits the information which he/she wants to communicate The impact of the message will depend on sender’s communication skill, social status (authority), knowledge attitude and prestige in the community

MESSAGE o

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A message is the information/desired behaviour in physical form which the communicator transmits to his audience to receive, understand, accept and act upon The message may be in the form of words, pictures or signs Components of message are:  Message code – any group of symbols that can be structured in

a way that is meaningful to same person, eg., language Message content - the material in the message i.e. selected by the source to express his purpose Message Treatment – i.e. decisions which the communication source makes in selecting, arranging both codes and contents.

CHANNEL o

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By channel is implied the “physical bridge” or the media of communication between the sender and the receiver Channels can be:  Interpersonal (face to face communication) may be verbal or non-verbal  Mass media TV, radio, printed media, etc. Every channel of communication has its advantages and limitations The proper selection and use of channels results in successful communication

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MODE OF COMMUNICATION o o

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FEEDBACK o It is the flow of information from receiver to the sender. The reaction to the message

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TYPES OF COMMUNICATION o

One-way Communication (Didatic) – the flow of communication is “one way”

Verbal Communication (35%) Non-Verbal Communication (65%)

PRINCIPLES

RECEIVER

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from the communicator to the receiver. E.g. Lecture method Two-way Communication (Somatic) – Both sender and receiver take part  The process of learning is active and democratic  It is more likely to influence behaviour than one-way communication

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Communication should have objective and purpose Should be appropriate to situation Systematic analysis of the message, i.e. the idea, the thought to be communicated, so that one is clear about it. Selection and determination of appropriate language and medium of communication according to its purpose Organizational climate, including appropriate timing and physical setting to convey the desired meaning of the communication. Consultation with others for planning of communication, involves special preparation Message should convey something of value to the receiver in the light of his needs and interests The communication action following a communication is important in effective

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communication as this speaks more than his/her words “UNIT 3” BARRIERS OF COMMUNICATION o o o o o o

Physical/environmental barriers Personal barriers Physiological barriers Psychological barriers Cultural barriers Background barriers

IMPORTANCE NURSING o o

VITAL SIGNS, PAIN AND THERMOREGULATION

OF

COMMUNICATION

IN

A critical component of nursing practice Good communication  Generate trust between nurse and clients  Provides professional satisfaction  Is a means for bringing about change, i.e. nurse listens, speaks, and acts to negotiate changes that promotes client’s well-being.  Is the foundation of the relationship between the nurse and other members of the health team  Helps to promote managerial efficiency  Provides basis for leadership action  Provides means of co-ordination

● Vital signs - indicators of health status that indicates the effectiveness of circulatory, respiratory, neural and endocrine body functions - assessment of this provides data to identify nursing diagnoses, implement planned interventions, and evaluate outcomes of care - objective data that determine the general well-being of the body - measurable ● Guidelines in measurements of vital signs  Measuring vital signs is our responsibility  Assess equipment to ensure that it is working correctly and provides accurate findings  Select equipment on the basis of the patient’s condition and characteristics  Know the patient’s usual range of vital signs  Know the patient’s medical history, therapies and prescribed medications  Control or minimize environmental factors that affect vital signs  Use an organized, systematic approach when taking vital signs. Each procedure requires a step-by-step approach to ensure accuracy  On the basis of a patient’s condition, collaborate with healthcare providers to decide the frequency of vital sign assessment. The nurse is responsible for

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judging whether more frequent assessments are necessary. Use vital signs measurement to determine indications for medicine administration Analyze the results of vital sign measurement on the basis of patient’s condition and past medical history Verify and communicate significant changes in vital signs. When vital signs appear abnormal, have another nurse or healthcare provider repeat the measurement to verify readings. Instruct the patient or family caregiver in vital assessment and the significance of findings

● Vital Signs 1. Body Temperature 2. Pulse 3. Respiration 4. Blood Pressure 5. Pain ● When to take vital signs  Verified upon admission (baseline data)  Surgeries  Institutional policies  Giving medications  Nursing interventions  Status changes  Remember V-SIGNS!!! ● Equipment  Thermometer  Wrist watch with a “seconds” hand  Stethoscope  Sphygmomanometer  Alcohol swabs ● Preparation

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1. Wash hands before and after procedure 2. Identify and inform patient regarding the procedure 3. Provide privacy and position patient correctly 4. Explain procedure and evaluate accordingly I. Body Temperature - it is the difference between the amount of heat produced by body processes and the amount lost to the external environment - 36.5°C – 37.5°C  Core Temperature - Deep tissues: cranium, thorax, abdominal cavity and pelvic cavity - relatively constant - 37°C, 98.6°F  Surface Temperature - skin, subcutaneous tissue and fats - changes in response to the environment ● Thermoregulation  Skin receptors sense warm or cold stimuli and send signals to hypothalamus  Hypothalamus detects signals from receptors and sends signals to effectors to regulate body temperature ● Effector Responses  To cold: - Vasoconstriction - Epinephrine release - Shivering - Cold = VES!  To warmth: - Vasodilation: peripheral - Adjustments

- Sweating - Hot = VAS! ● Heat Production  Basal Metabolism  Epinephrine  Fever  Activity: Muscular (shivering)  Thyroxine  Heat = BEFAT! ● Heat Loss  Conduction  Radiation  Evaporation  Convection  Cool = CREC!

2. Mercury-in-a-glass

3. Forehead

● Factors Affecting Body Temperature  Age  Exercise  Hormone level  Stress  Environment ● Alterations in body temperature 1. Fever 2. Hyperthermia 3. Heatstroke 4. Heat Exhaustion 5. Hypothermia Death: >42°C Hyperthermia: 40-42°C Fever Pyrexia: 38-40°C Normal: 36.5-37.5°C Hypothermia: 35°C Death: 106°F - may be delirious, unconscious, or having seizures

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-signs: warm, flushed skin and often don’t sweat ● Hypothermia - core body temperature below the normal lower limit  Mechanism: - excessive heat loss - inadequate heat production - impaired hypothalamic thermoregulation  Signs and Symptoms: - decreased body temperature, pulse and respiration - severe shivering - feelings of cold and chills - pale, cool, waxy skin - frostbite (nose, fingers, toes) - hypotension - decreased urinary output - lack of muscle coordination -disorientation - drowsiness progressing to coma● Skill: Temperature  Steps: 1. Clean thermometer from bulb to stem 2. Insert thermometer in appropriate area and wait accordingly 3. Check reading 4. Clean thermometer from stem to bulb 5. Document accordingly ● Nursing Interventions for Hyperthermia  Clothing of client adjusted appropriately

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Antipyretics administered as ordered Rest and sleep provided Temperature and skin color assessed frequently Tepid sponge bath rendered Oral fluid intake increased (at least 2-3L) Nutrition promoted Cure for fever = CART TON!

● Nursing Interventions for Hypothermia  Limbs kept close to body  Oral (warm) or intravenous fluids given  Apply warm pads or hyperthermia blankets  Dry clothing provided  Apply warm blankets  Cover client’s scalp with a cap or turban  Environment should be warm  Cure for cold feet = LOAD ACE! II. PULSE - palpable bounding of blood flow in a peripheral artery - wave of blood created by contraction of the left ventricle of the heart - heart pumps and the blood enters the arteries with each heartbeat, causing pressure pulses or pulse waves ● Arterial Compliance, Elasticity, and Bilateral Equality  Compliance – ability of the arteries to contract and expand  Elasticity – expansibility or deformities of the arterial walls - normal artery feels straight, smooth, soft and palpable

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Bilateral Equality – check both extremities

● Stroke Volume Output - amount of blood that enters the arteries with each ventricular contraction - 70 ml (amount of blood pumped by a healthy adult heart per contraction) ● Cardiac Output - amount of blood volume that enters the arteries every minute - 4-6L (amount of blood an adult heart can pump in a minute during rest) - CO = SV x HR ● Factors Affecting Pulse Rate  Medications  Age  Sex: gender  Stress  Changes in position  Hemorrhage  Exercise  Fever  MASS CHEF changes pulse rate! ● Pulse Sites (PICTURE) 1. Temporal 2. Facial 3. Carotid 4. Brachial 5. Radial 6. Femoral 7. Popliteal 8. Posterior Tibial 9. Dorsalis Pedis ● Pulse Assessment  Pulse Rate 8

- review the patient’s baseline rate for comparison - assumes position – sitting, standing, and lying position – alterations in blood volume and sympathetic activity - if there is abn...