FUNDAMENTALS OF NURSING • Viriginia Henderson

Theoretical Foundations of Nursing needs theory

Nursing Emphasizing the basic human needs and how
Metaparadigm of Nursing nurses can assist in meeting those needs
4 concepts that comprises a nursing theory
14 FUNDAMENTALS NEED
• person — recipient of car
1. Breathing
• environment — internal and external surroundings
2. Eating / drinking
• health — degree of wellness
3. Elimination
• nursing — action of the nurse by providing care.
4. Movement
Theories:
5. Sleep and rest
• Florence Nightingale
6. Clothing
Founder of Modern Nursing
"Lady with the lamp" 7. Temperature
8. Hygiene
Environmental Theory 9. Safety
• the act of utilizing the environment of the 10. Learning needs
patient to assist him in his recovery. 11. Communication
12. Values and beliefs
5 Environmental Theories
13. Work and accomplishments
1. Fresh air
14. Recreational Activities
2. Clean water
3. Efficient drainage • Martha Rogers
4. Cleanliness Science of unitary human being
5. Direct sunlight Nursing is both science and art

Hildegard Peplau
Humans should be able to co-exist with
" interpersonal relations theory" environment
"Pep talk" = therapeutic communication
• Dorothea Orem
Nurse: client relationship
(Professional relationship)
THREE TYPES OF NURSING SYSTEM
4 Phases of nurse patient interaction
(NPI) / nurse patient relationship NPR • wholly compensatory
Patient entirely dependent to the nurse
• orientation
• partly compensatory
starts when patient meets the nurse
*define the problem Patient can do some activities
• supportive—reeducative
explore the patient's needs
Patient needs to learn first before doing
• identification
select appropriate care for patient. activities

"Planning phase" • Imogene King

• exploitation Goal Attainment Theory
implementation of care needed
4 factors affecting the attainment of goals:
• resolution
a. Role
termination of the relationship
b. Stress
c. Space (environment)
d. Time
• Betty Neuman
EXPANDED CAREER AND ROLES
Stress Adaptation Theory
Advance Practice Registered Nurse (APRN)
Adaptation and manipulation of stressors are needed
Post-graduate related to nursing
to foster damage Nurse Researcher
• Sister Callista Roy Investigate nursing problems to improve care
Adaptation Model Nurse Administrator
Goal: enhance life processes through adaptation Manages the delivery of nursing service
• Madeleine Leininger Nurse Educator

Transcultural Nursing Clinical teaching

Nurse Entrepreneur
Belief, traditions, practices of the patient must be observed
Manages health-related business
• Jean Watson Forensic Nurse
Human Caring Theory Specialized care for individuals who are victims or
The practice of caring is central to nursing perpetuators of trauma
Informatics Nurse Specialist
• Lydia Hall
Supports the use of technology in the nursing
Core, Care, Cure Theory
lractice
1. Core — patient receiving nursing care
2. Care — role of the nurse NURSING PROCESS
3. Cure — role of the doctor Systemic, logical way of caring for a patient
Cyclic humanistic —Individualized
• Faye Abdellah
ADPIE
21 Nursing Problems
Assessment
Identifies 10 steps and 11 nursing skills to Diagnosis
identify patient problems / need Planning
• Dorothy Johnson Implementation
Behavioral Systems Model Evaluate
Fostering of efficient behavioral functioning
in the patient to prevent illness • Assessment
establish baseline data
• Joyce Travelbee
TYPES:
Human—Human Relationship
• Initial Assessment (ER)
Help patient to find meaning in the experience of suffering Commonly done within 24 hours of admission
Help maintaining HOPE • Problem Focused Assessment
Determine the status of a specific problem
SCOPE OF NURSING identified = Pain
Health Promotion
• Emergency Assessment
Goal: enhance lifestyle during life threatening crisis
HEALTH PREVENTION
Goal: to maintain optimal health • Time-Lapsed Assessment
compare current status to baseline
HEALTH RESTORATION
Goal: Rehabilitation
*Activities
Prevent complications
• gather data
PALLIATIVE CARE
a. Subjective—verbalized
Goal: provide comfort through symptomatic caring
ROLES AND FUNCTIONS b. Objective— objective
Care Provider / Performing direct care • Sources
Care giver
Leader manages other nurses a. Primary — patient only
Communicator Communicate needs of patient
Case Manager oversee the care of the patient b. Secondary — S/O, HCT, other people
Teacher Health teaching patient
Client Advocate Protect client's rights Research Consumed use research to improve
Counselor Help client in coping management
Change Agent Helps client in modification of behaviors
 • methods of data gathering c. Vital Signs — cardinal signs (signs of life)
a. Interview — planned communication with a *when to assess
purpose • upon admission
TYPES • when the patient has a change in health
• directive — highly structured, time is limited, close— status or report unstable symptoms
ended questions • before and or after invasive procedure /
• non–directive — rapport building, open ended surgery
questions. • before and or after administration of
medication.
b. Physical Exam—Uses senses, cephalocaudal • Before and after any nursing intervention
(head-to-toe) approach, review of systems Techniques for Vital Signs
* techniques of physical assessment I P P A • Body Temperature— balance heat produce and
• I inspection: sense of sight heat loss in the body. Normal: 36.5—37.5
• Direct— naked eyes
TYPES:
• Indirect— instruments
a. Core — deep tissues
• P palpation: sense of touch
b. Surface — skin (depends on the environment.
Check the texture and presence of nodules
• Light— uses one hand, use gentle pressure *Processes of heat production
• Deep— bimanual a. BMR— Basal Metabolic Rate:
Considerations: rate of energy utilization in the body required to
1. Light before deep maintain essential activity
2. Hands should be warm b. Muscle Activity (Exercise)
3. Finger nails should be short c. Thyroxine output — T4
4. Areas of tenderness, should be palpated last.

d. Sympathetic stimulation stress response (fight or

• P percussion: striking of an area of the body to
flight)
elicit sounds that can be heard through feelings or
e. Fever
vibrations
Heat loss
• Direct — dominant hands
a. Radiation: transfer of heat without contact
• Indirect — instruments
b. Conduction: transfer with contact
Percussion of sounds
c. Convection: dispersion of heat by air current.
• Flatness — extremely dull
d. Evaporation: continuous of vaporization of
— very dense tissue.
moisture
• Dullness — thud-like sound
Factors:
—fluid-filled dense tissues
a. Age: = temperature
• Resonance — hollow sound
b. Diurnal Variation: Highest temp: 4—6pm
— air filled spaces (lungs Lowest Temp: 4—6am
(Circadian Rhythm)
• Hyper-resonance — booming sound
c. Exercise: 38.4 —40 Celsius.
—emhysematous lungs
d. Hormones — estrogen
• Tympany — drum-like sound
e. Environment
— air filled stomach
• Auscultation: sense of hearing
Direct — unaided ear
Indirect — Stethoscope
General: IPPA
Abdominal Exam: IAPePa
Bowel Sounds: Borborygmi
 Routes of Temperature Taking • Pulse Rate

a. Oral — most accessible and convenient route Wave of blood created by the contraction of the left
*Considerations: ventricle of the heart to the body.
• (+) Intake of hot and cold drinks, wait 30 minutes.
• Placement: under the tongue side of the frenulum *FACTORS:
• Contraindications: mouth sores, infant with extrusion • Age = Higher the age, lower the pulse
reflex, comatose, oral surgery, nasal packing • Sex = females (higher)
b. Axillary — most safe and non invasive • Exercise = decreases your pulse rate, to compensate to
high energies of activity when exercising.
*Considerations Contraindication: • Medications
• Placement: • rectal lesions • STRESS
—middle of the axilla • rectal surgery • Fluid Volume (Hypervolemia/hypovolemia)
—Pat dry the axilla * SITE OF PULSE TAKING
• diarrhea
• Radial —most readily available
• Contraindications: • cardiac problem
• Temporal— used when radial pulse is not accessible
—lesions, paralysis
• Carotid— used to assess cardiac arrest/shock
c. Rectal— most accurate
• Apical—used to assess in infants and children up to
Placement: rectum
3years old (below the nipple line)
Length:
* used to determine discrepancies with radial pulse
• infants: 05 inches
PULSE DEFICITS = apical pulse - radial pulse Normal = 0
• children: 1 inch
• Brachial — blood pressure taking, cardiac arrest in
• adults: 1.5 inches
infants.
• Femoral — cardiac arrest, shock
d. Tympanic— pediatric patients
Determines circulation to the leg
*Considerations:
• Popliteal — determines circulation to the leg.
• placement: pull pinna
• Posterior Tibial — determine circulation to the foot.
<3years old: back and down
• Dorsalis Pedis
>3 years old: back and up
PULSE RATES:
*Fever
a. Tachycardia = >100 bom
• Pyrexia = >37.5 degrees celsius
b. Bradycardia = < 60bpm
• Hyperpyrexia= >40 degrees celsius
PULSE RHYTHMS
Corrigans
CLASSIFICATION OF FEVER
Pulse that is forceful then suddenly collaps
• within 24 hours
Thready
a. intermittent— normal to abnormal
Not easily felt
b. remittent— always abnormal but temperature fluctuates.
Weak
• more than 24 hours
Can be felt but slower
a. Relapsing — abnormal — normal — abnormal
Pulse alterans
b. Constant— no/minimal changes alterations
Paradoxical
RESOLUTION OF FEVER
pulse volume weakness during inspiration
• Lysis— GRADUAL decrease to normal temperature.
• Crisis— SUDDEN decrease to normal temperature
VITAL SIGNS
* Fine
• Respiratory Rate
• congestive heart failure
rise and fall of the chest
• pulmonary fibrosis
• inhalation
*Coarse
• exhalation
• pulmonary edema
*Factors:
• bronchitis.
• Increase:
• Stress • poor oxygen concentration • BLOOD PRESSURE
• Exercise • Increase environment temparature Measurement of the pressure exerted by the
• Decrease: blood a it flows. *Kororkoff sound—ticking
sound auscultated during bp
• medications • Increased ICP
*Factors taking
• low environment temperature d. Sex = male
a. Age
• Breathing Rate b. Exercise e. Medication
Tachypnea quick shallow breaths c. Stress f. Race = African American
Bradypnea slow breathing Classification of Blood Pressure
Apnea cessation of breathing Categories Systolic Diastolic
Eupnea normal breathing
• Breathing Volume 1. Normal <120 <80
2. Pre Hypertension 120—139 80—89
Hyperventilation
3. Hypertension 1 140—159 90—99
over-expansion of lungs, rapid and deep
4. Hypertension 2 >160 >100
Hypoventilation
under-expansion of lungs, shallow

• Ease or Effort *Methods of BP Taking

Dyspnea difficulty of breathing Palpatory BP initial bp taking
Orthopnea ability to breathe in an Ausculfactory BP use of stethoscope
upright / standing position *Considerations
• Position: sitting / semi fowlers/ supine
• Normal Breath Sounds
• Arm supported at the level of the heart.
Tracheal harsh and high-pitched
• 1 inch / 2 finger breaths above
Bronchial loud and high-pitched
antecubital space — wrap cuff
Bronchovesicular medium in pitch and • Insert 2 fingers in the wrapped cuff
loudness • Auscultory BP: inflate cuff 30 mmHg
Vesicular soft and low-pitched above palpatory BP
• Deflate the cuff 2—3 mmHg/second
• Adventitious Breath Sounds
ERRORS IN BP TAKING
Stridor shrill, harsh sound, during inspiration
FALSE HIGH FALSE LOW
Stertor snooring or sonorous respiration >cuff too narrow >Cuff too wide
>arm below the level >Arm is above level
of the heart. of the heart
>over inflated cuff
• Wheezing high-pitched musical/ whistling

• Crackles short high-pitched and intermittently

crackling sound
• Pain fifth vital sign / subjective PHARMACOLOGIC MANAGEMENT
Unpleasant/ uncomfortable and highly personal experience World Health Organization
Causes:
Analgesic Ladder—depends on the intensity of the
• Tissue Damage
pain.
• Inflammation
Step One: Mild (1—3)
• Nerve Damage
• Psychological Conditions. Non-opioid analgesics
—NSAIDS (NonSteroidalAntiInflammatory
PAIN ASSESSMENT: PQRST drugS)
P-Provoking Factors • ibuprofen
• "what makes your pain better or worse?" • aspirin
Q-Quality • acetaminophen/paracetamol
• characteristics of pain • celecoxib
R-Region
• location of the pain Step Two: moderate (4—7)
S-Severity Combination of non-opioid and mild opioid
• rating of the pain analgesics.
a. Codeine
0- no pain
b. Hydrocodone
1—3 mild pain
c. Tramadol
4—7 moderate pain
8—10 severe pain Step Three: Severe (8—10)
T-Time Opioid Analgesics = High risk for substance
onset, duration, frequency abuse.
PAIN MANAGEMENT: a. Morphine sulfate
Non-Pharmacologic b. Methadone Controlled
substance
1. Cognitive Behavioral Therapy c. Fentanyl

DIAGNOSIS
a. Distraction — change attention away from pain Purpose: Problem identification
ex. Watching TV
Types:
b.Relaxation Response — meditation, music therapy,
• Actual (+) problem
deep breathing
• Risk (-) problem
c. Guided Imagery
(+) risk factors
d. Emotional Counseling
• Health Promotion
e. Hypnosis
(-) illness (+) problem
• Syndrome
2. Physical Interventions
(-) problem (+) cluster of risk factors
a. Massage — increase endorphins • Possible
b. Heat and Cold Application (-) Problem (-) risk factors (+) manifestations
• decreases pain and inflammation
* cold— vasoconstriction
*warm— vasodilation (dr's order = risk for burns)
c. Acupressure—Acupuncture
d. Immobilization
e. Yoga
f. Range of Motion Exercises
PLANNING
Goal: formulate goals/ desired outcomes
Guideline: S M A R T
Specific Measurable Attainable Realistic Time-bounded
Types:
Initial— first planning after initial assessment
Ongoing— hospitalization
Discharge— starts upon admission.

IMPLEMENTATION
Purpose: putting plans into actions
TYPES

• Independent within the scope of nursing practice.

• Dependent with doctor's order
Telephone order: Let the doctor sign within 24 hours after the order

• Collaborative/Interdependent with other health care

professionals.

EVALUATION
Measures the outcome of the nursing action and its effectiveness.