NCMA113 LECTURE – SUMMER MIDTERM 2021

- This may have been a cure for headache. The remains of

Coverage for Lecture: skulls where the hole has healed that some patients even
• Nursing as a Profession survived the operation.
• Nursing Process - To remove the evil spirit from the body of person.
• Fluids and Electrolytes
• IV Therapy
• Blood transfusion
• Dosage and Computations
• Concept of Administering Medications
• Concept of Pain

NURSING AS A PROFESSION
Discussed by Prof. Francis A. Vasquez, MAN, RN Important events during intuitive nursing
Definition of Nursing 1. Growth of religion
As an Art… 2. Growth of civilization
- Is the art of caring for the sick and well individual. a) Near east
- It refers to the dynamic skills and methods in assisting sick and b) Far east
well individual in their recovery and in the promotion and c) Ancient Greece
maintenance of health. d) Ancient Rome
- Remember: our client is not always a sick client, our client can Near east
also be well individual, we want that person to maintain his - Mode of nomadic life → agrarian society → gradual
normal state of health. development of urban community life.
- A nurse must develop manual dexterity – the ability to use your - Nomadic life – they move from one place to the other after they
hands in a skillful. (Kagaanan ng kamay) consume the resources in that area.
- Different nurses have different style. - Agrarian society - knows how to cultivate soil and plant trees
As a Science... that’s why they stay in one area.
- Is the scientific knowledge and skills in assisting individual to - Urban community life - A leader was born, nag karoon ng
achieve optimal health. structure.
- It is the diagnosis and treatment of human responses to actual - Nursing as a duty of slaves and wives.
or potential problem. - Birth of 3 religious’ ideologist:
- Nursing diagnosis – disease or illness itself; based on the • Judaism
response of client. • Christianity
- Medical diagnosis – given by a doctor based on his assessment • Mohammedism or Islam
or based on the interpretation of results of the laboratory and Contributions to Medicine and Nursing
diagnostic procedures. 1. Babylonia – Code of Hammurabi
- Actual problem – already existing - 1st recording on the medical practice.
- Potential problem – the capacity in developing. - Established the medical fees.
- Example: UTI - Discouraged experimentation.
• Patient A: Fever and painful urination - Specific doctor for each disease.
• Patient B: painful urination - Right of patient to choose treatment between the use of
• We are focusing on the client’s response. As a nurse, we charms, medicine, or surgical procedure.
are going to help relieve the pain. 2. Egypt – Art of Embalming
- We are using the nursing process or ADPIE (Assessment, - Mummification, removing the internal organs of the dead
Diagnosis, Planning, Intervention and Evaluation) body, instillation of herbs and salt to the dead.
Era in Nursing - Salt attracts water. The salt is extracting or pulling the fluid
from the body tissues.
Period of Intuitive Nursing
- Used to enhance their knowledge of the human anatomy.
- Practiced since pre-historic among primitive tribes and lasted
- Documentation about 250 diseases and treatments
through the early Christian era.
- Slaves and patients’ families nursed sick.
- Nursing was untaught and instinctive. (Instinctive – common
sense) 3. Israel – Teaching of Moses
- “The Father of Sanitation”
Trephining (6500BC)
- Discovered Artesian Well
- The first known surgery was trephining or drilling the skull.
- Wrote five books in the Old Testament.
• Practice of Hospitality and charity
Aki & Kaye 1 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

• Laws of control of spread of communicable disease and the - Established the Alexian Brothers School of Nursing,
ritual of circumcision of male child. the largest school under religious auspices exclusively
• Referred to nurses as midwives, wet nurse, or child’s course. in US and it closed in 1969.
Far East The Rise of Secular Orders
1. China – Materia Medica - Queens, princesses and other ladies of royalty founded many
- Book that indicates the pharmacologic drug used for religious orders.
treatment. 1. Order of St. Francis of Assisi (1200 – present)
- No knowledge on anatomy - Believed in devoting lives to poverty and service to the
- Use of wax to preserve the body of the dead. poor.
- Use of pharmacologic drugs. 2. The Beguines
2. India – Shushurutu - Composed of lay nurses who devoted their lives in the
- 1st recording on the nursing practice. service of suffering humanity.
- Hampered by Taboos due to social structures and practices - Founded in 1170 by priest Lambert Le Begue.
of animal worship. 3. The Oblates
- Medicine men-built hospitals. 4. Benedectines
• They use intuitive form of asepsis. 5. Ursulines
• There was proficient practice of medicine and surgery. 6. Augustinians
Ancient Greece Important Nursing Personages
- Nursing was a task of untrained slave. St. Clare
- Caduceus - Took vows of poverty, obedience to service and chastity.
- Insignia of medicine - Founded the 2nd order of St. Francis of Assisi
- 3 parts: Staff, Wings and Serpent. St. Elizabeth of Hungary
- The patroness of nursing
• Staff – medicine is the leader in the health profession.
- A princess, daughter of a Hungarian king
• Wings – doctor will always be there where help is
- Sees her calling to give care for the sick fed thousands of
needed.
hungry people.
• Serpent – represents as cure.
St. Catherine of Siena
- Hippocrates
- 25th child of a humble Italian parents
- Father of scientific/ Modern Medicine
- “Little saint” – took care of the sick as early as 7 years old.
- 1st to reject the idea that diseases are caused by evil spirits.
St. Vincent De Paul
- 1st to apply assessment.
- He organized the charity group called the “La Charite” and
- Practice medical ethics.
the “Community of Sisters of Charity.”
Ancient Rome
- He founded the “Sisters of Charity School of Nursing” in
- Paganism → Christian Philosophy
Paris, France where Florence Nightingale had her 2nd
- Romans’ Motto: “If you’re strong, you’re healthy”
formal education in nursing.
- Care of the ill was left to the slaves or Greek physicians.
The Dark Period of Nursing
- Fabiola
- Also called the period of reformation until the American Civil
• Converted to Christianity by Marcella and Paula War
• Made her home the first hospital in the Christian World. - The American Civil War was led by Martin Luther, the war was
Period of Apprentice Nursing a religious upheaval that resulted to the destruction in the unity
- 11TH century – 1836 of Christians.
- “On the Job” training period - The conflicts swept everything connected to Roman
The Crusades Catholicism in schools, orphanages, and hospitals.
- Religious war - Nurses were lowest people of the society.
- Military religious orders and their works
1. Knight of St. John of Jerusalem (Italian) Period of Educated Nursing
- Also called as “Knights of the Hospitalers” - Began on June 15, 1860 when the Florence Nightingale School
- Established give care. of Nursing opened at St. Thomas Hospital in London.
2. Teutonic Knights (German) Florence Nightingale
- Took subsequent wars in the Holy Land. - Mother of modern nursing
- Cared for the injured and established ten hospitals in - Lady with the lamp
the military camps. - Born on May 12, 1820 in Florence, Italy.
3. Knights of St. Lazarus - Her self-appointed goal – to change the profile of Nursing.
- Care for those who suffered Leprosy, syphilis, and - She compiled notes of her visits to hospitals, her observations
chronic skin diseases. of sanitation practices and entered Deaconesses School of
4. Alexian Brothers Nursing at Kaiserwerth, Germany for 3 months.
- Founded in 1348 - Contributions:
Aki & Kaye 2 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

• her book “Notes on nursing: What it is and What it is not” - Brotherhood of Miserecordia
• We need to correlate theory to practice. What is thought in - For poor people Located at Roxas Boulevard
the school is what must be practice in the area. Prominent Personages during the Philippine Revolution
• Paid instructors. 1. Josephine Bracken
• The nurses must receive decent quarters. - Wife of Jose Rizal installed a field hospital in an estate in
• Environmental theory Tejeros that provided nursing care to the wounded night
and day.
Period Contemporary Nursing 2. Rosa Sevilla de Alvaro
- World War II – present - Converted their house into quarters for Filipino soldiers
- This refers to the period after World War I and the changes and during the Phi-American War in 1899.
development in the trends and practice of Nursing occurring 3. Maria Agoncilla de Aguinaldo
since 1945 after World War II. - 1st president of Philippine Red Cross (Batangas chapter)
Development and Trends 4. Hilaria de Aguinaldo
- W.H.O. established by UN to fight diseases by providing health - Wife of Emilio Aguinaldo organized the Filipino Red
information, proper nutrition, living standard, environmental Cross
conditions. 5. Melchora Aquino
- The use of atomic energy for diagnosis and treatment. - Nursed the wounded Filipino soldiers, gave them shelter
- Space medicine and Aerospace Nursing. and food.
- Medical equipment and machines for diagnosis and treatment - Tandang sora
- Health related laws Hospital and School of nursing
- Primary health care – nurses’ involvement in CHN 1. Iloilo Mission Hospital Training School of Nursing (1906)
- Utilization of computers - Ran by the Baptist Foreign Mission Society of America
- Technology advances such as development of disposable - Miss Rose Nicolet → 1st superintendent
equipment and supplies that relieved the tedious task of nurses. - March 1944 – 22 nurses graduated.
- Development of the expanded role of nurses. - April 1944 – a board exam was held outside of Manila.
The Nursing Leaders - It was held in the Iloilo Mission Hospital thru the request
• Florence Nightingale (1820-1910) – mother of modern nursing of Ms. Loreto Tupas, principal of the school.
• Clara Barton (1821-­1912) – established American Red Cross 2. St. Paul’s Hospital School of Nursing (1907)
• Lillian Wald (1867-­1940) – Founder of Public Health Nursing - Most reverend Jeremiah Harty under the supervision of St.
• Lavinia Dock (1858-­1956) – women’s rights to vote. Paul de Chartres.
• Margaret Higgins Sanger (1879-­1966) - 1st birth control - Rev. Mother Melaine – superintendent
information clinic - Miss E. Chambers – Principal
• Mary Breckinridge (1881-­1965) – nurse who practice 3. Philippine General Hospital (1907)
midwifery. - 1906 – Mary Coleman Masters → trained Filipino girls for
nursing
History of Nursing in the Philippines - Elsie McCloskey-Gaches became the chief nurse.
Early beliefs, practices, and care for the sick - Anastacia Giron-Tupas, the 1st Filipino chief nurse and
Shaman/ Albularyo superintendent.
- a person regarded as having access to, and influence in, the 4. St. Luke’s Hospital School of Nursing (1907)
world of good and evil spirits. - Opened after 4 years as a dispensary clinic.
Health care during the Spanish Regime - Miss Helen Hicks – first principal
1. Hospital Real de Manila – 1577 - Vitaliana Beltran – first Filipino superintendent of nurses
- 1st hospital established. - Jose Fores – first Filipino Medical Director
- Founded by Gov. Francisco de Sande. 5. Mary Johnston Hospital School of Nursing (1907)
- To give service to king’s Spaniard soldiers - Was called as Bethany Dispensary founded by the
2. San Lazaro Hospital – 1578 Methodist Mission.
- Fray Juan Clemente - It became an emergency hospital during Japanese
- Named after the Knights of St. Lazarus occupation.
- Hospital for the lepers. - Burned down in 1945.
3. Hospital de Indios – 1586 6. Philippine Christian Mission Institute School of Nursing
- Franciscan Orders 7. San Juan de Dios Hospital School of Nursing (1913)
- Hospitals for the poor Filipino people 8. Emmanuel Hospital School of Nursing (1913)
4. Hospital de Aguas Santas – 1590 9. Southern Islands Hospitals School of Nursing (1918)
- Fray Juan Bautista College of Nursing
- Named after its location (near spring) because people 1. UST College of Nursing – 1946
believed that spring has a healing power. - 1947 – 21 graduate nurses
5. San juan de Dios Hospital – 1596 - 1st college of nursing in the Philippines
Aki & Kaye 3 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

2. MCU College of Nursing – 1947 Factors Influencing Contemporary Nursing Practice

- 1st college who offered BSN – 4-year program
3. UP College of Nursing - 1948
- Miss Sotejo – 1st dean
4. FEU Institute of Nursing – June 1955
5. Fatima College of Nursing – 1973
Nursing Leader in the Philippines
1. Anastacia Giron Tupas
- Founder of Filipino Nurses Association – established on
Oct 15, 1922.
- 1st Filipino chief nurse of PGH
Roles and Functions of the Nurse
- 1st Filipino superintendent of nurses in the Philippines
• Client Advocate – promote decision making to patient and
2. Francisca Delgado
family.
- 1st president of Filipino Nurses Association
3. Cesaria Tan • Teacher
- 1st Filipino to receive master’s degree in nursing abroad. • Caregiver – hands on patient
• Communicator – communicate to patient, family, and other
FROM COURSE UNIT health care provider.
Contemporary Nursing Practice • Manager – manage all the time.
Recipients of Nursing • Leader – if we go to community, we implement, we give
1. Patient – A Latin word meaning “to suffer” or “to bear”; directions.
person who is waiting for or undergoing medical treatment • Counselor – to give advise.
and care. Usually, people become patients when they seek • Research consumer – there is upgrade to improve.
assistance because of illness or for surgery. • Change agent
2. Client – a person who engages the advice or services of
another who is qualified to provide this service. The term NURSING PROCESS
client presents the receivers of health care as collaborators Discussed by Prof. Francis A. Vasquez, MAN, RN
in the care, that is, as people who are also responsible for - Systematic, chronological, step by step procedure of ADPIE.
their own health. - It is a systematic, rational method of providing care to patients.
3. Settings for Nursing – In the past, the acute care hospital - It is a five-step critical thinking and decision -making process
was the main practice setting open to most nurses. Today the nurse may utilize to provide individualized patient care.
many nurses work in hospitals, but increasingly they work - If you want to take care your patient, you need to move forward
in clients’ homes, community agencies, ambulatory clinics, from assessment to evaluation. But if you’re going to evaluate
long-­term care facilities, health maintenance, that nursing care you rendered to the client, you move backward.
organizations (HMOs), and nursing practice centers. You’re going to evaluate the nursing care that you have
4. Nurse Practice Acts – or legal acts for professional performed. So that you will know if the plans or goal of care
nursing practice, differ in various jurisdictions, they all have been met. If the goals of care have been met, then the
have a common purpose: to protect the public. Nurses are problem should not exist anymore.
responsible for knowing their state’s nurse practice act as - Specific to the nursing profession
it governs their practice. - A framework for critical thinking
5. Standards of Nursing Practice – the purpose is to - Purpose: Diagnose and treat human responses to actual or
describe the responsibilities for which nurses are potential health problems
accountable. Establishing and implementing standards of - Characteristics:
practice are major functions of a professional organization. • Organized framework to guide practice.
6. Standards of Professional Performance describe behaviors • Problem solving method.
expected in the professional nursing role. • Systematic
• Goal oriented – under the planning
• Dynamic – always changing, flexible. (Medical problem
stays for a longer period but nursing problem is dynamic)
• Utilizes critical thinking process.
• Client-centered
• Universally applicable
• Interpersonal and collaborative
Critical Thinking
- You are trying to analyze the problem of the patient.
- A discipline specific, reflective reasoning process that guides a
nurse in generating, implementing, and evaluating approaches
Aki & Kaye 4 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

for dealing with client care and professional concerns (National - This is important in helping you formulate nursing diagnosis,
League of Nurses). expected outcomes and interventions. It is a vital
- This is important in ensuring that the nurse delivers safe, communication tool to other health care team members.
competent and skillful practice. In doing so, an excellent quality 4 types of Assessment
of care is received by the client. Initial Assessment
Problem solving - First time to see the patient.
- Identify what are the different nursing care that are needed to - Provides an in-depth, comprehensive database, which is critical
solve the problem of the patient. for evaluation changes in the client’s health status.
- A process that involves clarifying the nature of the problem and - This is performed within the specify time after admission to
suggesting possible solutions. In nursing, client’s condition is establish complete database for problem identification.
observed over time to ensure its initial and continual - Example: Nursing admission assessment, nursing health history.
effectiveness. Problem-Focused Assessment
- Commonly used approaches to problem solving include trial - Period of confinement
and error, intuition, the research process, and the - The nurse determines whether the problem still exists and
scientific/modified scientific method. whether the status of the problem has changed (i.e., improved,
Decision making worsened, or resolved)
- A critical thinking process for choosing the best actions to meet - Example: Hourly assessment of clients intake and output and
a desired goal. checking of vital signs of client.
- The decision-making process and the nursing process share Emergency Assessment
similarities, and the nurse uses decision-making in all phases of - Takes place in life-threatening situations in which preservation
the nursing process. of life is the top priority.
- It is essential that the nurse use critical thinking in each step or - Example: Rapid assessment of an individual’s airway breathing
phase of these processes so that decisions and care are well and circulation during a cardiac arrest; Assessment of suicidal
considered and delivered with the highest possible quality. tendencies.

Advantages of Nursing Process Time-Lapsed or Ongoing Assessment

• Provides individualized care. - Follow-up check up
• Client/family is an active participant. - Takes place after the initial assessment to evaluate any changes
• Promotes continuity of care. in the client’s functional health.
• Provides more effective communication among nurses and - Example: Reassessment of a clients’ functional health patterns
healthcare professionals. in a home care or outpatient settings.
• Develops a clear and efficient plan of care. Type Time Purpose
• Provides personal satisfaction as you see client achieve goals. First time to see the
• Professional growth as you evaluate effective of your patient. And
Initial Completing database
interventions. Under go to seminars and trainings performed after
admission
Ongoing process
To determine status of
integrated with
Problem- a specific problem
nursing care.
focused identified in an earlier
Period of
assessment.
confinement
During any To identify life-
physiological or threatening problems
Emergency
psychological crisis To identify new or
NOTES:
of the client overlooked problems
• Nursing care plan- product of nursing process. Compare current
• Goals of care- planning Several months after
Time-lapsed status to baseline date
• Intervention- laging may rationale initial assessment
previously obtained

ASSESSMENT Steps of Assessment

- To establish database Collecting Data
- This is the deliberate and systematic collection of information - Gathering information about a client's health status in order to
about a patient to determine the patient's current and past health form database.
and functional status and his/her present and past coping - Database – all information about the client.
patterns. - Health assessment – review to systems
- This is the systematic and continuous collection, organization, - Physical exam – inspection, palpation, percussion, and
validation and documentation of data. auscultation.
• Make sure information is complete and accurate.

Aki & Kaye 5 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

• Validate prn (if necessary) - Recreation/ hobbies

• Interpret and analyze data. 7. Social data
• Compare to standard norms. - Family relationship, ethnic affiliation, education history,
• Organize and cluster data. occupational history, economic status, home and
Source of Data neighborhood conditions.
8. Psychologic data
Primary Secondary 9. Patterns of health care
• Physical exam 10. Review of systems
• Nursing history
• Client or family
• Team members, Data Collection Methods
• Laboratory reports 1. Observation
• Diagnostic tests - A method that makes use of the senses in gathering data.
- It is a conscious, deliberate skill that is developed through
Types of Data effort and with an organized approach.
Subjective Objective - It involves two important aspects: (a) noticing the data, and
(b) selecting, organizing, and interpreting the data. Nursing
• Symptoms • Signs
• Covert • Overt observations must be organized so that nothing significant
• Verified only by the • Can be observed and is missed.
patient. measured. - Examples: overall appearance, facial expression, body
• Examples: itchiness, severe • Example: discoloration of gestures, skin color, smell, etc. (4 senses)
pain, or feelings of worry. the skin, BP 130/80 2. Interview
- A planned communication or a conversation with a purpose.
Components of Nursing health history: - Example: history taking
1. Biographic data - Approach of an interview:
- Demographic profile a.) Directive
- Client’s name, age, sex, marital status, occupation, - A highly structured interview that elicits specific
religious affiliation, income, address etc. information.
2. Chief complaint/ reason for visit - Close type of questions is asked.
- “What brought you to the hospital? What seems to be the - When time is limited. Example is emergency
problem?” situation.
- Chief complaint should be recorded in the clients’ own b.) Non-directive
words. - Rapport-building interview
3. History of present illness - Unstructured interview that provides flexibility on
- Use chronologic story. (sunod sunod) how the nurse directs the focus of the conversation.
- When the symptoms started - Client controls the purposes and the subject matter.
- Whether the onset of symptom was sudden or gradual - Stages of an interview:
- How often the problem occurs exact location of distress. a) Opening or Introduction
- Exact location of distress - The most important part of the interview.
- Character of complaint (e.g., intensity of pain, quality of - Purpose of this is to establish trust.
sputum) - “Good morning sir! I will be your nurse for
- Activity in which the client was involved when the problem today...” Accompanied by nonverbal gestures like
occurred. smile, handshake, and a friendly manner.
- Aggravating factors b) Body or Development
4. Past History/illness - Which clients communicates what he or she think,
- Childhood illness (common colds, chicken pox, mumps, feels, know in response to question from the nurse.
measles), immunization (BCG, vaccine), allergies, - Example: What have you brought you to the
accidents, and injuries, hospitalization, medication. hospital today?
5. Family history of illness c) Closing
- Mother: (+) HPN, (-) DM, (-) PTB - When the nurse has gathered all information, she
- Father: (-) HPN, (-) DM, (+) PTB requires for the objective part of the assessment.
- Shows only the diseases run in the family - This is important to maintain the trust and in
6. Lifestyle facilitating future interaction,
- Personal habits – e.g., amount, frequency, and duration of - “Do you have any questions?”
substance use. Ex. Smoking and alcohol.
- Diet – description of typical daily diet.
- Sleep / rest patterns
- Activities of daily living (ADL)

Aki & Kaye 6 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

- Types of interview questions: - Ways of examination:

a) Closed questions a) Cephalocaudal – “head to toe approach” This is an
- Are questions that is restrictive that requires examination of the client that follows the head-neck-
specific answers such as a “yes”, a “no” or any thorax-abdomen-extremities-toes sequence of
information. assessment.
- A person has difficulty communicating will find b) Body System – This type of examination focuses on the
closed question easier to answer. structures and functions of a specific body system:
- Ex. Does it hurt? Did you take your medicine? respiratory system, circulatory system, nervous system,
b) Open-ended questions etc.
- Not answerable by yes or no. c) Screening examination – “review of systems” This
- If you need more information manner of examination gives emphasis on the client’s
- They allow client the freedom to talk about what chief complaint and its associated signs. This is also a
they wish. brief review of essential functioning (nursing
- Are questions that encourage discovery, admission assessment form)
exploration, elaboration, clarification or Collecting Data
illustration of the client’s experiences, thoughts,  Make sure information is complete and accurate.
or feelings.  Validate prn (if necessary)
- Ex. Tell me how you feel today.  Interpret and analyze data “compare to standard norms”
c) Neutral questions  Organize and cluster data. According to subjective and
- Client can answer without direction or pressure objective.
from the nurse. Example
- They allow client to think for themselves. • Obtain info from nursing assessment, history and physical
- Example: Why do you think you had operation? (H&P) etc.
d) Leading questions • Client diagnosed with hypertension (objective)
- Directs the client’s answer. • B/P= 160/90 (objective)
- The phrasing of the questions suggest what • 2Gm Na diet and antihypertensive medications were
answer is expected. prescribed (objective, and secondary type of data)
- Example: you’re stress about the surgery • Client statement “I really don’t watch my salt” “it’s hard to do
tomorrow? Aren’t you? and I just don’t get it” (subjective)
- This type of questions can create problems if the Organizing Data
client in an effort to please the nurse keeps - The nurse uses an organized assessment framework.
inaccurate response. This can result inaccurate - Nurses used written or computerized format called nursing
data. assessment, nursing history, or nursing database form.
3. Examination - 11 Typology of Functional Health Pattern (Gordon)
- Objective part of data collection 1. Health perception/ Health Management – describes the
- The process by which the nurse makes use of his/her senses clients perceived pattern of health and well-being and how
to gather relevant information from the client. health is managed.
- Unlike, interview, by which information is taken from the 2. Nutritional/ Metabolic Pattern – describes client’s pattern
responses of the client, examination is a more accurate way of food and fluid consumption.
of gathering relevant data from the patient. 3. Elimination Pattern – describes pattern of excretory
- Examination techniques: function (bowel, bladder, and skin).
a) Inspection is the deliberate, purposeful, observations 4. Activity- Exercise Pattern – describes pattern of exercise,
in a systematic manner. Nurses use the physical activity, leisure, and recreation.
senses: visualizing, hearing, and smelling. 5. Sleep-Rest Pattern – describes pattern of sleep, rest, and
b) Palpation is the technique that uses the sense of touch. relaxation.
The hands and the fingers are the most sensitive tool 6. Cognitive-Perceptual Pattern – describes sensory-
that a nurse has. perceptual and cognitive patterns.
c) Percussion is the act of striking one object against 7. Self-Perception/ Self Concept Pattern – describes client’s
another to produce a sound. The tones produced during self-concept and perception of self-pattern (self-worth,
percussion are used to assess location, shape, size, and comfort, body image, feeling state).
density of a tissue. 8. Role-relationship Pattern – describes pattern of
d) Auscultation is the act of listening with a stethoscope participation and relationship.
to sound produce within the body. Pitch, loudness, 9. Sexuality reproductive Pattern – describes client’s pattern
quality, and duration of the sound are being assessed of satisfaction and dissatisfaction with sexuality patterns;
during auscultation. describes reproductive patterns.

Aki & Kaye 7 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

10. Coping/ Stress tolerance Pattern – describes client’s - Example: Acute pain is a response to an injury such as surgical
general coping pattern and effectiveness of pattern in terms procedure or chemical burn.
of stress tolerance. Medical Diagnosis Nursing Diagnosis
11. Values-beliefs Pattern – describes patterns of values, Focuses on the
beliefs and goal that guide the client’s choices or decisions. Focuses on illness, responses to actual or
Validating Data injury or disease potential health
- Double checking or verifying data to ensure that it is accurate process problems or life
and factual. Focus processes
- This ensures that assessment information is complete. Ineffective Airway
- You may also obtain additional information that may have been Pneumonia
Clearance
overlooked. Comparing subjective and objective data. Diabetes mellitus
Decreased Mobility
- Cues – are subjective or objective data that can be directly
observed by the nurse. Remains constant Changes as the client’s
- Inferences – are the nurse’s interpretation or conclusion based until a cure is response and/or health
on the cues. effected problem changes
- We are checking this one with:
• Compare Day 1 at the ward –
Duration Hyperthermia
• Clarify
Day 1 - COVID-19 Day 2 at the ward –
• Double check Day 2 – COVID 19 Ineffective Airway
• Determine factors that may interfere accurate measurement. Day 10 – COVID Clearance
• References 19, discharged After 6 hours –
Documenting Data Ineffective breathing
- Accurate documentation is essential and should include all data pattern
collected about the client’s health status. Identifies condition
- Data are recorded in a factual manner and not interpreted by the the health care
nurse. practitioner is
• F-actual licensed and licensed and qualified to
• A-ctual qualified to treat intervene.
• T-imely Management Identifies situations
- For example, the nurse must record the client’s intake as “coffee in which the nurse
240 ml, juice 120 ml, 1 egg and 1 slice of toast” rather than as is
“appetite good” or “normal appetite” a judgment. Cerebrovascular Self-Care Deficit:
Accident (Stroke) Dressing & Grooming
DIAGNOSIS Collaborative problem
- Second step of nursing process - An actual or potential physiological complication that nurses
- Interpret and analyze clustered data. monitor to detect the onset of changes in patients’ health status.
- Identify clients’ problems and strengths. - A partnership between a team of health care providers.
- This is a clinical judgment concerning human response to health - A patient in a participatory collaborative and coordinative
condition/s, life processes or vulnerability for that response by approach for share decision making around health issues, nurses
an individual, family, or community that a nurse is licensed and manage collaborative problems such as hemorrhage, infections
competent to treat. and paralysis using medical nursing.
- Formulate nursing diagnosis (NANDA: North American - For example, a patient with a surgical wound is at risk
Nursing Diagnosis Association) – statement of how the client is developing an infection, thus the physician describes the
responding to an actual or potential problem that requires antibiotics. The nurse then monitors patient for fever and other
nursing intervention. signs of infection and implements appropriate wound care
Medical Diagnosis measures. A dietitian recommends a therapeutic diet, high in
- Within the scope of medical practice protein and nutrients to promote wound healing.
- Focuses on curing pathology.
- Stays the same as long as the disease is present. Types of Nursing Diagnosis (WRAP)
- Based on the result of laboratory and examination. Wellness nursing diagnoses/
Nursing Diagnosis Health Promotion Nursing diagnosis
- Within the scope of nursing practice. - Describes human responses to levels of wellness in an
- Identify responses to health and illness. individual, family or community that have readiness for
- Can change from day to day. enhancement.
- Focuses on care aspect - This is a clinical judgment concerning a patient’s motivation
- Actual problem – already existing and desire to increase wellbeing and actualize human health
- Potential problem – there is a chance that the problem will potential.
develop.
Aki & Kaye 8 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

- Used clients in any health state that express readiness to - Risk factors are the environmental, physiological,
enhance specific health behaviors. psychological, genetic, or chemical elements that place a person
• Readiness for enhanced family coping at risk for a health problem.
• Readiness for enhanced spiritual well Signs and Symptoms (Defining Characteristics)
Risk nursing Diagnosis - What’s the evidence of the problem?
- Can be based on actual problem - Proves the problem is present.
- Problem does not exist, but the presence of risk factors indicates Example:
that a problem is less likely to develop. • Problem: activity intolerance.
- This is a clinical judgment concerning the vulnerability of an • Etiology: imbalance between oxygen supply/demand
individual, family, group, or community for developing an • S/S: (a.m.b.) as manifested by abnormal HR and BP in response
undesirable human response to health conditions/life processes. to light activity.
- This type of diagnosis DO NOT have defining characteristics or
related factors because they have not yet occurred. Nursing Diagnosis: P –e –s
• Risk for infection
• Risk for activity intolerance
• Risk for aspiration
- Risk Factors:
- They are the environmental, physiological, psychological,
genetic, or chemical elements that place a person at risk for
a health problem.
- These are the diagnostic-related factors that help in
planning preventive health care measures.
Actual Nursing Diagnosis
- Client problems that are present at the time of the nursing
assessment.
- Examples:
• Ineffective breathing pattern
• Ineffective tissue perfusion
• Activity intolerance
Possible Nursing Diagnosis
- Evidence about the health problem is incomplete or unclear.
- This may be compared to a physician who list several rule out
medical diagnoses in a patient admission assessment. The
physician made an order diagnostic test to gather more data to
Actual Problem High Risk Etiology and S/S
make a decision. With an increased database, the nurse may be
able to establish possible nursing diagnosis as valid or eliminate NANDA: domain 4: NANDA: domain related to aging
activity/rest, class 2: 11: process as
it as invalid for a particular patient. safety/protection,
activity/exercise, manifested by
- “Possible” class 2: physical
impaired physical inability to sit and
• Possible social isolation injury, risk for
mobility impaired skin
stand by himself
• Related to unknown etiology.
integrity
Syndrome Diagnosis ND: impaired physical
- Two or more problem mobility ND: high risk for
impaired skin
Formulating Nursing Diagnosis integrity, bed sore
Actual nursing diagnoses (PED/PES format) Main prob: infected related to bike
Problem (Diagnostic Label) wound. accident as
manifested by open
- Nsg. Dx - This is the diagnostic label that describes client’s
NANDA: domain 11: wounds on the
health problem or response for nursing therapy given.
safety/protection, class right elbow,
- The purpose of this is to direct the formation of client’s goals
2: physical injury, risk presence of
and desired outcomes. for impaired skin inflammation and
Etiology (Related Factors/Risk Factors) integrity purulent discharge
- r/t - Identifies one or more probable causes of health problem,
gives direction to the required nursing therapy and enables the ND: impaired skin
nurse to individualized nursing care. integrity
- What’s causing or contributing to the client’s problem. Main prob: chest pain related to physical
- Related factors are the etiological or causative factors for the activity
diagnosis.
Aki & Kaye 9 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

NANDA: domain 12: Actual Nursing diagnosis

comfort, class 1:
physical comfort, acute
pain

ND: acute pain

Main prob: manas related to impaired
renal function
NANDA: domain 2:
nutrition, class 4:
metabolism, excess
fluid volume

ND: fluid volume

excess
• High risk problem- is based on actual problem
• ND- nursing diagnosis
• Possible- hindi malinaw contributing factor Risk Nursing diagnosis
• Risk- malinaw contributing factor
• Purulent- may nana
• Acc. To maslows prioritize physical

Two-part Diagnostic statement

Three-part diagnostic statement

Do’s and Dont’s when writing nursing diagnosis

Example 1:
× Imbalanced nutrition: less than body requirements related
to improper feeding of the nurse.
- Make sure that your nursing diagnosis will avoid
court mitigation.
 Imbalanced nutrition: less than body requirements related
to impaired swallowing.

Aki & Kaye 10 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Example 2: PLANNING
× Impaired skin integrity related to bedsores. - Third step of the nursing process
- Make sure that the problem is different from the - This is when the nurse organizes a nursing care plan based on
etiology. the nursing diagnoses.
 Impaired skin integrity related to immobility. - Enumerate interventions we need to perform.
Example 3: - Nurse and client formulate goals to help the client with their
× Risk for ineffective airway clearance related to problems. (we always involve the patient)
Emphysema. - Expected outcomes are identified.
- Avoid medical terms. - Interventions (nursing orders) are selected to aid the client reach
 Risk for Ineffective airway clearance related to retained these goals.
bronchial secretions. - The nurse collaborates with the patient and the family and the
Example 4: rest of the health care team to determine the urgency of
× Ineffective Sexuality pattern related to Homosexuality. identifies problems and prioritizes patient needs.
- Avoid a nursing diagnosis that is judgmental. - A deliberative, systematic phase of nursing process that
 Ineffective Sexuality pattern related to conflicts with involves decision making and problem solving.
sexual orientation. - SMART- Specific, Measurable, Attainable, Realistic and Time
Example 5: bound.
× Impaired oral mucous membrane related to irritating agents. - When we start conceptualizing the plan of care to be rendered
- Avoid vague nursing diagnosis. to a specific client, we us nurses should prioritize the actualize,
 Impaired oral mucous membrane related to excessive emanate or life threating conditions first this is called
intake of Anti-cholinergic (Atropine sulfate) prioritizing.

Guidelines For Writing A Nursing Diagnostic Statement

Types of Planning
1. Initial Planning
- Admission assessment (short and quick)
- It answers initial assessment.
- Initial comprehensive plan of care
2. Ongoing Planning
- Confinement (day to day/shift planning)
- done by all nurses who work with the client, occurs at the
beginning of the shift as the nurse plans the care to be given
that day.
- PURPOSES:
• To determine whether the client’s health status has
changed.
• To set priorities for the client’s care during the shift.
• To decide which problems to focus on during the shift.
• To coordinate the nurse’s activities so that more than
one problem can be addressed at each client contact.
3. Discharge Planning
- The process of anticipating and planning for the needs
before discharge.
- Before patient go home
- We should have discharge plan that will guide pt. on things
he must perform himself at home to sustain recovery like
take home medications, diet and activities to do and when
should go back to hosp. like follow up check up.

Aki & Kaye 11 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Types of Goals Patient-Centered and SMART

1. Short term goal - reflects a patient’s highest possible level of wellness and
- Less 6 months independence in function.
- Usually used - It is realistic and based on patient needs, abilities, and resources.
2. Long term goal It is focused on PATIENT’s specific behavior NOT the nurse’s
- More than 6 months goal or interventions.
Ex. Combination of long and short term: • Pt will walk 50 ft on his 2nd week of rehabilitation program.
− Overweight of 100 pounds, after 10 mos. of weight (not smart)
reduction program the pt. will lose 100 pounds or the pt. • Pt will eat 75% of his meal. (smart)
will be able to loose 10 pounds per mos or pt. will lose 2.5 • Pt will be OOB 2-4hrs with minimal assistance. (smart)
pounds per week. • Pt will maintain HR<100 (not smart)
• Pt will state pain level is acceptable at 5/10 PS 2-3 hrs. after
Planning Process medication. (not smart)
Setting Priorities Nursing-sensitive patient outcome
- Begin by prioritizing client problems. - a measurable patient, family, or community state, behavior, or
- Prioritize list of clients nursing diagnoses using Maslow. perception largely influenced by and sensitive to nursing
- Rank as high, intermediate, or low interventions, such as: Reduction in pain frequency and severity.
- Client specific
- Priorities can change.
- Priority setting is the ordering of nursing diagnoses or patient
problems using notions of urgency and importance to establish
a preferential order for nursing interventions.
- This may use models such as: Maslow’s Hierarchy of Human
Needs and the ABC’s of emergency care (Airway- Breathing-
Circulation and definitive management)
• Airway comes first before breathing. (there must be Goal statement- should have condition and smart
Airway Patency) patency means walang bara. Selecting Intervention
- Factors to consider: - interventions are nursing care we need to perform to the pt.
• Client’s Values and Beliefs – values concerning health may - Interventions are selected and written.
be more important to the nurse than to the client. - The nurse uses clinical judgment and professional knowledge
• Client’s Priorities – involving client in prioritizing and care to select appropriate interventions that will aid the client in
planning enhances cooperation. reaching their goal.
• Resources Available - Interventions should be examined for feasibility and
• Urgency of Health problem acceptability to the client.
o High - If untreated, result in harm to patient or others. - Interventions should be written clearly and specifically.
o Intermediate - Non-emergent, non-life-threatening - Nursing Intervention is any treatment based on clinical
needs of the patients. judgment and knowledge that a nurse performs to enhance
o Low - May not always related to a specific illness but patient outcomes. Must be evidenced-based.
affect the patient’s future well-being. - This includes direct and indirect care measures aimed at
• Medical treatment plan individuals, families and/or community.
Prioritize the following nursing diagnosis: Categories of nursing interventions
− Anxiety related to difficulty in breathing 1. Independent (Nurse-initiated)
- Actions that a nurse can perform without supervision
− Deficient fluid volume r/t high grade fever
or direction from others.
− Sleep pattern disturbance r/t persistent cough
- Si nurse mag dedecide.
− Ineffective airway clearance r/t tenacious secretions
• Vital signs monitoring
− If client have this all problem una iprioritize ineffective airway
• Client having difficulty of breathing with position
clearance, fluid volume, anxiety, last is sleep pattern.
the client on high back rest.
Developing a Goal and Outcome statement
2. Dependent (physician-initiated)
- Goal and outcome statements are client focused.
- Nursing actions requiring MD orders.
- Worded positively.
• During emergency, the patient is having difficulty
- Measurable, specific observable, time-limited and realistic.
of breathing, you administered go to therapy.
- Goal – broad statement. Ex: Client will achieve therapeutic
• Administering insulin subcutaneously
management of disease process.
- Expected Outcomes – objective criterion for measurement of 3. Collaborative
- nursing actions performed jointly with other health
goal. Ex: AEB B/P readings of 110-120/70-80 and client
care team members.
statement of understanding importance of dietary sodium
- Whatever you do to the patient, you are accountable.
restrictions by day of discharge.
Aki & Kaye 12 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

• Medication administration
• Catheterization
• Counselling
• Discharge instruction
2. Indirect Care
- These are treatments performed away from a patient but on
behalf of the patient or group of patients.
- Examples:
• Managing patient’s environment
• Documentation
− Verb- in interventions we use action words
Skills needed during Implementation Phase
1. Cognitive skills - include intellectual skills like problem solving,
decision-making, critical thinking, and creativity. Crucial to
safe, intelligent nursing care
2. Interpersonal skills- nurse ability to communicate with others.
caring, comforting, advocacy, referring, counseling/ supporting
3. Technical skills- hands on skills, tasks, procedures, and
psychomotor skills, manipulating equipment, giving injections,
bandaging, moving, lifting.
4. Therapeutic use of self – is being willing and being able to care.

EVALUATION
IMPLEMENTATION
- This is the ''Doing'' step − Done to determine the effectiveness of the nursing care plan
- carrying out nursing interventions (orders) selected during the − final step of the nursing process but also done concurrently
planning step. throughout client care
- This includes monitoring, teaching, further assessing, − A comparison of client behavior and/or response to the
reviewing NCP, incorporating physicians’ orders and established outcome criteria.
monitoring cost effectiveness of interventions. − Continuous review of the nursing care plan
- Utilize NIC as standard. − Examines if nursing interventions are working
- Putting the plan into action − Determines changes needed to help client reach stated goals.
- Types: Independent (nurse initiated), Interdependent/ − An appraisal whether expected outcomes are met
Collaborative and Dependent (need doc. order). − An appraisal of the effectiveness of nursing care plan
- Key components: should have action word − Possible results:
• Monitor GOAL is: Met, Partially met, Not met
• Teach − Outcome critieria met? Problem resolved! Then u stop
• Administer performing intervention but continue taking care of the patient
• Perform − Outcome criteria not fully met? Then continue plan of care- on
- Monitor VS q4h (every 4 hours) going
- Position Client on HBR. High back rest. − Outcome criteria unobtainable- then review each previous step
- Teach client amount of sodium restriction, foods high of the NCP and determine if modification of the NCP is
in sodium, use of nutrition labels, food preparation and needed. Reevaluate the patient
sodium substitutes. − Were the nursing interventions appropriate/effective?
- Teach potential complications of hypertension to
instill importance of maintaining Na restrictions. Factors that Impede Goal Attainment
- Assess for cultural factors affecting dietary regimen.  Incomplete database
- Perform passive range for motion exercise for 30 mins  Unrealistic client outcomes
every morning.  Nonspecific nursing interventions
- Perform wound dressing aseptically twice a day.  Inadequate time for clients to achieve outcomes
- Perform art therapy when needed.
- Instruct the importance of ongoing follow-up patient
feels well.
Types of Care
1. Direct Care
- These are interventions performed through interactions
with patients.
- Examples:

Aki & Kaye 13 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Nursing Diagnosis
First problem: Diarrhea
• NANDA: Domain 3: elimination and exchange, Class 2:
Gastrointestinal Function (may diarrhea under nito so un
ung gagamitin nating nursing diagnosis)
• Nursing diagnosis: (problem) diarrhea related to
(etiology) ingestion of contaminated food (S/S) as
manifested by elimination of watery stools
• There can be also a pt present more than one problem.
Tingnana ang cues kung meron pa problem at nakita natin
na may lagnat sya so gagawa kapa ulit ng isang NCP. Sa
mga beginners like us 1 nursing problem and 1 NCP
Nursing Care Plan although u only have one pt.
Example 1 • First problem diarrhea, second is fever, third dehydration.
Clients name: Clara Cruz Second problem: Fever
Age: 23 y/o • NANDA: Domain 11: safety and protection, Class 6:
• 1 day PTA, client attend a wedding ceremony. SHe ate thermoregulation (may hyperthermia under nito so un ung
baked mussels and carbonara. 8 hrs PTC, client gagamitin nating nursing diagnosis)
experienced abdominal pain and 2 bouts of watery stools. • Nursing diagnosis: (problem) hyperthermia is related to
Client self-medicated with diatabs but offered no relief. 2 (etiology) infection (S/S) as evidenced by body temp. of
hrs PTC client exp. 3 bouts of water stools and abdominal 38.5c and warm to touch skin.
apin. Client stated “grabe ang pagtatae ko hinang hina na • Kung marunong ka gumawa ng 3 part nursing diagnosis
ako at mainit din ang pakiramdam ko.” Examination kaya mo rin gumawa ng 2 part nursing diagnosis (problem
revealed a sunken eyeballs, poor skin turgor, body and etiology).
weakness, BP of 90/80, HR of 110 bpm and T of 38.5C Third problem: Dehydration
hence client was admitted. Buscopan 10mg 1 tab prn for • NANDA: Domain 2: nutrition, Class 4: metabolism (may
abdominal pain and hydrite 1 tab dissolve in 1 glass of dehydration under nito so un ung gagamitin nating
water per LBM were ordered by AP. nursing diagnosis)
• PTA- prior to admission • Nursing diagnosis: dehydration related to diarrhea as
• PTC- prior to consultation evidence by body weakness, sunken eyeballs, poor skin
• AP- attending physician turgor.
• COC- color orange Background knowledge
Assessment: Cues First problem: Diarrhea
First problem: Diarrhea • Ingestion of contaminated food → m.o. release toxins→
• Subjective:
increased GI irritation/peristalsis→ increased cell
“grabe ang pagtatae ko hinang hina na ako at mainit din
ang pakiramdam ko.” As verbalized by the client. permeability→ LBM
Goals of Care
• Objective:
Vital signs: BP of 90/80, HR of 110 bpm and T of 38.5C First problem: Diarrhea
Sunken eyeballs, poor skin turgor, loose watery stools • After 12-24 hrs of nursing care, client will establish
Second problem: Fever normal bowel movement as manifested by elimination of
formed stools
• Subjective:
Intervention
“mainit ang pakiramdam ko” as verbalized by the client.
First problem: Diarrhea
• Objective:
1. increased oral fluid intake of the client.
Vital signs: BP of 90/80, HR of 110 bpm and T of 38.5C
2. Restrict foods that irritate the GI tract.
Sunken eyeballs, poor skin turgor, loose watery stools,
3. Collaborative: administer antidiarrheal drug as ordered by the
warm to touch skin
doctor.
Third problem: Dehydration
Rationale
• Subjective:
First problem: Diarrhea
“grabe ang pagtatae ko hinang hina na ako at mainit din
1. Fluid replacement prevents dehydration.
ang pakiramdam ko.” As verbalized by the client.
2. To prevent abdominal pain.
• Objective: 3. None
Vital signs: BP of 90/80, HR of 110 bpm and T of 38.5C
Sunken eyeballs, poor skin turgor, loose watery stools

Aki & Kaye 14 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Example 2 3. Dependent: oxygen therapy helps achieving normal o2

saturation in the blood
Evaluation
− TIP: Aralin sakit as whole then check sa nanda kung tama
− Parang binalikan lang ung goal of care pinast tense lang
− After 2-4hrs of nursing care the patient was able to exhibit or
improve gas exchange as evidenced by CRT of less than 2 and
absence of cyanosis.

FLUIDS AND ELECTROLYTES

Discussed by Prof. Donato A. Mirador
Fluids
- 60% of an adult’s body weight
- Infants = more water (80%)
- Elderly = less water
- More fat = less water
- More muscle = high water
- Infants and elderly - prone to fluid imbalance
- younger people have a higher percentage of body fluid than
older and fat people.

− This is called pathophysiology used to learn the disease of the

patient and is included in background knowledge in the table
− Trigger factor- allergies
− Airway inflammation- because of histamine release
Cues
• Subjective:
He begins complaining of breathing difficulty and chest pain
as verbalized by the patient.
• Objective:
Vital signs: RR of 60/min, HR 120bmp, expiratory wheezes,
CRT of 3-4secs, perioral cyanosis, pallor.
Nursing Diagnosis
• Impaired gas exchange related to bronchial constriction as
evidenced by wheezes, perioral cyanosis, capillary refill, etc. Fluid compartment
Background knowledge Intracellular Fluid
• How impaired gas exchange developed - 25 liters of the total fluids in the body.
Extracellular Fluid
• Narrowed down ang pag susulat dito
- 15 liters of the total fluids in the body.
• Tigger factor → airway inflammation→ bronchial a) Intravascular
constriction→ narrowed airway→ wheezes, cough, shortness - Plasma 3 liters
of breath, tightness in chest. - Red cell 2 liters
Goals of care b) Interstitial
• State goal of care by setting time frame - 12 liters
• After 2-4hrs of nursing care, patient will exhibit optimal gas
Formula:
exchange as evidenced by a capillary refill test of less than 2
seconds, absences of cyanosis and normal RR. ECF – Plasma volume = ITF
Intervention
1. Place the client in Fowler’s position Fluid Environment (Normal values)
Extracellular Fluid Intracellular Fluid
2. Instruct patient to perform pursed-lip breathing.
3. Dependent: administer oxygen therapy via face mask at 5-6 Na 142 mEq/L Na 15 mEq/L
K 5 mEq/L K 141 mEq/L
liters per minute as ordered by the doctor.
Ca 5 mEq/L Ca <1mEq/L
Rationale
Mg 3 mEq/L Mg 58 mEq/L
1. Upright position promotes greater lung expansion. Cl 103 mEq/L Cl 4 mEq/L
2. Pursed-lip breathing allows slower and intentional breathing HCO3 28 mEq/L HCO3 10 mEq/L
allowing: blood to absorb more oxygen. P 4 mEq/L P 75 mEq/L
Aki & Kaye 15 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

SO4 1 mEq/L SO4 2 mEq/L − GC in ECF and LC in ICF permits diffusion to become faster
Glucose 90 mg Glucose 0-20 mg and it increases rate of diffusion. The difference bet. The
Amino Acid 30 mg Amino Acid 200 mg concentration of substances in both sides affects the rate of
Cholesterole 0.5 gm Cholesterole 2- 95 gm diffusion.
Phospholipids 0.5 gm Phospholipids 2- 95 gm Osmotic Pressure
Neutral Fats 0.5 gm Neutral Fats 2- 95 gm - The minimum pressure, which needs to be applied to a solution
PO2 35 mm Hg PO2 20 mmHg to prevent the inward flow of its pure solvent across a
PCO2 46 mmHg PCO2 50 mmHg semipermeable. (When we look at ECF and ICF there are non-
pH 7.4 pH 7.0 diffusible solutes that can be found)
- ECF side – cannot pass this semipermeable, there are the one
Fluid Transport who attracts the water.
- How does fluid is being transported from one compartment to
another.
- It can be from intracellular to extracellular or vice versa.
Diffusion
- The movement of a substance from an area of high
concentration to an area of low concentration.
- Diffusion happens in liquids and gases because their particles
move randomly from place to place. − In this illustration this vertical line signifies the semi-permeable
- ex. Perfume, coffee mix in water membrane and on the ECF side there are non-diffusible solutes
Kinetics of Diffusion meaning these solutes cannot pass or cross the semi-permeable
1. The greater the concentration difference between the area membrane so what they do is to attract water because they have
the greater the rate of diffusion. the capacity to hold the water therefore water is being attracted
2. The less the molecular weight the greater the rate of from ICF to ECF.
diffusion. − Ex. Of these is hyponatremia in the ECF it attracts water from
3. The shorter the distance the greater the rate inside the cell going to the ECF.
4. The greater the cross section of diffusion pathway the Active Transport
greater the rate of diffusion - The movement of ions or molecules across a cell membrane into
5. The greater the temperature the greater is the molecular a region of higher concentration, assisted by enzymes and
motion the greater is the diffusion. (Means temp. increases requiring energy.
the rate of diffusion) - Substances from one side of the ECF going to the ICF. There is
Diffusion through the cell membrane a substance form ECF which needs to be transported to the ICF
a) Effect of lipid solubility in diffusion utilizing enzymes and energy. It can be adenosine triphosphate
- ex. O2, CO2, alcohol, fatty acids = very soluble in lipid or ATP adenylate cyclase w/c utilizes adenosine
(passes easily in the cell membrane) monophosphate and when these subs. Is transported to ICF
b) Carrier mediated facilitated diffusion = (insoluble, insulin these adenosine recovers its phosphate compound restoring to
carries glucose across cell membrane) its original form.

c) Diffusion through membrane pores = 8 A (Armstrong) (0.8

nanometer) Problems that Cause Altered Fluid Volume
- ex. Water molecule, urea molecule, chloride smaller than • Vomiting, diarrhea, fever, and infection.
the pore • Excessive sweating.
d) Effect of electrical charge • Heat-related illness.
- Electrical charges affects diffusion greatly. • Excessive urination— known as polyuria, which can be caused
- ex. Na cannot easily pass because of the positive charge. by renal disease, renal failure, adrenal insufficiency, and
e) Effect of concentration difference on net diffusion rate. overuse of diuretics.
• Blood loss from wounds, injuries, and bleeding disorders.

Types of fluid for replacement

Hypotonic
- Solutions that have a lower osmolality than body fluids.
- Use: cellular dehydration for fluid replacement
- Fluid going inside the cell and it will swell.

Aki & Kaye 16 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Hypertonic factor is 60 micro drops per ml while in macro drop it has 15 to

- Solutions that have a higher osmolality than body fluids. 2 drops per ml.
- Use: (most commonly used in edema) to reabsorb fluids to
Vol in cc
lessen edema Cc per hour =
- > traumatic brain injury, intracranial hypertension, intracranial hours to run
pressure reduction, hypovolemic shock, hyponatremia, Vol in cc x gtt factor
hypertonic saline for sepsis. Hours to run =
flow rate x 60 min
Isotonic
- Solutions that have the same osmolality as body fluids. IV THERAPY
- Use: balance the fluid in both ECF and ICF Discussed by Prof. Donato A. Mirador
Definition of terms
• Hypotonic - solutions that have a lower osmolality than body
fluids. Given to the client, the fluid moves from vessels to
interstitial fluids until it reach cell.
• Hypertonic - solutions that have a higher osmolality than body
fluids.
• Isotonic - solutions that have the same osmolality as body fluids.
Fluid stays inside of the blood vessels/ interstitial spaces.
• Phlebitis – an inflammation of the vein that can result
• Hypertonic- water or plasma gets out of the cell. It makes the
mechanical or chemical trauma or local infection.
cell shrink
• Infiltration – seepage of IVF out of the vein and into the
• Isotonic- water coming out is being replaced by another vol. of
surrounding interstitial space.
water. The cell becomes flaccid.
• Air embolism – obstruction caused by a bolus of air that enters
• Hypotonic- fluid is going inside the cell making the cell swell
the vein through an inadequately primed IV line, from a loose
so the cell becomes turgid meaning the cell is swelling.
connection, or during tubing change or removal of IV line.
Tonicity of IV Fluids • Catheter embolism – obstruction that results from breakage of
the tip of the catheter during IV-line insertion.
• 0.3%NaCl Hypotonic
Intravenous (IV) therapy
• 0.45% SALINE (1/2 NS) Hypotonic
- The insertion of a needle or catheter/cannula into a vein, based
• 0.9% NS Isotonic on the physician’s written prescription.
• 5% dextrose in water D5W Isotonic - The needle or catheter/ cannula is attached to a sterile tubing
• D5 ¼ NS Isotonic and a fluid container to provide medication and fluids.
• Lactated Ringer’s solution Isotonic - Is used to sustain clients who are unable to take substance orally.
• D5LR Hypertonic - Replaces water, electrolytes, and nutrients more rapidly than
• D5 ½ NS Hypertonic oral administration.
• D5 NSS Hypertonic - Provides immediate access to the vascular system for the rapid
• D10W Hypertonic delivery of specific solutions.
- Provides a vascular route.
Formula for IV computation 10 golden rules for administering drug safely.
Macro Drops 1. Administer the right drugs. (We cannot administer a solution
Flow Rate =
volume in cc x drop factor (15 or 20ml) when it is not needed)
no.of hours to run x 60 min. 2. Administer the right drug to the right patient. (IV line serve as
→ We can determine drop factor in drip chamber of fluid set where parenteral medications)
in the spike when it is connected to the IV bottle. In the drip 3. Administer the right dose. (We should have the ability of
chamber we can notice whether there is needle or it will form a computing the right dose, we have to validate and make sure
big drop or macro drop. When there is no needle in the drip that the dose is correct)
chamber the drop factor is considered to be 15 or 20 per ml but 4. Administer the right drug to the right route. (There are some
regular is 15 drop per ml. drug administered intramuscular, subcutaneous or intradermal)
→ Used in computing drop per minute or per flow rate. 5. Administer the right drug to the right time. (Drugs ordered by
→ No. of hours (sol. Is intended to be run or consume) the doctor have frequencies that is why there is q6 for every 6
Micro Drops hours, q8 for every 8 hours and PRN means when needed)
volume in cc x 60 ugtts/𝑚𝑚𝑚𝑚 6. Document each drug you administer. (Put your signature)
Flow Rate =
no.of hours to run x 60 min. 7. Teach patient about the drugs he is receiving. (To educate the
client regarding the drugs that the patient is receiving)
→ 1 liter= 1,000 cc
8. Proper documentation provides:
→ 500 ml= 500 cc
- An accurate description of care that can serve as legal
→ ml and cc is the same protection.
→ If flow rate is in micro drops or if we see needle in drip chamber - A mechanism for recording and retrieving information.
these tubings are intended to be used by pediatrics patients so
they have a larger no. but it is in a form of macro drops. So drop

Aki & Kaye 17 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Label the IV solution specifying: Types of Solutions

• Type of IV fluids • Hypotonic - solutions that have a lower osmolality than body
• Medication additives and flow rate. fluids.
• Use of any electronic infusion device. • Hypertonic - solutions that have a higher osmolality than body
• Duration of therapy and the nurse’s name and fluids.
signature. • Isotonic - solutions that have the same osmolality as body fluids.
Tonicity of IV Fluids • Crystalloids – solutions that contain electrolytes (for fluid
- IV fluids are classified based on volume replacement, this is where hypo, iso and hyper are
their types and classification of patterned).
fluids are based on tonicity. • Colloids/ plasma expanders – pull fluid from the interstitial
- Tonicity – is an action word because compartment into the vascular compartment (given for pt. who
it defines the possible movement of have hge or hypervolemia in order for them torecover from
fluids inside the body. decrease in blood volume).
- 3 types of tonicity:
 Hypotonic- are solutions when given to the clients the IV Cannulas
fluid moves from the intravascular wherein the fluid is Steel needle of butterfly sets
introduced or loaded and the water/solution moves - Wing tip needle with a metal cannula.
from the vessel to the interstitial fluids spaces until it - Needle is 0.5 – 1.5 inches in length (G16 -26)
reaches the cell - Use in small and fragile bones.
 Isotonic- the fluids are introduced to the IV line and - Infiltration is more common.
the fluids stays inside the blood vessels or in the - Inserted while avoiding the joints.
interstitial fluid spaces because the concentration of Plastic needle
these fluids is the same as the concentration of the - Use in short term therapy.
solutes in the extracellular fluid compartment. - Use for rapid infusion and more comfortable for the client.
 Hypertonic- when we compare this sol. To the body - In-needle catheter can cause catheter embolism. (because the
fluids of the patient, it has a higher mol. Content of catheter, the needle inserted inside that is the one who will
solutes it can be through the glucose or dextrose or penetrate the skin of the client)
through electrolytes and major electrolytes are sodium
and potassium so they form to have higher Types of an IV Cannula and purposes
concentration in the content when it comes to • Gauge 14- 25 – the smaller gauge the larger the outside
hypertonic solution. diameter.
• 0.45% SALINE (1/2 NS) Hypotonic • G14 -19 – for rapid fluid administration (blood products or
• 0.9% NS Isotonic anesthetics)
• 5% dextrose in water D5W Isotonic • G20 - 21 – for peripheral fat infusion
• D5 ¼ NS Isotonic • G22 - 24 – STD IV fluid and clear liquid medication
• Lactated Ringer’s solution Isotonic • G24 - 25 – for very small veins (for infants)
• D5LR Hypertonic
• D5 ½ NS Hypertonic
• D5 NSS Hypertonic
• D10W Hypertonic
Local IVF Color

− The lower the size the larger is the gauge, the higher is the size
the lower is the gauge or diameter.

Aki & Kaye 18 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

IV Tubing
- Contains the spike end, drop chamber, roller clamp, Y – site and
adapter end.
- Use of vented or non – vented tubing.
- Shorter secondary tubing – use for piggyback solutions,
connecting them to the injection site.

Selection of Peripheral IV Site

• Veins in the hand, forearm, antecubital fossa, scalp and feet.
• Assess the veins of both arms closely before selecting a site.
• Start IV site selection distally. (We should start peripheral,
away from the body. We must start first the farthest before
going to the vein near the body)
• Determine the client’s dominant side. (We must avoid the
dominant side. Because the patient’s will use his hands for daily
activity)
• Bending the elbow on the arm with IV may obstruct the flow
Drip chamber causing thrombophlebitis and infiltration.
Microdrip • Use an arm board as needed in the area of flexion.
- Are used if fluid will be infused at 50cc/ hr
- Used if solution contains potent medication that needs to be
titrated.
- Delivers 60drops/ ml.
- Being use when computing micro drops per minute because the
chamber contains needle.
- Commonly used tubing for infants and babies
Macrodrip
- Use if solution is thick or need to infuse rapidly.
- Delivers 10 – 20drops/ ml.

Filters
- Filters provide protection by preventing particles from entering
the client’s veins.
- Filters are used in IV lines to trap small particles such as
undissolved antibiotics or salt or medications that have
precipitated in solution.
- Usually used when nurses will hook a blood for transfusion of
the client because it prevents blood clot and other particles.

Intermittent infusion sets

- Used when intravascular accessibility is desired for intermittent
administration of medications by IV push or IV piggyback.
- (Sometimes there are drugs that are made or prepared in small
amount and even drug illustration, in children if they will
receive medications that are very reactive. The drug
concentration is very high. The nurse is putting the drugs inside
the soluset mixing it with IV solutions and starting to drip as
piggyback. This is a type of intermittent infusion set where in Administration of IV Solution
there is a time when this drug should be given to the client.)  Check the IV solution for the type of amount, percent of
- An IV lock is attached for intermittent infusion devices. (That solution and rate of flow.
is why there is regulator that you can control whenever the  Assess the health status and medical disorders.
infusion is too fast or slow)  Wash hands thoroughly and use sterile technique.
- Patency is maintained by periodic flushing with normal saline  Prime the tubing to remove air from the system.
solution (sodium chloride and normal saline are  Check the IV solution for the type of amount, percent of
interchangeable names). solution and rate of flow.
 Assess the health status and medical disorders.
 Wash hands thoroughly and use sterile technique.
 Prime the tubing to remove air from the system.

Aki & Kaye 19 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Complications in IV Insertion BLOOD TRANSFUSION

• Infection – redness, swelling and drainage at site; chills, fever, Discussed by Prof. Donato A. Mirador
malaise, headache. Blood
• Tissue damage – skin color change, sloughing of skin, - Comes from Erythropoiesis – RBC production has to get
discomfort at site. Can be brought about by infiltration or erythropoietin from the kidney.
• Phlebitis – heat, redness, tenderness, not hard and swollen. - Erythropoietin – hormone produced by the kidney. It is a
• Thrombophlebitis – heat, redness, tenderness, hard and hormone that enhances the maturity of the RBC.
cordlike vein. - Normal RBC production also requires:
• Infiltration – Edema, pain, and coolness at the site. When 1. Iron
needle of IV line penetrates to the veins and the IV sol. Is 2. Vit. B12
pouring outside the vein the sol. Is accumulated causing edema 3. Folic Acid
• Catheter embolism – decrease BP, pain along vein, weak, 4. Vit. B6
rapid pulse, cyanosis of nail beds, loss of consciousness. When 5. Protein
tip of the catheter was accidentally punctured or detached by the Iron Stores and Metabolism
needle. - Total body iron content is 3g present in hemoglobin.
• Circulatory overload – increased BP, distended jugular veins, - Stored in small intestine, transported within the marrow where
rapid breathing, dyspnea, moist cough, and crackles. (common it is incorporated in the hemoglobin to produce another RBC.
in children) - With Iron Deficiency
• Electrolyte overload – signs depend on the specific electrolyte • Bone marrow iron stores are depleted.
imbalance. If it is potassium it is hard, rapid pumping action of • Hemoglobin synthesis is depressed.
the heart but if it is sodium it is increased in perspiration etc. • RBC produced are small and low in hemoglobin.
• Hematoma – ecchymosis (purplish discoloration), immediate - If there is iron deficiency, it is a sign of bleeding in the
swelling, and leakage of blood at the site, and hard painful gastrointestinal tract.
lumps at the site. Vit. B12 and Folic Acid Metabolism
• Air embolism – tachycardia, dyspnea, hypotension, cyanosis, - To utilize folic acid/ Vit B12, our body must use intrinsic factor.
decreased level of consciousness. – this enhances the Vit B12 Absorption.
- Without intrinsic factor, Vit B12 will only be eliminated by the
Computation colon.
volume in cc x Drop factor - In order to utilize Vit B12 within the stomach and up to the
• Gtts/ min =
no.of hours x 60 min. distal ileum intrinsic factor is being released and therefore Vit
B12 will be absorbed.
→ Vol. in cc (volume of IV fluids) - Deficiency in folic acid metabolism: Production of abnormally
→ Used for drops per minute large RBC –megaloblast (type of rbc that are large but immature,
trapped in the marrow)
→ drop factor can be 15 if it is a macrodrop 15 drops per ml.
if it is in microdrop it has to be 60 drops per ml Blood
- Composed of:
→ no. of hours (where solution is intended to finish) 1. Plasma – fluid portion (55%)
Vol in cc x DF 2. Cellular Component (45%)
• Nos. of hours =
gtts /min x 60min • RBC – Erythrocytes
• WBC – Leukocytes
Vol in cc • Platelets – Thrombocytes
• Cc/ hr =
no. of hours - Blood is 7% to 10% of body weight 5-6 L.
total volume to infuse - Functions:
• Infusion time =
ml/hr being infused 1. Carries O2 absorbed from lungs.
2. Carries nutrients absorbed from GI tract.
Calculation of infusion of unit dosage per hour - These two important functions of the blood, helps the
Order: continuous heparin Na by IV at 1000 units per hour body to perform metabolism.
Available: IV bag 500 ml D5W with 20,000 unit of heparin Na. 3. Carries waste products that are eliminated in the body.
Question: How Many ml/hr are required to administer the correct 4. Carries hormones and antibodies. (That helps the body to
dose? perform bios functions and helps the body bacterial
Answer: infections and other infection.)
20,000 units Red blood cells
• Conc/ml=
500ml
= 40 units/ml
- Hemoglobin (95%) contains iron, can transport O2 because iron
has the capacity to bind with oxygen.
1000 units
• ml/hr.=
40 units
= 25ml/hr - Reticulocytes – immature RBC, starts the formation of RBC.
After reticulocytes they form immature RBC until it becomes
matured/ erythrocytes.
- Hemoglobin binds with O2 – arterial blood (this oxygen comes
from diffusion of oxygen in the alveoli, it is caught up by the
blood then it will be delivered by the heart through the arterial
Aki & Kaye 20 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

to the cells, and then this hemoglobin after delivering oxygen to Blood components (that can be transfuse)
the cells, before they leave the cell they absorb hydrogen as a Red Blood Cells
product of metabolism/ bi-product of metabolism) - Used to replace erythrocytes.
- Hemoglobin binds with H – venous blood (decrease pH level) - Preparation: 250ml
which means acidity is rising. - When we transfuse RBC, it increases the hemoglobin by 1g/dl
- 15 g of hemoglobin per 100 ml of blood and hematocrit by 2 - 3 %
- Commonly used for Acute and chronic anemia
Blood groups and their constituent agglutinogens and Fresh Whole Blood
agglutinins - Use to resolve hypovolemic shock resulting to hemorrhage.
Blood groups Agglutinogens Agglutinins - Preparation: 500ml
O - Anti A & Anti B - Rarely use. (because instead giving fresh whole blood, doctors
A A Anti B tend to a fragmentalize this whole blood in to different
B B Anti A components.)
AB A&B - Platelets
Agglutinogens - Use to treat thrombocytopenia and platelet disfunctions.
- blood group antigens are A & B inherited by a person and - X – matching is not required.
may have neither of them. - Preparation: 50 – 70ml /unit or 200 – 400ml/ unit
- Are antigen A & B these are inherited of persons from their - Administer immediately and given for 5 – 30min. (after that
parents or maybe none of them will be inherited from the platelet will no longer be used. Because it will form a thick
parents meaning there can be absence of these rubbery like substance.)
agglutinogens in the blood and in that case, it falls under - Evaluated after client 1 hr and 24 hrs after transfusion of
the blood type of O, while if agglutinogen A appears in the platelets.
blood it is blood type A, if agglutinogen B appears in the Fresh frozen plasma
blood it is blood type B and if both appears in the blood it - Use to provide clotting factors or volume expansion.
is blood type AB. - Infused within 6 hours of thawing.
Agglutinins - Infused as rapidly as possible. (Or else, it will get thick rubbery
- Strong antibodies react specifically with either type of consistency and it will no longer be transfused to the client if
antigen. more than 6 hours.)
- In the blood type group O, since there is no agglutinogen - X- matching is needed.
they can form agglutinin anti-A and anti-B, which means - There will be elevations of prothrombin time and arterial
in blood type group O if we will transfuse blood, whether plasma thromboplastin time.
it is A or B, the formation of agglutinins Anti A and Anti Albumin
B will surely destroy the blood that is being transfuse. - Use to treat hypovolemic shock or hypoalbuminemia.
- In the blood type A, which has agglutinogen A can only - Prepared from plasma and can be stored for 5 years.
form agglutinin anti B. therefore, blood type A cannot - 25g/100ml of albumin = 500ml of plasma
receive blood type B because there is an agglutinin Anti B - Albumin can be able to increase the volume of the blood. That
to destroy blood type B. is why it is a potent drug or transfusion to treat hypovolemic
- In blood type B which is agglutinogen B it forms agglutinin shock or hypoalbuminemia.
anti A if blood type A will be transfused to blood B Cryoprecipitate
agglutinin anti A will be formed to destroy blood type A - Use to replace factor VIII and fibrinogen.
that is being transfused to the patient. - (From 12 it cascades to 1 until it forms blood clot. If one of
- The opposite of blood type O is AB because AB has two these factors is missing, the cascades will not continue, and
types of agglutinogen therefore, it will not form agglutinin blood clot will not be formed. Just like in the case of dengue
on both agglutinogen or antigen. hemorrhagic fever, the virus stays in factor VIII, but it does not
do anything to the clotting factor. Our body antibodies, they are
Blood Typing the one destroys the virus in the factor VIII and then after
Blood groups Anti A serum Anti B serum destruction of the virus, the factor VIII is also destroyed. It is a
O - - form of autoimmune problem and fibrinogen is also replaced
A REACTION NO REACTION when we transfused cryoprecipitates to the patient)
B NO REACTION REACTION - Prepared from FFP.
AB REACTION REACTION - Can be stored for 1 year but once thawed, the product must be
- Anti-serum A has the ability to have reactions with antigen A used.
which is in the blood type A. Types of Blood Donation
- When we get a sample of blood type A, and we expose to Anti Autologous
A serum there will be a reaction. It means that Antigen A is - Donation of the client’s own blood before the scheduled
present in the blood type A but if we will expose type A blood procedure.
to anti serum B there will be no reaction means that there is no - Reduces the risk of disease transmission and potential
antigen B present and this process is the same with blood type transmission complications.
B. - Can be made every 3 days as long as hemoglobin remains with
in a safe range.

Aki & Kaye 21 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

- Donation should be made within 5 weeks of the transfusion date if same blood set is to be used so we have to change it every
and end at least 3 days before the date of transfusion. (so that is after transfusion)
how a person who wishes to have this own blood for transfusion • Check the date of expiration. (two nurses are required to check
should follow this transfusion) the data)
Blood Salvage • Inspect the blood for abnormal color, leaks, clots, bubbles.
- An autologous donation. • Blood must be administered 20-30 minutes from its being
- Involves suctioning of blood from body cavities, joint spaces. received from the blood bank. (blood is sometimes frozen, and
- Blood may need to be washed by a special process that removes should be left at room temp. but not to extend too warm)
tissue debris before reinfusion. • Never refrigerate blood in refrigerator other than blood bank. (if
Designated Donor blood is not utilize by the patient nurse should tell the lab. To
- When recipients select their own compatible donors. fetch the blood to manage it)
- It is the client who bring the donor and the donor will donate • Monitor vs and assess lung sounds. (before blood transfusion
blood for the client and that blood that is compatible is being initial VS is taken and after blood is hooked to the client vital
used. It will also undergo examinations. signs should be taken every after 15min for 1 hour and after 1
- Does not reduce the risk of contracting infection but they feel hour it will be taken every 30 minutes and after that it will be
comfortable. taken hourly until the blood is consumed)
- Compatibility: • 2 RN need to check the physicians order, client’s identity,
• Rh type and ABO type are identified. client’s identification band.
• Use to prevent transfusion reaction. • Check the blood bag tag, label, and blood requisition form.
• Crossmatching – the testing of donor’s blood and the − Written in the label: expiration date, serial no., blood type,
recipients for compatibility. name of the client. So if this matches with the patient data
it will then be administered.
Complications
• Transfusion reaction. Informed of the allergic reaction. (there is Client Assessment
some blood, even though there are crossmatch. There is some • Assess for any cultural or religious beliefs. (as nurses we have
protein part of the blood that causes transfuses reaction.) Doctor to be knowledgeable with the background of the patient)
might order to antihistamine. • Informed consent has been obtained. (should be signed by the
• Circulatory overload (when transfusion of blood exceeds the patient or significant others)
expected blood that can be received by the client) • Check the clients vital sign and medical status.
• Septicemia (that bacteria may be present in the blood that is
being transfused. To prevent this development, the desired DOSAGE AND COMPUTATION
number of hours is 4-6hours, and it should not exceed.) Discussed by Prof. Francis Vincent Acena, MAN, RN, RM
• Iron overload (iron comes from hemoglobin, if blood is - Nurses are often intimidated by the math that occurs in every
undergoing hemolysis and nurse is pushing through to complete practice in most clinical and academic settings nurses must
transfusion it is better to set aside transfusion bcs nurse is demonstrate a 100% accuracy with medication dosage because
infusing too much iron and potassium and too much iron in the patient safety depends on practitioners ability to calculate
body can cause liver damage) medications correctly in timely manner.
• Disease transmission (most common hepatitis B and human - Patient safety is a key concern for nurses; ability to calculate
immune virus) drug doses correctly is an essential skill to prevent and reduce
• Hypocalcemia and citrate intoxication medication errors.
• Hyperkalemia (heart rate is becoming faster and harder so it is Common Medical Abbreviations Related to Medication
detrimental to the condition of the patient) Routes
Routes – kung saan natin pinapadaan yung mga gamot papunta sa
Nursing Intervention katawan ng pasyente.
• A large volume of blood transfused rapidly through a central • IM– Intramuscular (Intra – within/ inside, w/in the
catheter into the ventricle of the heart will cause cardiac muscles)
dysrhythmias. (The nurse should be aware that the volume must • IO– Intraosseous (directly into the bone marrow)
be transfuse slowly) • IV– Intravenous (vein)
• No solutions other than NS should be added on blood • IVP– Intravenous Push (blood stream/ vein)
components. (or else, IV and blood reactions will develop, it • ID – Intradermal (under the skin)
will cause blood clot)
• IN – Intranasal (nose)
• Infusion should not exceed more than 4 hrs.
• IP – Intraperitoneal (within peritoneum or the walls of
• Medication is never added to blood components. (stop blood abdominal cavity.)
transfusion when medication is needed run plain NSS to clear
• IT – Intrathecal (spinal canal, subarachnoid space so it
the tubings so that blood cells will be pushed with IV fluids and
reaches the CSF, useful in anesthesia, chemotherapy, pain
then medications can now be given)
management)
• Blood administration set should be changed every 4 - 6 hrs.
• IVPB – Intravenous piggyback ( sometimes called
(change blood set if there is another blood to be transfused.
secondary IV infusion)
There are filters in the blood set for transfusion and this might
• p.o – By mouth
clogged and therefore blood transfusion might not be possible
• SC / SubQ – Subcutaneous
Aki & Kaye 22 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

• SL – Sublingual (under the tongue) • gm or G- gram

• top. – Topical (on the skin) • gr- grain
• Supp – suppository (rectal) by insertion to a body • ml-milliliter
• pess – pessary, Vaginal suppository • cc-cubic centimeters
Measurement • L -liter
• Kg– kilogram • Neb -nebule
• gm– gram • Amp -ampule
• mg– milligram • Tsp -teaspoon
• mcg– microgram • tbsp. -table spoon
• mEq- milliequivalent • ODBB- once a day before breakfast
• L– liter • R – refused
• mL– milliliter • NA - not available
• μg– microgram • Syr – syrup
• gtt – drop • Susp – suspension
• μgtt – micro drop • Elix -elixir
• tbsp – tablespoon • Supp - suppository (rectal)
• tsp – teaspoon • Pess - vaginal suppository
• mg/dL – milligrams per deciliter • Gtt - drop; gtts- drops
Medical abbreviations • a – before
• OD- once a day - the drug is given at 8 am or 9 am unless • ac –before meal
specified by the doctor. • cap. -capsule
• BID- twice a day- the drug is given at 8 am and 6 pm • hs or HS –at bedtime: Hours of sleep
• TID- thrice a day- the drug is given at 8 am, 12 nn or 1pm and • MDI –metered dosage inhaler
6 pm. • P –after
• QID- four times a day- the drug is given at 8am, 12nn, 4pm and • Rx –prescription
8 pm • stat –immediately
• prn- whenever necessary/needed, no specific time unless time • Tab –Tablet
interval is specified by the doctor. • Tx –Treatment
• FR –Fast Release
Example (prn):
• TR –Timed-Release
• You have patient that always complain of abdominal pain now
• XR –Extended Release
you reffered him/her to the doc. and the doctor ordered:
Conversion
- Buscopan 10 mg 1 tab prn for abdominal pain
- Buscopan 10 mg 1 tab prn q 4 hrs. for abdominal pain
- In the first example, you can give Buscopan when
necessary, but the 2nd example you can give Buscopan
whenever necessary, but the nurse must observe a 4-hour
interval between doses. If the client is still in pain and the
4-hour interval is not yet done, the nurse can re-assess the
client and can refer the client’s severity of pain to the doctor.
• q- every
• q4 hrs.- every 4 hours. The drug is given at (4am-8am-12nn-
4pm-8pm-12mn). The drug is given 6x a day (24 hrs. divided
by 4 hrs.) or RTC (Round-the-clock)
• q6 hrs.- every 6 hours. The drug is given at (6 am-12nn -6pm-
12 mn). The drug is given 4x a day (24 hrs. divided by 6 hours)
or RTC.
• q8 hrs - every 8 hours. The drug is given at (8am-4pm-12mn).
The drug is given 3x a day (24hrs divided by 8) or RTC.
• p.o.- per orem or by mouth
• SL- sublingual- the medication is placed under the tongue.
• o.d. - occulus dexter or right eye
• o.s. - occulus sinister or left eye
• o.u. - occulus uterque or both eyes or each eye
• a.d. –right ear
• a.s. - left ear
• a.u. both ears
• HS - hours of sleep, at bedtime or half strength
• mg- milligrams

Aki & Kaye 23 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Used in identifying how many tablets you will give to the patient
Desired dosage is the ordered dosage of the physician.
Stock dose is the amount of drug present in each tablet.
Example:
The physician orders 500 mg of Amoxicillin tablet TID for the
patient. The drug is available in 250 mg tablets. How many tablets
should be given to the patient?

500 mg
= 2 tablets
250 mg
Example 2:
The physician orders 1g of Paracetamol tablet prn for the patient.
The drug is available in 500 mg tablets. How many tablets should
be given to the patient?
• 1g x 1000= 1000mg

Mass
• Kg → g → mg → mcg ( x by 1,000 ) big to smallest
Example:
1 Kg to g? [ 1 kg x 1000 = 1000g]
3 g to mg? [ 3 g x 1000 = 3000 mg]
5 mg to mcg? [ 5 mg x 1000 = 5000 mcg]
• mcg → mg → g → kg ( ÷ by 1,000 ) small to biggest
500 mcg to mg? [ 500mcg ÷ 1000 = 0.5 mg ]
1000 mg to g? [ 1000 mg ÷ 1000 = 1 g ]
250 g to kg? [ 250 g ÷ 1000 = 0.25 kg ]

• lb ←kg ( x by 2.2 ) Calculating Mixtures and Solutions

• lb → kg ( ÷ by 2.2 )
desired dosage
x stock volume = amount of soltion to be given
stock dose

Stock volume
- the amount of the solution where the drug is diluted.
- is the amount of the solution where the drug is diluted or
the amount of sterile water to dissolve powder-based meds.

Example 1:
The physician orders 500 mg of Ceftriaxone q8 for the patient. The
Volume
drug is available in 1 g vial. You plan to dilute it in 10 mL of sterile
• Liter to mL L → mL (multiply by 1,000) big to small water. How much should you give to your patient?
Example: How many mL in 5 Liters?
Computation: 5 liters x 1000 = 5000 mL 500 mg
x 10 mL = 5mL
• mL to Liter mL → L (divide by 1,000) small to big 1000 mg
Example: How many liters in 3000 mL? • 10ml- diluted medication
Computation: 3000 mL ÷ 1000 = 3 L • 5ml= 500ml, ito lang kukunin para i-inject sa pt.
Time • Kung gaano karami ung kukunin liquid/medication ganun din
• Hour to minutes hr → min (multiply by 60) karami air na ilalagay sa syringe
Example: How many minutes in 3 hours?
Computation: 3 hours x 60 = 180 minutes
• minutes to hour min → hr (divide by 60)
Example: How many hours in 120 minutes?
Computation: 120 minutes ÷ 60 = 2 hours

Calculating Tablet Dosages

desired dosage
= number of tablets
stock dose

Aki & Kaye 24 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Example 2: 3. Name of the drug to be administered.

The physician orders 5 mg of Metoclopramide prn for the patient. - this must be clearly written.
The drug is available in 10 mg per 2 mL preparation. How much - The name of the drug could be in generic name or with brand
should you give to your patient? name beside it.
4. Dosage of the drug
5 mg - the doctor is one who determines the dosage or strength of the
x 2 mL = 1mL
10 mg drug to be given to the client, for example 500 mg of Ampicillin.
- The nurse calculates the amount to be given to the client based
CONCEPTS OF ADMINISTERING MEDICATIONS on the dosage ordered by the doctor.
Discussed by Prof. Francis A. Vasquez, MAN, RN 5. Frequency of administration
- This indicates the number of times the client will take the drug
MEDICATION 1 – CONVERSION in a day or the number of times the nurse will administer the
Administration of medication drug to the client in a 24-hour basis.
- One of the most common tasks performed by a nurse that - Remember: the frequency of administration can affect the total
requires systematic, organized, and accurate drug preparation, dosage that the patient receive 1day.
administration and documentation that are needed to ensure - Example is “Ampicillin 500 mg 1 cap p.o. QID”. The dosage or
client’s safety and possible resolution of his health problems. strength of the drug is 500 mg to be given QID which means 4
- Three phases: times a day therefore the client will receive a total of 2,000 mg
1. Drug preparation – read and analyze the doctor’s order. Try of Ampicilin within 24 hours or 1 day.
to compute whether the dosage is correct. 6. Route of administration
2. Drug administration – you must know how to administer - this implies how the drug is to be given to the client.
the drug particularly the route like oral, topical, parenteral - Example is “p.o.” which literally means “per orem” or by
and in parenteral u have intradermal, subcutaneous, mouth; SC or subcutaneously via injection.
intramuscular and intravenous. 7. Signature of the person writing the order.
3. Drug documentation – you must document the drug that - Once the order is signed by the doctor, the order becomes legal.
you administered. Task not documented is task not done.
- You need to know each drug that you going to administered to Types of Drug or Medication Orders
your client. Know indication of the drug kung para saan ba siya, 1. Standing Order
action of the drug to the body, adverse reaction of the drug and - a drug order that must be carried out as specified by the
dosage of the drug or route. doctor until it is cancelled or changed by the doctor.
- Drugs have different therapeutic action such as the - Ex. Doc change the drug, dosage of the drug per dose,
following: frequency, route, hold or stop the drug
• Palliative – it relieves the symptoms of the disease but does 2. Single Order
not treat the disease itself. Examples are the pain relievers - a drug order that must be carried ONLY ONCE. This is a
such as mefenamic acid, Morphine, and aspirin. one-time order only.
• Curative- it cures the disease process itself. Example of this - Example: Penstrep ¼ IM (intramuscularly) before
are the antibiotics or antiviral drugs such as penicillin, discharge. Here, the nurse will only administer the drug
ampicillin. before the client goes home or upon discharge from the
• Supportive- it maintains body function until treatment hospital.
takes over. Example is paracetamol for fever. 3. Stat order
• Substitutive- it replaces body fluid or substances. Example - a drug order that must be carried out AT ONCE or
is Insulin for diabetes Immediately.
• Chemotherapeutic- it destroys malignant cells. Example is - Example is “Morphine sulfate 10 mg IV stat”.
Vincristine for Leukemia 4. prn order
• Restorative- it restores client’s health. Example of this are - a drug order that must be carried when needed or when
the vitamins and mineral supplements. necessary. It allows the nurse to administer the drug if
based on his knowledge and assessment, the client needs
Medication/ Drug Orders the drug.
1. Client’s Full Name - Example is “Buscopan 10 mg 1 tablet prn for abdominal
- for accurate identification of the client pain.”
2. Date and time the order is written. - Combine prn and standing order: buscopan 10 mg 1 tab
- for documentation and monitoring purposes. every 4 hrs prn for abdominal pain so if sumakit sa umaga
- In some agencies, a drug order for narcotics is only valid for 48 ng 8 am kailangan ibigay agad at kapag sumakit ulit ng 10
hours, hence, if the doctor did not make any order to cancel or am hindi na pwede ibigay kase may interval na 4 hrs so
continue that narcotic drug, his order is automatically cancelled next na bigayan 12 pa and if masakit talaga siya sabi ng
after 48 hrs. pasyente pain scale of 10/10 u have to notify the doc.
- The nurse should not carry out that order anymore.
- To monitor how long the patient take the drugs
Aki & Kaye 25 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Interpreting Drug orders Right Documentation

• “Tetracyline 250 mg 1 tab p.o. TID. - Document or record each drug you administered. In case if a
Interpretation: Administer 1 tablet of 250 milligrams of drug is not administered, be sure to record the reason why the
Tetracycline orally three times a day. drug was not administered. Possible reasons are: R, NA, or P.
• “Lanoxin 0.25 mg 1 tab OD” - Notify the doctor for any drug not administered.
Interpretation: Give 1 tablet of 0.25 milligrams of Lanoxin Right to Refuse
orally once a day. - A client of legal has the right to refuse any medication.
• “Solucortef 80 mg IV q 8 hrs” - Your responsibility is to make the client informed of the
Interpretation: Administer intravenously 80 milligrams of possible consequences of his action. In some agencies, the client
Solucortef every eight hours. needs to sign a Refusal Form. Be sure to inform the client’s
• “Nifedipine 10 mg SL stat” doctor.
Interpretation: Immediately administer sublingually 10 Right Assessment
milligrams of Nifedipine. - Some medications like prn medications require assessment
form the nurse.
• “Ventolin inhal 1 neb q 4hrs prn for DOB”
- Vital signs
Interpretation: “If necessary for difficulty of breathing, perform
Right Evaluation
inhalation with 1 nebule of ventolin
- Evaluating the client after drug administration allows the nurse
every four hours.
to monitor the client’s response to the drug or if there are any
side effects or adverse reactions the client is experiencing.
10 Rights the Nurse Must Observe in Administering
Medications
Routes of Drug Administration:
Right Client or Patient
Oral Route
- Administer the drug to the right client. - Form: Solid – Tablet, capsule, caplet, lozenge (strepsils)
- Ask the client to state his full name if applicable. (Do not state - Liquid- Syrup- sugar based, drops- for infants, elixir-
the patients name) alcohol based, suspension- dissolve in water, emulsion-
- Counter check the stated name to his identification band. oil based, extract
Right Medication or Drug Sublingual
- Give the medication ordered by the doctor. You may also - the drug is placed under the tongue.
counter check if the medication card is up to date by checking Buccal – the drug is placed near the cheek.
the Doctor’s order found in the client’s chart. Topical
- Nurses: based on pt. chart or doc order we make medication - the medication is applied on the skin or mucus membrane.
card - Forms: Cream, soap, powder, liniment, patch, ointment,
- Doctor: writes drug order on the patients chart lotion, shampoo, paste, tincture, suppository, pessary, gel,
Right Dose inhalation
- Administer the drug with the dose ordered by the doctor. (Most Parenteral
of the time doc. will just give the strength of the drug 500 mg, a) Intradermal
b) Subcutaneous
200 mg, 1g and its up to the nurses the amount of drug to be
c) Intramuscular
given: volume or no. of tablets)
d) Intravenous
- Carefully and accurately compute the dosage of the drug.
- Be familiar with usual range of dose of the drug that you are MEDICATION 2 – DRUG COMPUTATION
preparing and administering. Medication error
- Question the dose if it is beyond the usual range of dose. (we - One of the most common sources of errors and legal problems
can verify the dosage to the doc. that he is asking to administer) of nurses. Errors can originate from any part of the drug order.
Right Time or frequency - Example, the nurse administers a wrong medication, or the
- Administer the drug according to the frequency indicated by the nurse administers the right medication to a wrong patient.
doctor and following the hospital’s or agency’s policy of drug - Most often than not, the nurse administers the right medication
administration. For example OD- 8 am, BID 8 am and 6 pm. to the right patient but with wrong dosage.
- Since the nurse cannot administer all the drugs of all his patients - The dosage given to the client maybe overdose or underdose.
at the same time, some agencies allow the nurse to administer Therefore, knowledge and skills in computing accurately drug
the drug 30 minutes early or 30 minutes late. Follow agency dosages across lifespan is of utmost important on the part of the
policy. nurse.
Right Route Drug dosage
- The doctor is the one who orders what drug to be given to the
- Administer the drug based on the order of the doctor and check
client.
if the route is safe for the client.
- Included in his order are the dosage of the drug, the route of
Right Client Education administration and the duration and frequency the nurse must
- Explain to the client why he is receiving the drug, how will the administer the drug.
drug help her condition, what to expect and possible side effects. - Remember the different types of drug orders: standing, single,
stat and prn orders.

Aki & Kaye 26 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Example In other countries like USA, the pharmacist dispenses the drug per
Given: patient based on the drug order of the doctor and the pharmacist
• Norvir 100 mg 2 tabs BID. places a prescription label on the container of the drug that includes
Questions: the client’s name, address and the instruction on how to take the drug.
a. What type of drug order the doctor used? It’s like a personalized drug container. Other information are the
b. How many times per day are you going to administer following:
Norvir?
c. What is the dosage/strength of the drug are you going to
administer per dose?
d. What is the total dosage of the drug the patient is receiving
per day?
Answers:
a. Standing order
b. The frequency stated in the order is BID which means twice
a day (Example: Give the first dose of the drug at 8am and
the 2nd dose at 6 pm/day)
c. Norvir 100 mg 2 tabs BID means that each tablet contains
100 mg. Since you will administer 2 tablets, you will
administer 200 mg of Norvir per dose.
d. Since the frequency indicated in the order is BID, the total
dosage of the drug the client is receiving per day is 400 mg.
( 200 mg/dose x twice/day is 400mg/day)

Understanding drug labels

Name of drug: Amoxicilin
Form: Oral Suspension
Supply dosage: 125 mg/5 ml
Total Volume per bottle: 100 ml
- kapag isa lang pangalan generic
name ito

- Brand Name or Trade name of the drug: KEFLEX . The small

R besides Kelfex means “registered” trade name by DISTA
Products Co. (pharmaceutical company)
- Generic Name: Cephalexin MEDICATION:
- Form of the drug: Capsule ADMINISTRATION AND DOCUMENTATION
- Strength/capsule: 250 mg - Administration of medication is one of the most common
- Number of capsules/bottle: 100 procedures a nurse performs in the hospital.
- Active ingredient: Cephalexin Monohydrate - The efficient, organized and timely administration of prescribed
- Expiration date. medications may alleviate pain, promote comfort and well-
being, cure and support the rehabilitation process of the patient.
- Knowledge and skills in administering medications while
adhering to the 10 Rights in medication are a must on the part
of the nurse.
- Likewise, correct and proper documentation of the drugs
administered and were not administered are equally important.

General Safety Guidelines in Administering Medications

1. Verify doctor’s order. If you think that the medication order is
in error or if you are having a hard time reading the doctor’s
order, verify it with the doctor who made the order.
2. Always assess the client’s condition before and after you
administer the medication. This will tell you if the client still
needs the medication specially the prn meds or if the client’s
condition is improving or not.
3. The nurse is accountable to every medication he administers to
his client. Be sure you adhere with the 10 rights of medication
and be knowledgeable about the medications you administer.
4. Use only clearly labeled medication and check for expiration
date.
Aki & Kaye 27 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

5. The nurse who prepared the drug must administer the drug and - Never allow the tip of the dropper to touch any part of the
don’t let yourself administer a drug you didn’t prepared. eyes of the client. (horizontal position pag hawak sa
6. Calculate drug doses accurately. dropper)
7. Identify the client correctly. Ask the client to state his name and - Instruct patient gently close his eyes to prevent drug from
check his identification bracelet or tag. coming out and roll his eye balls to spread the drug.
8. Do not leave the medication at the bedside except for some b) Opthalmic Ointment (application)
medications. - Position of the client: supine, head on a pillow, patient
9. Know your hospital policy in receiving verbal or telephone looks up or sitting, head is tilted back, patient is looking up.
orders. - Pull lower lid down.
10. Update your medication sheet and medication card for non- - Apply the medication from the inner canthus to outer
EMR wards or hospitals. (If any change is done, update the canthus. Avoid applying the medication on the lacrimal sac
medication card) because of the presence of blood vessels.
11. If the client refuses to take the medication, verify why he - Never allow the tip of the tube to touch any part of the
doesn’t want to take the drug and discuss the possible effect of patient’s eyes. It will contaminate the medication.
his action. Notify your head and client’s doctor. - Instruct patient gently close his eyes.
12. If an error in medication is made, report immediately to your Otic Drugs
charge-nurse and client’s doctor. - Place the client in a sidelying position on his unaffected side.
- Pull pinna backward and upward for adults (above 2 years old)
Steps of Administering Medications: and backward and downward for children (below 2 years old)
1. Identifying the client. to straighten auditory canal. (horizontal hawak sa dropper)
2. Informing the client. - Instill the drug and never allow the tip of the tube to touch any
3. Administering the medication. part of the patient’s ear to avoid contaminating the drug.
4. Provide necessary interventions when needed. - Instruct the patient to remain on sidelying position for 15-20
5. Record the drug administered. minutes to allow the drug to enter the auditory canal.
Preparing and administering Oral medications: - If both ears need treatment, allow a 30-minute interval between
1. Verify doctor’s order and check medication card. instillations.
2. Compute accurately for the drug dosage. Rectal Suppository
3. Perform hand washing. - Provide Privacy and place client on Sim’s position.
4. Get the right drug. Read the label of the drug upon getting it - Wear clean gloves.
from the cabinet, before pouring the drug into the medicine - Separate the buttocks and insert the suppository then hold the
glass and before returning the drug inside the cabinet. buttocks together to allow the drug to go further inside the
5. If you are using a liquid drug like suspension or elixir, place the rectum.
label of the drug against your palm so that drippings will not - Could be laxative drug (commonly used drug para lumambot
flow onto the drug label making it hard for you to read the label ang poop)
the next time you use it. Vaginal Suppository or Pessary
6. Use appropriate vehicle for oral drug administration. Medicine - Provide privacy and place the patient in dorsal recumbent
dropper, oral syringe, teaspoon, tablespoon and medicine glass. position. Put on drapes.
In using medicine glass, be sure to read at lower meniscus. - Prepare the pessary and wear clean gloves.
7. Greet the client, identify yourself and identify the client. - Separate the labia minora with your non-dominat hand and
8. Explain the procedure to the client. using the applicator, insert the pessary into the vaginal canal by
9. Place client on Fowler’s position when administering an oral pushing the plunger.
drug. - Remove and dispose the applicator and gloves properly.
10. Again, check client’s identity. - Make the patient comfortable.
11. Administer the drug. For children with stranger anxiety, it’s best
to allow the child to sit on the lap of the mother to decrease
anxiety. If you are using a dropper or oral syringe, be sure to
place the dropper or oral syringe on the side of the mouth.
12. Provide water.
13. Make the client comfortable.
14. Document the drug given.

Administering Topical Medications

- Topical drugs applied, instilled or sprayed and intended to be
absorbed on the skin or mucous membrane.
Opthalmic Medication
a) Opthalmic drops (installation)
- Position of the client: supine, head on a pillow, patient
looks up or sitting, head is tilted back, patient is looking up.
- Pull lower lid down and the drug is instilled in the
conjunctival sac.

Aki & Kaye 28 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

CONCEPTS OF PAIN
Discussed by Dr. PA Maroma Nociceptive Pain
Pain - Subdivided into: Somatic and Visceral pain
- An unpleasant sensory and emotional “suffering” experience
usually associated with disease or injury.
- Universal-experienced by everybody, complex- influenced with
emotional, behavioral changes etc., subjective experience- it is
felt only by the patient.
- Most common reason why a person seek medical care.
- Fifth vital signs. (While monitoring the vital signs we should
ask the patient if he/she is in pain)

Example:
− Exposed to extreme heat nabanglian ng mainit na tubig so there
will be damage to the cell and these damage cells release
chemical like histamine, bradykinin, prostaglandin, that is
noxious stimuli and there will be injury and stimulation of
peripheral sensory nerves and there will be propagation of nerve
impulse and this impulse pass through the spinal cord (serves as
sensory pathway) via spinal thalamic tract going to thalamus
(serves as relay center for all sensory impulses) and proceding
to the cerebral cortex where it is interpreted as pain.
• Superficial cutaneous pain- affects the skin and subcutaneous.
• Deep somatic pain/ muscle pain- affects muscles and bones. Somatic pain
• Visceral pain- affects the internal organs. - Caused by: mechanical (distention of an organ), chemical
• Neuropathic pain- affects the nerves, brain and spinal cord. (release of chemical mediators), thermal, electrical injuries
(nakuryente), D/O affecting bones, joints, muscle, skin,
Acute pain connective tissue.
- Short duration (less than 6 months) - Superficial ''Cutaneous'' somatic pain
- Results from acute injury, disease or surgery usually temporary, • Ex; Insect bite, paper cut
sudden onset and easily localized (postoperative, trauma- • "sharp'' or "burning'' discomfort.
stabbed by a knife, burns, procedural- like simple blood - Deep somatic pain
extraction or endoscopy, obstetric-labor pain)
• Ex: trauma (fractures)
- Acts as a warning signal (activates "fight or flight" reaction).
• Localized sharp, throbbing & intense sensations.
There is stimulation of sympathetic nervous system therefore
there is: Higher HR, BP, RR, mydriasis- causes pupillary
Neuropathic Pain
dilatation, sweating- increased in perspiration.
- Results from damage to the (brain, spinal cord) pain pathways
- Endoscopy- direct visualization of cavity or organ.
or pain processing centers in the brain.
- Example: laryngoscopy, hepatitis a, appendicitis, labor pains,
- Example: Phantom limb pain (pt. have an amputation), spinal
burn injury
cord injuries (nabaril, nasak-sak), strokes, diabetes, and herpes
zoster (shingles)
Chronic Pain
- Long duration (more than 6 months)
- Chronic cancer pain
- Chronic noncancer pain
- Cancer occupies space therefore pag malaki na yung tumor, it
occupies space and compress the nerve and veins. It also
spreads through blood stream or to nearby structures. It can also
be secondary to chemotherapy or radio therapy
- Chronic non cancer is a prolong duration more than 6 mos and
most common type is secondary to arthritis they experienced
low back pain.
- It can also cause obstruction.
- Example: hepatitis c and b, osteoarthritis

Aki & Kaye 29 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

center for sensory impulses → limbic system brain → cerebral

Cancer Pain cortex/ sensory cortex where it is interpreted as pain.
- May be either nociceptive or neuropathic pain.
- Tumor creating a pressure in the organ – nociceptive pain
(visceral pain)
- Effects of chemotherapy or radiation – neuropathic pain
- Note: regardless of its nature, pattern, or cause, pain that is
inadequately treated has harmful effects beyond the suffering it
causes.

Impact of Unrelieved Pain

1. Physiologic impact
- Prolongs stress response, ↑ HR, BP & oxygen demand, ↓
GI motility (mabagal peristalsis), causes immobility
(difficult to gain cooperation of client because it is hard for
them to turn, after surgery the most common complication
because of pain exp. is that of atelectasis it is the no. 1 lung
complication after surgery. After anesthesia wears off
• A delta fibers- are small myelinated fibers w/c carries fast
narcotics and analgesic will be given a round the clock), ↓
traveling impulses
immune response, delays healing, ↑ risk for chronic pain.
• C fibers- are unmyelinated so they carry slow travelling
- Example: we give morphine to the patient every 4hrs 8am,
impulses
12pm, 4pm, 8pm, 12am, 4am with 6 doses within 24hrs and
after that the patient is prn as necessary • Synapse- at the opposite side of the spinal cord →
- Unrelieved pain become chronic spinothalamic tract
2. Quality of Life impact A delta fiber
- Interferes with ADL, causes anxiety, depression, fear, - myelinated fibers aka "mechanical nociceptors (respond
anger & sleeplessness, impairs family, work & social predominantly to mechanical rather than chemical or thermal
relationships. stimuli)
3. Financial impact - carries rapid (3-30m/sec) sharp, acute pain. Ex: touching a hot
- Increases hospital lengths of stay, leads to lost income & iron.
productivity. - Produces intermittent.
C fibers
Pain Transmission - Unmyelinated/ poorly myelinated fibers.
Transduction - Conduct thermal, chemical, and strong mechanical impulses.
- Conversion of chemical information to electrical impulses - Throbbing, aching, or burning sensation (0.5-2m/ sec)
- Chem’I mediators (PG, bradykinin, S, histamine, subs P) ➔ - Produces persistent pain.
stimulate free nerve endings "nociceptors.” Transmission Phase
- Impulses are carried by nerve fibers (peripheral sensory nerve); - Peripheral nerve fibers form synapses with neurons in the SC.
A-delta fibers & C- fibers. - It will ascend to reticular activating system, limbic system
(center of behavior), thalamus (sensory pulses), cerebral cortex.

− Point of cellular injury → injured cell release chemical

mediators like histamine, prostaglandin, bradykinin,
leukotrienes → stimulation of nociceptors/ peripheral nerves
like A delta and C fibers → propagation of nerve impulse →
pass through the dorsal horn of spinal cord → synapse of the
opposite side → spinothalamic tract → thalamus has relay

Aki & Kaye 30 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

Perception
- Brain experiences pain at the conscious level (conscious
experience of discomfort)
- Nalaman mo ng masakit

− Sign of painful stimulus → spinal cord → message conveyed Red- transduction

to the brain → cries as respond to the pain → pull legs toward Yellow- transmission
the body or withdrawal from painful stimuli. Violet- perception
Pain Threshold Impulse can be block both in ascending and
- The point at which the pain-transmitting neurochemicals reach descending in order to reduce or modulate
the brain, causing conscious awareness (same among healthy the pain
persons).
- Lowest pain stimulus Example:
Patient A have burn injury in the upper
Pain Tolerance
extremity with 4th degree burn which means
- amount of pain a person endures once the threshold has been up to the bone the nociceptors in here are
reached. destroyed so wala ng stimulation at hindi na madadala impulse to
- “Plain Tolerance is influenced by gender, age and culture.” the brain. Patient B have only superficial burn affects only epidermis
- Maximum of pain na kaya niyang tiisin and portion of dermis kaya mas masakit. Another is nadulas nag ka
hyper extension of the head so mawawalan ng transmission hindi
Modulation Phase ulit makakarating impulse sa brain. Another is nag karron ng
- Last phase of pain impulses transmission, during which the accident na apektuhan ang brain although may transduction at
brain interacts with the spinal nerves. transmission hindi naman siya ma pa-process ng brain kaya there
- At the point, pain is reduced due to endogenous opioids release. will be no pain perception.

Theoretical bases for Pain

Gate Control Theory
- Explains the relationship between pain & emotion.
- Results to a conclusion that pain is not just a physiologic
response ... that psychological variables (behavior & emotion)
also influence the perception of pain.
- In this theory: “Gating mechanism” occurs in the SC.

Aki & Kaye 31 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

- Portion of the SC that serves as the gating mechanism is the • Ex. Masakit sikmura ni pt. so maiisip mon a ito ay
substancia gelatinosa. peptic ulcer disease where in there are two types of
- Small diameter fibers are the a delta these gastric ulcer and duodenal ulcer. kapag mas
- Large diameter fibers are the a beta fibers masakit ang tiyan nya kapag kumakain ito ay gastric
- Gate closed the impulse will not reach the brain and there will ulcer kapag namn nagigin hawahan kapag kumaian
be decreased pain perception or pain modulation. that’s duodenal ulcer.
- Stimulation of large diameter fiber will close the gate and there 2. Aggravating factors
will be no pain or decreased pain. • What factors make the pain worse?
- Stimulation of the small diameter fibers will open the gate and • Ex. Kapag nag tatrabaho si pt. mas sumasakit ang
there will be pain. katawan niya.
- What stimulates the a data or large diameter fibers? It is by 3. Localization of pain
touch, massage therefore this is the focus of touch and massage • Can the client localize the pain or describe where it
therapy and other physical measures in order to relieve the pain travels or radiates?
- Similar gating mechanisms exist in the nerve fibers descending • Ex. Saan masakit? Examine it by using quadrants.
from the thalamus and cerebral cortex (areas that regulates 4. Character and quality of pain
thoughts & emotions, beliefs & values). • What words does the client use to describe the pain and
- When pain occurs, a person's thoughts and emotions can modify its character, quality or intensity? (have to quote and
perceptual phenomena as they reach the level of conscious unquote)
awareness. • Duration of pain
- Significance of gate control theory:
• Assess pain through PQRST or COLDSPA
• Recognition of holistic nature of pain.
Note: if the client is in pain when the nurse is obtaining the history,
• Development of many cognitive-behavioral therapies the session should be kept reasonably short or continued at a later
(imagery & distraction) to relieve pain. (kapag ang pt. ay time.
nalilibang na da-divert ang focus nya sa pain experience) Clinical manifestations
Acute pain
CNS Processing - Warning signal; stimulation of sympathetic NS (BP
1. Thalamus – relay station for sensory input from spinothalamic changes, tachycardia, etc)
tract of SC. Chronic pain
2. Midbrain – signals the cortex to increase awareness of the - Adaptation and coping occurs.
stimuli.
3. Cortex – discrimination of well-localized pain & interpretation Assessment Tools
of pain experience.

Terms used in the context of Pain:

1. Radiating pain – perceived at the source of the pain and
extends to the nearby tissues.
2. Referred pain – pain is perceived in an area distant from the
site of painful stimuli.
3. Intractable pain – pain that is highly resistant to relief. (severe
pain na hindi ma-relieve ng drug therapy or other measure)
4. Phantom pain – painful perception perceived in a missing body
part or in a body part paralyzed from a spinal cord injury.
(pakiramdam ng pt. masakit pa rin ung missing leg nya)
5. Phantom sensation – feeling that the missing body part is still
present. (pakiramdam na nandito pa ung leg na wala na)
6. Hyperalgesia – excessive sensitivity to pain.
7. Pain threshold ''Pain Sensation'' – the amount of pain
stimulation a person requires in order to feel pain.
8. Pain tolerance – maximum amount and duration of pain that
an individual is willing to endure.
9. Nociceptors – pain receptors.
10. Pain perception – the point which the person becomes aware
of the pain.
Nursing process
Assessment
− Data gathering through physical exam or through interview and
sources is the patient or the significant others
History:
1. Precipitating factors
• Does the client associate any activities, food, or other
environmental factors with the onset of pain?

Aki & Kaye 32 of 34

 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

• Opioids/ Narcotics
• Adjuvants - potentiators or enhancers
WHO Analgesic Ladder
1. Mild to moderate pain
- Lasting 3-4 hours
- Start with low doses of nonopioid drugs.
2. Intermediate pain
- Or pain not well controlled with nonopioid.
- Combine nonopioid with a low dose opioid.
3. Severe pain
- Add a higher dose opioid to the nonopioid or use a drug
that potentiates its analgesic effect like antihistamine.
Non-opioids/ non-narcotic analgesics
- Mild to moderate pain.
- Relieve pain by altering neurotransmission at the peripheral
level (site of injury).
- ASA acetyl salicylic acid, acetaminophen, NSAIDs non
esteroydal inflammatory drugs- like ketorolac, parecoxib. (side
effects lahat ng NSAIDs are gastric irritants so dapat ibigay ang
gamot after meal)
Opioids/ Narcotics
- Mainstay in the management of all types of pain
- Work centrally by blocking the release of neurotransmitter in
the SC.
• Morphine, Codeine, Hydrococlone, Oxycodone,
Hydromorphone, Metnadone, Tramadol, Meperidine
(Demerol)
• Withdrawal symptoms, antidote/ narcotics antagonist:
Naloxone (Narcan)
• If you give narcotics u should also give narcotic antagonist
Adjuvants
- Potentiators or enhancers
- Promethazine (Phenergan) antihistamine, antiemetic, sedative
agent + Morphine = enhanced opioids effects.
- Pag sinama sa opiods mas maganda ang effect niya.
Patient-controlled Analgesia
- Allows client to self-administer their own narcotic analgesic by
means of an intravenous pump system.
- Dose & time intervals between doses are programmed into the
device to prevent accidental over dosage.
- Can be given parenteral, orally or tinatapal sa katawan.
Intraspinal Analgesia
- Infused into the subarachnoid or epidural space of the SC
through a catheter inserted by a physician.
- Nurses DO NOT administer INTRASPINAL ANALGESIA!!!
Nursing Management Related to Side Effect of Medications
- Monitor for and implements measures for managing side-
effects of the drugs used
• Risk for impaired gas exchange r/t resp. depression (pos.
Pain Management patient, check VS especially oxygen saturation)
• Drug therapy • Constipation (provide high fiber diet if pwede na sya
kumain)
• Physical measures
• Risk for injury r/t drowsiness & unsteady gait (put side rails
• Cognitive-behavioral measures
up, provide support, pabantayan)
• Invasive techniques
• Risk for imbalance nutrition r/t anorexia & nausea (serve
Drug therapy
attractively and warm food)
- Gold standard form of pain control
- 3 groups of medications • Risk for deficient fluid volume r/t reduced oral intake.
(needs IV fluid therapy, hypertonic sol. with electrolytes,
• Non-opioids/ non-narcotic analgesics
hyper alimentation)
Aki & Kaye 33 of 34
 FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM

• Disturbed sleep pattern r/t depression of the CNS (provide

env. w/c is properly ventilated)
Note: if artificial airway is obstructed by secretion it is useless
therefore maintain this by suction apparatus.

Physical Measures/ Nondrug interventions

Cutaneous stimulation
- Transcutaneous electrical nerve stimulation (TENS)
- Percutaneous electrical nerve stimulation (PENS)
• a combination of acupuncture needles w/ TENS
• 30mins 3x a week for 3 weeks
• Using needles
- Thermal therapy (heat- causes vasodilation inc. blood
supply, muscle relaxation and promotes wound healing &
cold- causes vasoconstriction, reduces edema formation,
numbs the nerve endings)
- Therapeutic touch • Cervical Chordotomy- destruction of the spinal tracts in the
- Massage spinal canal in cervical canal
- Vibration
• Thoracic Chordotomy- destruction of the spinal tracts in the
thoracic cord
• Pain pathway can be blocked in any way para lang hindi
mapunta ang impulse sa brain.
• Rhizotomy- destruction of sensory route
• Chordotomy- destruction of the ascending tract
• If patient undergo spinal surgery he/she is positioned flat, good
body alignment, whole body is turned to side.

− The illustration above is the TENS it applies low voltage of

electrical current to the skin.
− Used by physical therapist
Cognitive-behavioral measures
- Effectiveness of these measures reflect the premises of the gate
control therapy.
• Distraction - divert the attention.
• Imagery- use one imagination to give pleasant substation
of pain.
• Relaxation
• Hypnosis
• Music therapy
• Aromatherapy
• Prayer & meditation
Invasive Techniques
- For intractable pain (cannot be cured by medications), severely
debilitating.
- Used when chronic or persistent pain can no longer be
adequately controlled with drugs or other pain-reducing
methods.
• Nerve block (temporary, ablation)
• Spinal cord stimulation
• Surgical procedures Hiwalay po ung reviewer ng Lecture and Laboratory. Masyado
kasing mahaba kaya pinaghiwalay ko HAHAHA at thank you kay
kaye, dahil may katulong na rin ako dito sa paggawa ng reviewer
kaya mabilis namin to natapos hohoho. Good luck sa exam natin!!
– Aki

Aki & Kaye 34 of 34

 NCMA113 LABORATORY – SUMMER MIDTERM 2021
• Moisture causes contamination.
Coverage for Laboratory: • Never assume that an object is sterile.
• Asepsis and Infection Control • Always face the sterile field
• Safety and Security • Sterile to sterile
• Positioning, Turning and Moving • Sterile areas must be above the waist.
• Bed Making • Prevent unnecessary traffic and air currents.
• Open and unused sterile articles are no longer sterile after
• Hygiene and Comfort Needs
procedure.
• Routes of Drug Administration • A person who is considered sterile must maintain sterility.
• (Handwashing and Gloving) • Surgical techniques are a team effort.

Two types of Microorganism found on the Skin

ASEPSIS AND INFECTION CONTROL
1. Transient flora
Discussed by Prof. Francis Vincent Acena, MAN, RN, RM
- Found on the outer layers of skin and are fairly easily
Terminologies
removed by handwashing.
1. Asepsis – Is the freedom from disease causing microorganisms.
- They are the organisms most likely to result in hospital-
2. Nosocomial infection – Infections that are associated or
acquired infections.
acquired in a hospital or other health care facility. (sometimes
- Pandadalian lang
called Hospital-acquired Infection)
2. Resident flora
3. Iatrogenic infection – Are the direct result of diagnostic or
- Are more deeply attached to the skin and are harder to
therapeutic procedures (Kozier, 2008)
remove.
4. Communicable Disease – an illness caused by an infectious
- Always there or present.
agent or its toxins that occurs through the direct or indirect
transmission of the infectious agent or its products from an
infected individual or via an animal vector or the inanimate
environment to a susceptible animal or human host. Ex.
Measles, hepatitis and HIV virus
5. Contagious Disease- disease that easily spreads directly from
one person to another.
6. Infectious Disease- disease not transmitted by ordinary contact
but require a direct inoculation through a break in a previously
intact mucous membrane. On the other hand, all contagious
diseases are infectious.
− When the skin is broken transient m.o penetrate the inner layer
7. Carrier – is an individual who carries and can pass on a
of the body w/c is why one of defense of m.o is intact skin
genetic mutation associated with a disease.
8. Contact - is any person or animal who is in close association
Infection
with an infected person, animal, or freshly soiled material.
- Implantation and successful replication of an organism in the
9. Disinfection – destruction of pathogenic microorganism
tissue of the host resulting in signs and symptoms.
outside the body through direct physical or chemical means.
- 2 types of infection:
(Physical: sunlight exposure, heat etc. Chemical: sodium
1. Local infection – limited to a specific body part.
hypochlorite, alcohol, etc)
2. Systemic infection – when microorganism spread and
10. Sterilization – defined as the complete destruction of all
damage different body systems.
microorganisms including the most resistant bacteria and
spores.
Types of Microorganism causing infection
Two types of Asepsis
Bacteria
Medical asepsis
- Are single-cell microorganisms with well-defined cell walls
- Also known as Clean Technique
that can multiply independently on artificial media without the
- Procedures used to reduce the number of microbes and
need for other cells.
prevents spread.
a) Spherical – cocci
Surgical Asepsis
b) Rod-shaped – bacilli
- Also known as Sterile Technique
c) Spiral-shaped – spirilla
- Procedures use to eliminate any microorganism.
Virus
- Used in invasive procedure like in urinary catheter or
- Are subcellular organisms made up of only a ribonucleic acid
operating room.
or a deoxyribonucleic acid nucleus covered with proteins.
- Free from all microorganism.
- Principles of surgical asepsis

Aki & Kaye 1 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

Fungi Mode of transmission (Germs get around)

- Organisms that exist by feeding on organic material. (Yeast - Contact (hands, toys, sand), droplets (when you speak, sneeze
and molds) or cough)
- Eukaryotes like plants and animals, they have well organized 1. Direct transmission – direct transfer of microorganism
self. from one person to another person. Through hands or kiss
Parasites 2. Indirect transmission – vehicle borne (eating utensils or
- Is an organism that lives on or in a host organism and gets its clothes), vector borne (animal, insects). From touching
food from or at the expense of its host. one object with m.o to touching yourself to break this
a) Protozoa – which adapts to invade and live in cells and link use face covering face shield wash hands and
tissues on their host. Ex. Amoebic dysenteric and malaria disinfection like chemicals that can reduce bacteria
b) Helminths – larger enough to be seen by the naked eye. 3. Airborne transmission – dust and droplets (small
c) Ectoparasites – live on the external surface of host. particles)
4. Droplet transmission – large particles that travel up to 3 ft
Nosocomial Infection & Healthcare associated Infections when coughing and sneezing.
Common microorganism Causes Portal of Entry (how germs get in)
Urinary Tract Improper catheterization - Mouth, cuts in the skin, eyes
- Escherichia coli (E.coli) technique Inadequate - Example respiratory droplets produced from the lungs when
- Pseudomonas aeriginosa handwashing infected person cough it can traveled to 6ft then lands to nose
Surgical Sites or mouth of other people to prevent this practice social
Improper dressing change
- Staphylococcus Aureus distancing or self-quarantine
technique Inadequate
- Methicillin-resistant Susceptible host (next person)
handwashing
strains (MRS) - Babies, children, elderly, people with a weakened immune
Blood Stream
Improper I.V. catheterization, system, unimmunized people, anyone.
- Staphylococcus Aureus
tubing & site care technique - Person who cannot defend against infection
- Enterococcus
Pneumonia - If we break chain of infection we can keep everyone safe
Improper suctioning technique
- Staphylococcus Aureus
Inadequate hand hygiene Precautions
- Pseudomonas aeriginosa
Chain of Infection 1. Standard precaution
- A way of gathering the information needed to interrupt or - A set of infection control practices used to prevent
prevent an epidemic. transmission of diseases that can be acquired by contact
- Each of the links in the chain must be favorable to the with blood, body fluids (hand hygiene, use of PPE, gloves,
organism for the epidemic to continue. mask, goggles)
- Breaking any link in the chain can disrupt the epidemic. 2. Transmission-based precaution
Which link it is most effective to target will depend on the a) Airborne precaution
organism. - These are used for microorganisms transmitted by
- Breaking chain of infection is vital to avoid the spread of m.o small particle droplets that can remain suspended and
Germs/ The Organism/ Infectious Agent become widely dispersed by air currents. (Patient
- Bacteria, viruses, parasites placement, Respi protection N95)
- Any microorganism that is capable of producing an infectious b) Droplet precaution
process. - These are used for microorganisms transmitted by
- Factors to consider: large particle droplets through coughing, sneezing, or
• Number of microorganism present talking which disperse into air currents (PPE: Eye
• Their ability to enter and survive inside a host. protection, mask, gown, gloves)
• Virulence c) Contact precaution
- These are used for organism that can be transmitted
• Susceptibility of the host
by hand or skin-to-skin contact, such as during client
Reservoir (Where germs live)
care activities or when touching the client's
- People, animals/pets, wild animals, food, soil, water
environmental surfaces or care items (PPE: eye
- Place where microorganism survive, multiply and wait
protection, mask, gown, gloves)
transfer to a susceptible host.
Body defenses against infection
- Can be on surfaces like table tops, door knobs and people
1. Non-specific defenses
- Breaking this include washing hands and disinfecting surfaces
a) Skin & Mucous membrane – intactness, acidity- destroy
Portal of Exit (How germs get out)
m.o
- Mouth (vomit, saliva), cuts in the skin, during diapering and
b) Nasal Passages – moist mucous & cilia- filter dust
toileting (stool).
c) Lungs - alveolar macrophages- mononuclear phagocytes
- Can include blood, skin and mucous membrane, respi tract, GI
d) Eyes – tears- wash out dirt and m.o
tract, GI tract, transplacental from mother to baby.
e) Vaginal canal – duoderlein bacilli
- Exits through coughing and sneezing
Aki & Kaye 2 of 19
 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

f) Inflammatory response • Level C – air purifying respirator

2. Specific Defenses • Level D – standard work clothes without a respirator
- Immunity: Antigen-antibody response
Preventing Infection: Levels of preventive care HANDWASHING
1. Primary Prevention - The rubbing together of all surfaces and crevices of the hands
- True prevention using a soap or chemical and water.
- Applied to clients that are healthy. - It is a component of all types of isolation precautions and is
- Health promotion/Health Educ the most basic and effective infection control measure that
- Immunization, nutrition, physical fitness prevents and controls the transmission of infections agents.
2. Secondary prevention • Hand washing
- Focuses on ill or sick individuals, and those at risk of • Antiseptic hand wash
developing complications. • Antiseptic hand rub/surgical hand antisepsis
- Directed towards diagnosis & intervention. - Handwashing (CDC 2008) is the vigorous, brief rubbing
- Screenings, surgery, medications. together of all surfaces of lathered hands, followed by rinsing
3. Tertiary Prevention under a stream of water for 15 seconds.
- Focuses on permanent or irreversible disability. - Antiseptic Handwash (CDC 2008) – washing the hands with
- Minimizing the long-term effects of illness warm water and soap or other detergents containing antiseptic
- Rehabilitation (PT) agent.
- Antiseptic Hand rub – applying a hand rub product to all
surfaces of the hands to reduce the number of microorganisms
present.
- Surgical Hand Antisepsis – antiseptic hand wash or hand-rub
technique that all surgical personnel perform before surgery to
eliminate transient and reduce resident hand flora.
HAND HYGIENE GUIDELINES (Boyce, et al, 2003) and
WHO (2009)
1. When hands are visibly dirty, soiled with blood or other body
fluids, before eating, after using the toilet, wash hands with
water and either a microbial or non-microbial soap
2. Wash hands when exposed to spore-forming organisms such
Disinfection as C.difficile, Bacillus anthracis, or Norovirus (CDC, 2014)
3. If hands are not visibly soiled (WHO,2009), use an alcohol-
• Concurrent – Done while the individual is still the source of
based waterless antiseptic for routine decontamination of
infection.
hands in the following situations:
• Terminal – The patient is no longer the source of infection.
a) Before, after and between direct patient contact
• Quarantine – Limitation of the freedom of movement of
b) Before putting on sterile gloves and before inserting
persons or animals which have been exposed to a
invasive devices
communicable disease for a period of time equivalent to the
c) After contact with body fluids or excretions, mucous
longest incubation period of that disease
membranes, non-intact skin and wound dressings (even
Isolation
if gloves were worn)
1. Strict isolation – prevention of highly contagious or virulent
d) When moving from a contaminated to a clean body site
infection (handwashing, PPEs).
during care
2. Contact isolation – prevent infections transmitted primarily by
e) After contact with surfaces or objects in the patient’s
direct contact. Thru contact with open wounds. (you must
room
wear your gloves and PPE)
f) After removing gloves
3. Respiratory isolation – prevent transmission over a short
distance through the air. Thru particles (required to wear
Cleaning
mask)
- Physical removal of visible dirt and debris by washing,
4. Blood and body fluids Precaution – must wear gloves
dusting, or mopping surfaces that are contaminated.
5. Reverse isolation – siya lang yung walang sakit.
Use of barriers
6. Enteric isolation – prevent the spread through direct contact
- Techniques that prevent the transfer of pathogens from
from feces.
one person to another.
Personal Protective Equipment’s
Isolation systems
• Level A – self-rebreathing apparatus with garment totally
- Techniques used to prevent or limit the spread of
encapsulated chemical suit (gives the highest protection)
infection.
• Level B – positive pressure with non-encapsulated chemical
suit

Aki & Kaye 3 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

SAFETY AND SECURITY Types of restraining devices

Discussed by Prof. Evangeline Orata, MAN, RN, RM 1. Mechanical/ Physical
Safety - Wrist, ankle, elbow, mitten restraints and belt.
- The condition of being protected from harm or other non- 2. Chemical
desirable outcome. - Medication used to calm an individual’s behavior.
- refer to the control of recognized hazards in order to - Some examples of chemical restraints include
achieve an acceptable level of risk. antipsychotics, antidepressants, anti-anxiety, and
Security sedatives: things that are not used to treat a medical
- the protection against deliberate threats. condition.
- The process of ensuring our safety. 3. Environmental
• Promotion safety and preventing injury for the patient is - Side rails
fundamental for nursing practice. - Locked units
• No matter of what type of patient you care for safety is a high - Locking devices on wheelchairs
priority. - Grab bars
• It is important that nurses be aware of the potential for injury Safety measures: Guidelines in Apply Restraints
and promote safety at all time. • Apply only for the safety of the client, never for the
Risk assessment tool convenience of the nurse.
- The individual who are a high risk for a fall. • Apply with care to avoid damaging the tissue and causing
- 5 or greater indicate high risk for a fall. harm to the client.
- This table is Hendrich fall risk assessment. • Recognize the physiological and psychological effects of
applying restrains.
• Explain reason to the client and family.
• Review the policy and procedure manual.
• Choose the restraints that fits the need.
Documentation of Restraints
• Clients’ behavior that supported the need for the restraint and
what was used before applying restraints.
• Types of restraint used.
• Explanation of purpose of using the restraint to the client. Give
patient the rights to know.
Intervention to prevent falls in a health care facility • Exact time that the restraint was applied.
• Orient to new surroundings • Continued assessment of the client every 2hours and care
• Keep two ride rails up. given while in restraint.
• Keep call light, bedside table, water, glasses within each reach. • Notification of the physician.
• Use a night light. Complications in Restrain
• Keep bed in low position. • Suffocation from entrapment
• Make sure patient has nonskid footwear. • Impaired circulation
• Teach fall prevention techniques. • Altered skin integrity.
• Ambulate only with assistance when appropriate. • Diminished muscle and bone mass
• Locate patient close to nurse’s station. • Altered nutrition and hydration.
• Aspiration and breathing difficulties.
Restraints/ Protective Devices • Incontinence • Change in mental status.
- A physical or mechanical device used to limit or prevent a Alternatives to the use of Protective restraints
client’s movement.
• Use a bed alarm system. Orient the client
- Device that limits movement to the extent necessary for the
• Provide familiar environment.
treatment, examination or protection of the client.
• Increase the monitoring frequency. Not because na restrain na
Purposes for use of restraints
si patient after shift na titingnan much better na every now and
- Prevent the patient from falling and sustaining injury.
then take a look at the patient during restraining period.
• Disoriented clients
Ethical/ Legal Implication
• Prolonged bedrest
• Emotional issue on the part of the client, family and staff.
• Client who are hypotensive, client with bleeding,
• Many view restraints as a personal physical assault and are
receiving narcotics medication.
frightened and respond by becoming combative.
- Position and protect client during treatments and to maintain
• The application of restraints may subject the nurse to
ongoing care.
allegations of false imprisonment, battery, and lack of
- Protect client who are combative and against and may cause
informed consent.
harm to self or others.

Aki & Kaye 4 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

POSITIONING, TURNING AND MOVING 4. Avoid friction and shearing.

Discussed by Prof. Evangeline Orata, MAN, RN, RM - Friction is a force acting parallel to the skin surface.
Positioning of Patient 5. Raised bed to an appropriate height.
- Positioning a patient in bed is important for maintaining - Reduces the risk of muscle strain and body injury to both
alignment and for preventing bed sores (pressure ulcers), foot the client and nurse.
drop and contractures.
- Proper positioning is also vital for providing comfort for
patients who are bedridden or have decreased mobility related
to a medical condition or treatment.
Benefits of proper positioning
• Helps prevent muscle discomfort.
• Prevents undue pressure resulting in pressure ulcers, damage
to superficial nerves and blood vessels, and contractures.
• Maintain muscle tone and stimulate postural reflexes.
General Principles
1. Changing the position of inactive
client regularly (every 2 hours) 6. Turn patient as complete unit to avoid twisting the spine in
TSTS – Turn side to side turning client (prepare client)
- Plan a systematic 24-hour schedule - Arms – one side
for position changes. - Flexed one in chest lower extremities.
- Frequent position changes are 7. Place client in good alignment with joints slightly flexed.
essential to prevent pressure ulcers
in immobilized clients.
2. Enlist help if needed.
- Preferred method is 2 or more nurses to move or turn the
client and use assistive equipment.
- Weak, frail, in pain, paralyzed or unconscious rely on
nurses.
3. Consider client SAFETY.
- Bed wheels are locked.
- Use side rail if appropriate.
- Side rails
• Bars, along sides of the length of bed.
• Ensure client safety and are useful for increasing
mobility.

Supportive Devices
- Foot boots are made of rigid plastic or heavy foam.
- Keep foot flexed at proper angle.
- Removed 2 or 3 times a day to assess skin integrity/joint
mobility.
- Use only those support devices needed to maintain alignment
and to prevent stress.
- Avoid placing one body part, particularly one with bony
prominences, directly on top of another body part.
- Excessive pressure can damage veins and predispose the client
to thrombus formation.

Aki & Kaye 5 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

General Principles (cont.) 3. Lateral position

• Replace pillows and positioning device. - Patient lies on the side of the body with the top leg over
• Support limb in a functional position. the bottom leg.
• Use elevation to relieve swelling or proper comfort. - This position helps relieve pressure on the coccyx.
• Provide skin care after positioning. - Inserting suppositories, taking rectal temperature, giving
- Side to side we do the back rubbing. back rub.
- Powder or hypoallergenic lotion
• Check the doctor’s order.
- To determine any restriction of the client’s movement.
- Doctor’s order:
• BR – Bed rest
• CBR – complete bed rest
• CBR c BRP – with bathroom privileges
• CBR s BRP – without bathroom privilege
• Amb – May ambulate (pinapayagan na sya gumalaw
konti)
- Nurse documentation 4. Sims position
• FOB – flat on bed - Patient lies between supine and
• OOB – out of bed prone with legs flexed in front of the
• Ambulatory patient. Arms should be comfortably
placed beside the patient, not
Bed underneath.
- Ensure bed is clean and dry. - Vaginal and rectal examination,
- Free from Wrinkled or damp sheets. administration of enema,
- Increase the risk of pressure ulcer formation. suppositories, for relaxation. Colonic procedure
- Make sure extremities can move freely. 5. High Fowler’s position
- Toe pleats, horizontal/ vertical pleats. - Patient's head of bed is placed at a
Bed mattress nearly vertical. Hips may or may
• It should be firm, level enough support natural body not be flexed.
curvatures. - This is a common position to
• Sagging mattress - too soft, under filled waterbed used over a provide patient comfort and care.
prolonged period may contribute to hip flexion contractures, - For oral care
low back strain and pain. 6. Semi Fowler’s position
• Bed boards made of plywood and placed beneath a sagging - Patient's head of bed is placed
mattress. at a 30–45-degree angle.
• Bed Boards These plywood boards are placed under the entire - This position is used for
surface area of the mattress and are useful for increasing back patients who have cardiac or
support and body alignment. respiratory conditions, and for
• Always obtain information from the client to determine which patients with a nasogastric tube.
position is most comfortable and appropriate. (aask mo si 7. Trendelenburg position
client kung comfortable ba siya) - Place the head of the bed lower
than the feet.
Common patient positions in bed
- This position is used in situations
1. Supine position
such as hypotension and medical
- Patient lies flat on back.
emergencies.
- Additional supportive devices
- It helps promote venous return to
may be added for comfort.
major organs such as the head and
- For examination of chest and
heart.
abdomen
8. Reverse Trendelenburg
- The entire OR bed is tilted so the
2. Prone position
head is higher than the feet.
- Patient lies on stomach with head
- Used for head and neck procedures.
turned to side.
- Facilitates exposure, aids in
breathing, and decreases blood supply to the area.
- A padded footboard is used prevent the patient from
sliding toward the foot.

Aki & Kaye 6 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

9. Dorsal recumbent position Safety considerations

- A position in which an individual (usually a patient) lies • Perform hand hygiene.
on their back with their knees bent up in an outward • Checkroom for additional precautions.
position while their feet are planted flat on the ground, a • Introduce yourself to patient.
bed, table or resting platform allowing the pelvic area to • Confirm patient ID using two patient identifiers {e.g., name
be easily examined and observed. and date of birth).
10. Lithotomy position • Listen and attend to patient cues.
- Perineal and Vaginal procedures • Ensure patient's privacy and dignity.
• Place the client in the lithotomy position. • Assess ABC'S/suction/oxygen/safety.
• Lying on back with legs flexed 90 degrees at your • Ensure tubes and attachments are properly placed prior to the
hips. procedure to prevent accidental removal.
• Knees BENT at 70 to 90 degrees. • Ensure patient has a draw sheet or a friction reducing sheet on
• Padded footrests attached to the table will support the bed prior to repositioning.
your legs (stirrups).
BED MAKING
Discussed by Prof. Caroline V. San Diego, MAN, RN
- The ability of the nurse to keep the bed clean and comfortable.
- It is the technique of preparing different types of bed in
making patients/clients comfortable in his/her suitable position
11. Orthopneic or tripod position for a particular condition.
- Patient sits at the side of the bed with Purpose
head resting on an over-bed table on top • Main: To prevent complications by ensuring the comfort and
of several pillows. security for the patient.
- This position is used for patients with • To provide the client with a safe and comfortable bed to take
breathing difficulties. rest and sleep.
• To keep the ward neat and tidy. (This is to reduce of pathogens
12. Jack knife position in the client’s environment)
- Jackknife Position. also known as Kraske, for colorectal • To adapt to the needs of the client and to be ready for any
surgeries. emergency or critical condition of illness.
- while positioning, surgical staff should place extra • To economize time, material, and effort.
padding for the knee area. Parts of the Bed
Mattresses
- Used for the client should be firm, thick, and smooth.
- It gives support to the client.
- All should have a washable cover.
13. Knee-chest position - The size is 190cm width.
- For gynecologic or rectal examination - (para maaddjust un mattress or un bed, may dalawang bakal sa
footboard.)
Siderails
- Serve as a safe and effective means of preventing clients from
falling out of bed.
Footboard/ Footboot
Turning and Moving Patient - Used to support the immobilized client's loot in a normal right
• Must use correct body mechanics. angle to the legs to prevent plantar flexion contractures.
• Alignment - positioning body parts in relation to each other to Intravenous rods
maintain correct body posture. - usually made of metal, support intravenous infusion containers
while fluid is being administered to a client.
• Correct alignment helps patient feel comfortable, prevent
- (pag walang ganyan, IV stand ang ginagamit)
fatigue, decubitus ulcers and contractures.
Bed cradle
Moving the patient up in bed.
- A device designed to keep the top bedclothes off the feet, legs,
1. Lower the head of the bed.
and even abdomen of a client.
2. Place the pillow against the bed frame to protect the patient's
- It is a curved, semi-circular device made of metal that can be
head.
placed over a portion of the patient’s body and is sometimes
3. If patient has trouble breathing, raise the head of the bed.
called an Anderson frame.
4. Ask the patient to flex the knees and brace the feet on the bed.
5. Place one arm under the patient's head and shoulders.
6. If the patient is unable to help, get someone to assist you.

Aki & Kaye 7 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

Three basic Beds - Changing linen, we follow Medical asepsis, by keeping

Closed bed the soiled linen away from the uniform.
- This bed is usually made when it will remain empty for a - Hindi pwede itapon lang sa sahig yung soiled linen. Dapat
while. You can make it with a bedspread or with only a sheet may lagayan ka.
and blanket. - Dumb dusting is recommended.
- Made following discharge of patient. • A safe and comfortable bed will ensure rest, sleep, and prevent
- To keep the bed clean until new patient is admitted. several complications in bedridden patients. E.g., bedsore, foot
- Top linens are not folded back. Bed is ready for a new person. drop.
- Also used when the person is up for the day. - Tuck in properly the sheets.
Open Bed - Prevent wrinkles. Smooth dapat.
- This bed is used when it will be occupied within a short period - Pull the bottom sheet tightly with no wrinkle and keep the
of time. linen tuck far under the mattress and keep it fix tight and
- Fanfold top sheet to foot of bed to convert closed bed to open smooth.
bed. • Good body mechanisms maintain body alignment and
- Fanfold means to fold sheets like accordian pleats. prevents fatigue.
- Done to welcome a new patient or for patients who are - Kapag imumove patient ifeflex muna natin yung isang leg
ambulatory or out of bed. ng pasyente bago siya iturn on the lateral side.
Occupied Bed - Always raise the bed to appropriate height before
- This bed is made with the client in the bed. changing the linen.
- Usually done after the morning bath. - Go to opposite side para mailatag ng maayos ung linen.
Bed with cradle • Systematic ways of functioning save time, energy, and
- Cradle placed on bed under the top sheet. materials.
- Prevents top sheets from touching parts of the patient’s body. - When pt. are confine to bed we have must organize bed
- Used for burns, skin ulcers, lesions, blood clots, fracture, or making.
surgery. - We must assemble all the articles and arrange them
- Some cradles have light bulbs to provide heat for special conveniently.
treatment. - Bed sheets are folded in a way it can be replaced easily.
Commonly used bed positions Bottom sheet, top sheet, blanket, pillow case.
Equipment’s:
• Mattress cover, if used
• Bottom sheet
• Cotton and plastic draw sheet (or disposable bed
Protector called as underpad)
• Top sheet
• Blanket
• Pillowcase
• Pillow
• Pillow protector, if used
- Usually use by the health care providers as the first line of
• Chair – dito ilalagay yung mga linens (hindi pwede sa
intervention for the patient who are hypotension or shock.
sahig ilagay)

From Course Unit

Postoperative Bed
- Use for laparoscopic surgery. − Also known as recovery bed or anesthetic bed.
Surgical Bed − Used not only for clients who have undergone surgical
procedures but also for clients who have given anesthetics for
- To facilitate easy transfer of the patient from stretcher to bed.
a certain examination.
- Equip with mechanism that can elevate or lower the entire bed
− Used for a patient with a large cast or other circumstance that
flat form flex or extend components of the flat form.
would make it difficult for him to transfer easily into bed.
Principles to keep in mind in bed making
Water bed
• Microorganisms are found everywhere on the skin, on the
- Special mattress filled with water.
articles used by the client and in the environment. The nurse
- It controls temperature of water, reducing pressure on body
takes care to prevent the transference of microorganisms from
parts.
the source to the new host by direct or indirect contact or
- Indications: Patients confined to bed for long periods
prevent the multiplication of the microorganism.
Turning Frames (Stryker Wedge)
- Before and after bed making, we need to do handwashing
- It allows repeated changes between the supine and prone
to prevent cross contamination.
positions without disturbing spinal alignment.
Aki & Kaye 8 of 19
 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

- Indications: complication of immobility such as atelectasis, - Promote healthy skin and

pneumonia, decubitus ulcer and renal calculi. - Help prevent infection and disease.
Rotation Bed Maslow’s Hierarchy of Needs
- promote postural drainage, peristalsis and helps prevent the
complications of mobility.
- Indication: patients with spinal cord injury, severe burns
Circolectric Bed
- Permits frequent turning of several injured or immobilized
patient with minimal trauma or extraneous movement.
- Helps prevent and treat pressure ulcers, respiratory and
circulatory complications.
- Indications: Patients confined to bed for long periods of time.
Clinton Therapy Bed
- Also called the air-fluidized bed.
- Indications: Patients with managing burns and patients with • Comfortable, hindi makikipag-coodinate un pasyente kung
various disabilities. wala nito. You must assess, kailangan tinitingnan yung
Air Therapy Bed pasyente. (Kung body weakness ba or wala)
- Provide different levels of support to different body parts. • Safety
- Indications: Patients who are at risk to skin breakdown. • Belongingness
Fanfold • Known
- It is done by grasping the upper edge of the linen with • I am me
both hands; specifically folding the edge of the sheet used
in the bed 6-8 inches outward. Nursing responsibilities
Mitered corner - Assess a patient’s ability to perform self-hygiene care based
- A means of anchoring sheets on mattresses; a method of on individual needs and preferences.
folding the bed clothes at the corners to secure them in - Integrate nursing assessments and interventions during
place while the bed is occupied. It is accomplished on the hygiene care with nursing activities such as:
bottom sheet by placing the end of the sheet evenly under • Range of motion
the mattress.
• Wound dressing changes.
Toe pleat
• Inspection and care of intravenous (IV) sites
- A fold made in the top bed clothes to provide additional
• Provide any needed teaching or counselling for patients.
space for patient’s toes.
Foot drop • Ensure privacy, convey respect, and provide safety and
- Dropping of the foot from paralysis of the anterior muscle comfort during hygiene care.
of the leg; plantar flexion of the foot with permanent Point to remember:
contracture of the gastrocnemius(calf) muscle and tendon. • Proper hygiene care requires and understanding of the
anatomy and physiology of the skin, nails, oral cavity,
HYGIENE AND COMFORT NEEDS eyes ears, and nose.
Discussed by Prof. Caroline V. San Diego, MAN, RN • The skin and mucosal cells exchange oxygens, nutrients,
Terminologies and fluids with underlying blood vessels.
Hygiene • The cells require adequate nutrition, hydration, and
- Conditions and practices that help to maintain health and circulation to resist injury and disease.
prevent the spread of diseases. (WHO) • Good hygiene techniques promote the normal structure
- A highly personal matter determined by individual values and function of these tissues.
and practices.
Skin
- Care of the skin, feet, nails, oral and nasal cavities, teeth,
- Protection
hair, eyes, ears, and perineal-genital areas.
- Secretion
Personal hygiene
- Excretion
- Self-care by which people attend to such functions as
- Body temperature regulation
bathing, toileting, general body hygiene and grooming.
- Cutaneous sensation
Grooming
- Bundles of collagen and elastic fibers form the thicker dermis
- Art of keeping ones self-clean and neat.
that underlies and supports the epidermis. Nerve fibers, blood
Points to remember
vessels, sweat glands, sebaceous glands, and hair follicles run
• Goal of providing hygiene measures: through the dermal layers.
- Comfort, safety, and well-being of the client. - Sebaceous glands secrete sebum, an oily odorous fluid, into
• Personal hygiene activities: the hair follicles.
- Foster a positive self-image

Aki & Kaye 9 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

- Sebum softens and lubricates the skin and slows water loss Temperature
from the skin when the humidity is low. More important, it has regulation Factors that interfere with heat loss alter
bactericidal action. - Radiation, temperature control. We bed linen or
Subcutaneous tissue layer evaporation, gowns interfere with convection and
- Contains blood vessels, nerves, lymph, and loose connective conductions, and conduction. Excess blankets or bed
tissue filled with flat cells. convection coverings interfere with heat loss
- They fatty tissue functions as a heat insulator for the body. control body through radiation and conduction.
temperature. Coverings promote heat conservation.
- Subcutaneous tissue also supports upper skin layers to
withstand stresses and pressure without injury.
- Remember: Secretion and
• The skin often reflects a change in physical condition by excretion 1. Perspiration and oil harbor m.o.
alterations in color, thickness, texture, turgor, temperature, - Sebum lubricates 2. Bathing removes excess body
and hydration. skin and hair. secretions; may result to dry skin if
• As long as the skin remains intact and healthy, its - Sweat promotes done excessively.
physiological function remains optimal. heat loss by
evaporation
Function/ Implication to care
Description
Neonate
Protection
- Relatively immature at birth.
- Epidermis is an
- Epidermis and dermis are bound together loosely.
impermeable
1. Scraping or stripping weakens the - Skin is very thin.
layer that
epidermal surface. - Friction against the skin layers causes bruising.
prevents
2. Excessive dryness causes cracks and - Should be handled carefully during bathing.
entrance of
breaks in skin and mucosa that allow - any break in the skin may result to an infection.
microorganisms.
bacteria to enter. Emollients soften - Use cotton balls.
- Although
skin and prevent moisture loss, and Toddler
microorganisms
hydrating mucosa prevents dryness. - skin layers become more tightly bound together.
reside on skin
3. Constant exposure of skin to moisture - Child has a greater resistance to infection and skin irritation.
surface and in
causes maceration or softening, - More active play and the absence of established hygiene habits
hair follicles,
interrupting skin integrity, and necessitates provision of thorough hygiene and teaching of
relative dryness
promoting ulcer formation and good hygiene habits.
of surface of skin
bacterial growth. - Dapat tinuturuan na ng proper hygiene.
inhibits bacterial
4. Keep bed linen and clothing dry. Adolescence
growth.
5. Misuse of soap, detergents, cosmetics, - The growth and maturation of the skin increases.
- Sebum removes
deodorant, and depilatories cause - Girls - estrogen secretion causes the skin to become soft,
bacteria from
chemical irritation. smooth, and thicker.
hair follicles.
--Cleaning skin removes excess oil, - Boys - male hormones produce an increased thickness of the
- Acidic pH of
sweat, dead skin cells, and dirt, which skin with some darkening in color.
skin further
promote bacterial growth. - Sebaceous glands become more active, predisposing
retards bacterial
adolescents to acne.
growth.
- sweat glands become fully functional during puberty.
Sensation
Adult
- Skin contains 1. Minimize friction to avoid loss of
- Depends on bathing practices and exposure to environmental
sensory receptors stratum corneum, which may result
irritants.
for touch, pain, in the development of pressure
- With aging, the rate of epidermal cell replacement slows, and
heat, cold, and ulcers.
the skin thins and loses resiliency.
pressure. 2. Keep linens smooth to remove
- Moisture of the skin becomes less, increasing the risk for
- Handle with care sources of mechanical irritation.
bruising and other types of injury.
3. Remove rings from fingers to
prevent accidentally injuring
Feet, Hands and Nails
patient’s skin.
- Often require special attention to prevent infection, odor, and
4. Make sure that bath water is not
injury.
excessively hot or cold.
- Their condition influences the ability to perform hygiene care.
Without the ability to bear weight, ambulate, or manipulate
hands, the patient is at risk for losing self-care ability.
- Points to remember:

Aki & Kaye 10 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

• The nails grow from the root of the nail bed, located in the  Discomfort and pain, emotional stress, or fatigue
skin at the nail groove, hidden by the fold of skin called diminish the ability.
the cuticle. 4. Socioeconomic status
• A scalelike modification of the epidermis forms the - A person's economic resources influence the type and
visible part of the nail (nail body) extent of hygiene practices used.
• Has a crescent-shaped white area known as the lunula.  When patients lack socioeconomic resources, it
• Under the nail lies a layer of epithelium called the nail becomes difficult for them to participate and take
bed. responsible roles in health promotion activities such
as basic hygiene.
Oral Cavity 5. Health beliefs and motivation
- Lips surrounding the opening of the mouth. - Knowledge about the importance of hygiene and its
- The cheeks running along the sidewalls of the cavity. implication for well-being influences hygiene practices.
- The tongue and its muscles  Provide information that focuses on a patient's
- The hard and soft palate. personal health related issues relevant to the desired
- You must assess the patient: nabubuka ba ng pasyente un bibig hygiene care behaviors.
nya, kaya nya ba mag toothbrush mag-isa. 6. Cultural variables
- Difficulty in chewing develops when surrounding gum tissues - Cultural beliefs and personal values influence hygiene
become inflamed or infected or when teeth are lost or become care.
loosened. - People from diverse cultural backgrounds (e.g. Level of
- Regular oral hygiene helps to prevent gingivitis and dental education, gender preference, geographic location)
caries. frequently follow different self-care practice.
Hair  Do not express disapproval when caring for patients
Points to remember: whose hygiene practices differ from yours.
• Hair growth, distribution, and pattern indicate a person's  Avoid forcing changes in hygiene practices unless the
general health status. practices affect a patient's health.
• Hormonal changes, nutrition, emotional and physical stress, 7. Developmental stage
aging, infection, and some illnesses affect hair characteristics. - The normal process of aging affects the condition of body
tissues and structures.
• Hormonal and nutrient deficiencies of the hair follicle cause
- Affects the ability of a patient to perform hygiene care
changes in hair color or condition.
and the type of care needed.
Eyes, Ears, and Nose 8. Physical conditions
- Attending to the hygiene needs of the eyes, ears and nose - Physical limitations or disabilities associated with disease
require careful attention because of their sensitive anatomical and injury results to lack of physical energy and dexterity
structure. to perform self-care hygiene measures safely.
- Water lang gagamitin pag pupunasan yun mata.
Health assessment Questions
Factors influencing hygiene Cultural and Religious Practices:
1. Social practices • Do you have any preferences for how you bathe or clean
- Social groups influence hygiene preferences and practices, your teeth?
including the type of hygiene products used and the nature • How comfortable are you with someone helping you, with
and frequency of personal care practices. how we care for you?
2. Personal preferences • 1n what way can I best help you with your bath, hair care?
- Patients have individual preferences about when to Tolerance of hygiene activities:
perform hygiene and grooming care. • Does bathing cause any symptoms such as shortness of
- Culture plays a role in sensitivity to personal space and breath, pain of fatigue?
gender. • What can I do to minimize these symptoms?
- Help a patient develop new hygiene practices when • Which aspects of bathing or toothbrushing cause
indicated by an illness or condition. discomfort or fatigue?
 Safe and effective patient-centered nursing care • Do you use any aids to help you with your bath such as
improves patient satisfaction.
grab bars in your tub or shower?
3. Body image
• Do you prefer someone of the same gender to help in your
- Body image is a persons' subjective concept of his or her
hygiene care?
body, including physical appearance, structure, or
function. • With which parts of hygiene care do you need help?
- Body image affects the way in which individuals maintain Mouth care:
personal hygiene. • Do you have any mouth pain or toothaches, do your gums
 Surgery, illness, or a change in emotional or bleed during brushing or flossing?
functional status often affects a patient body image. • Do you wear any dentures or a partial plate?

Aki & Kaye 11 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

Feet and nails: • Ease anxiety through physical contact.

• How do you usually care for your feet and nails? • Decrease pain intensity through increased superficial
• Do you file or trim your own fingernails and toenails? circulation to the area.
Hair and scalp care: Strokes/ Techniques
• Have you recently experienced itching of the scalp or Effleurage
noticed flaking or dandruff? - Consist of long, slow, gliding strokes
• Have you noticed any changes in the texture or thickness - Enhances client comfort and relaxation.
of your hair? - Has a positive effect on cardio­vascular parameters (BP,
HR, RR)
Summary
- No two individuals perform hygiene care in the same manner.
- Individualized patient care should be based on learning about
his or her unique hygiene practices and preferences.
- Individualized hygiene care requires knowing the patient and
using therapeutic communication skills to promote a trusting
therapeutic relationship.
- Use the opportunities provided during hygiene care to assess a Petrissage
patients' health promotion practices, emotional status, and - Kneading motions
health care education needs and then offer educational
interventions.
- Developmental changes influence the need and preferences for
type of hygiene care.

Purposes of a Bed Bath

- Cleanses the skin. Tapotement
- Stimulates circulation. - Hacking motions
- Provides mild exercise.
- Promotes comfort.
- Allows assessment of skin condition joint mobility, and
muscle strength.
- Materials:
• Basin or sink with warm water Friction Rub
• Soap and soap dish or liquid chlorhexidine gluconate - Stimulates circulation.
(CHG) (CHG cloths optional)
• Linens: bath blanket; two bath towels; washcloth; clean
gown, pajamas, or clothes, as needed; and additional bed
linen and towels, if required
• Gloves, if appropriate
• Personal hygiene articles
• Shaving equipment if needed
• Table for bathing equipment’s Oral Hygiene
• Laundry hamper - "The human mouth is a mirror of health and disease."
Folding technique - Maintaining cleanliness of the oral cavity.
- Abnormalities: dental caries, periodontal disease, tartar, plaque
- Maintains the healthy state of the mouth.
• Cleanse’s teeth of food particles, plaque, and bacteria.
• Massages the gums.
- Relieves discomfort from unpleasant odors and tastes.
- Refreshes the mouth and gives a sense of wellbeing and thus
can stimulate appetite.
- Reduces the risk for cavities (dental caries and periodontal
disease)
- Frequency
Back rub/ Massage • Depends on the condition of the patient's mouth.
A comfort measure that has the following effects: • Some patients with dry mouth or lips need care every 2
• Aids in relaxation. hours.
• Decrease muscle tension. • Usually done twice a day or after eacl1 meal
Aki & Kaye 12 of 19
 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

- Assistance needed: Denture care

• Does the patient need assistance to do oral care? - Clean dentures as frequently as natural teeth.
• The nurse can help patients maintain good oral hygiene - Dentures are the patient’s personal property and should be
by: handled with care because they can be easily broken.
a) Teaching - Remove before going to bed - allows gums to rest and
them correct prevents buildup of bacteria.
techniques - Store in a labeled container covered with water or denture
b) Actual cleaner if available.
performing - Points to remember:
for weakened • Mouth care should be given before and/ or after meals, in
or disabled the morning and at night before the person goes to sleep.
patients. When a person is unconscious, they may need oral care
- Abnormalities: every two hours.
• Loose or • Oral care keeps the mouth and teeth clean and without
missing teeth odors. It prevents cavities, infection, gum disease and bad
• Swelling and bleeding of gums breath. It is a very important part of care.
• Unusual mouth odor • If you notice any of the following during oral care, they
• Pain or stinging in mouth structures. must be reported and documented:
Brushing techniques - Sores, redness, or bleeding in the mouth on the gums,
Major concerns are: cheeks, or lips
• Thoroughness in cleansing. - Pain during mouth care
• Maintaining an intact oral mucosa. - Coating of the tongue or cheeks
- Broken teeth or dentures
Materials: - Bad breath
• Water
ROUTES OF DRUG MEDICATION
• Toothpaste
Discussed by Prof. Caroline V. San Diego, MAN, RN
• Sink or small basin
Administering Parental Medications
• Towel
• Parenteral administration of medications is the administration
• Floss of medications by injection.
• Mouthwash • Parenteral administration is an invasive procedure that must be
• Gloves performed with aseptic techniques.
Brushing: Unconscious Patient • After a needle pierces the skin, the patient is at risk of
• Prevent aspiration. infection.
- Positioning - lateral position with head turned to the side • Each type of injection requires the application of specific skills
or side lying. Position back of the head on a pillow so that to ensure the medication reaches the proper location.
the face tips forward and fluid/secretions will flow out of • The effects of a parenterally administered medication develop
the mouth, not back into the throat. rapidly, depending on the rate of medication absorption.
- Place a bulb syringe or suction machine with suction • Always closely observe the patient’s response.
equipment nearby.

• Keeping the mouth open

- Never place your hand in the patient's mouth or open with
your fingers. Oral stimulation often causes the biting -
down reflex and serious injuries can occur.
- Use a padded tongue blade to open the patients mouth and
separate the upper and lower teeth.
• Materials:
- Denture cup
- Small basin
- Tissues
- Denture toothpaste
- Towel
- Mouthwash
- Denture solution or tablets
- Hand gloves

Aki & Kaye 13 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

Intramuscular Injection Step 2:

Delegation Considerations - Assess the patient’s medical history, medication history,
• The administration of injections cannot be delegated to an and history of allergies. Determine whether the patient is
unregulated care provider (UCP). allergic to any substances and the normal allergic reaction
• Instruct UCPs to report the occurrence of potential medication experienced.
side effects or any changes in the patient’s vital signs or level - Rationale: Certain substances have similar compositions;
of consciousness (e.g., sedation) immediately. never administer a substance to which a patient has a
Equipment known allergy.
• Proper size syringe and needle: Step 3:
- IM: Syringe2–3 mL for adult, 0.5–1 mL for infants and - Check the date of expiration for the medication.
small children; Needle, with length corresponding to the - Rationale: Drug potency may increase or decrease when
site of injection and the age of the patient medications are expired.
- Any site (children): 1.6–3.2 cm (depending on the size of Step 4:
the child) - Observe the patient’s verbal and nonverbal responses to
- Deltoid (adults): 2.5–3.8 cm receiving the injection.
- Ventrogluteal(adults): 3.8 cm - Rationale: Injections can be painful. Some patients have
• Small gauze pad, or alcohol swab, or both/ cotton balls with anxiety, which can increase their experience of pain.
alcohol & dry cotton balls
• Vial or ampule of medication
• Clean gloves Step 5:
• Medication administration record (MAR) or computer printout. - Assess the patient for contraindications.
• For intramuscular injections: Assess the patient for
muscle atrophy, reduced blood flow, and circulatory
shock.
- Rationale: Atrophied muscles absorb medication poorly.
Factors that interfere with blood flow to muscles will impair
the medication’s absorption.
Critical Decision Point:
- Because of documented adverse effects to intramuscular
injections, other routes of medication administration are
safer. Verify that an intramuscular injection is necessary
and explore alternative medication routes if possible.
Step 6:
- Aseptically prepare the correct medication dose from an
ampule or vial. Ensure all air is expelled from the syringe.
Check the label of medication against the MAR three times
while preparing the medication.
- Rationale: Aseptic preparation ensures that the medication is
• Needle diameter is measured by gauge. sterile. Preparation techniques differ for ampules and vials.
• As the gauge becomes smaller, the needle diameter becomes Checking the label against the MAR ensures the right
larger. medication is prepared for the right patient.
• An intramuscular injection usually requires an 18-to 27-gauge Step 7:
needle, depending on the viscosity of the medication. - Take the medication to the patient at the right time and
• Syringes come in numerous sizes, from 0.5 mL to 60 mL. perform hand hygiene.
• A 1 to 3 mL syringe is usually adequate for a subcutaneous or - Rationale: Taking the medication according to schedule
intramuscular injection. ensures the patient receives the effect of the medication at
• The use of a syringe larger than 5 mL is unusual for an the right time. Hand hygiene reduces the transfer of
injection. The larger volume creates discomfort. microorganisms.
Procedures Step 8:
Step 1: - Close the room curtain or door.
- Check the accuracy and completeness of each MAR or - Rationale: Closing the curtain or door provides privacy
computer printout against the prescriber’s original medication and avoids distractions.
order. Check the patient’s name and the medication name, Step 9:
route, dosage, and time of administration. Copy or rewrite any - Identify the patient using at least two patient identifiers.
portion of the MAR that is difficult to read. Compare the patient’s name and one other identifier (e.g., the
- Rationale: The order sheet is the most reliable source and only hospital identification number) on the MAR, computer
legal record of printout against the prescriber’s original printout, or computer screen against information on the
medication order. Check the MAR and the original medication patient’s identification bracelet. Ask the patient to state his or
order to ensure the patient receives the correct medications. her name, if possible, for a third identifier.
Illegible MARs are a source of medication errors.

Aki & Kaye 14 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

- Rationale: This process complies institutions requirements and Step 18:

improves medication safety. Identification bracelets are made - Hold the swab or gauze between the third and fourth fingers of
at the time of the patient’s admission and are the most reliable your non dominant hand.
source of information. The patient’s room number is not an - Rationale: The gauze or swab is readily accessible when the
acceptable identifier. needle is withdrawn.
Step 10: Step 19:
- Compare the label on the medication with the MAR one more - Remove the needle cap or sheath from the needle by pulling it
time at the patient’s bedside. straight off.
- Rationale: The final check of medication labels against the - Rationale: Preventing the needle from touching the sides of the
MAR at the patient’s bedside reduces medication cap avoids the risk of contamination.
administration errors. Step 20:
Step 11: - Hold the syringe between the thumb and forefinger of your
- Describe the steps of procedure and inform the patient that the dominant hand.
injection will cause a slight burning or stinging sensation. • Intramuscular injection: Hold the syringe as if you
- Rationale: Describing the process to the patient helps to were holding a dart, palm down.
minimize the patient’s anxiety. - Rationale: Quick, smooth injection requires proper
Step 12: manipulation of the syringe parts.
- Perform hand hygiene; put on disposable gloves. Step 21:
- Rationale: Hand hygiene and the wearing of gloves reduces - Administer the injection: Intramuscular injection.
the transfer of microorganisms. a) If the patient’s muscle mass is small, grasp a body of
Step 13: muscle between your thumb and fingers.
- Keep a sheet or gown draped over the patient’s body parts that - Rationale: Grasping the muscle ensures the
do not need to be exposed. medication reaches the muscle mass.
- Rationale: Use of a sheet or gown respects the dignity of the b) After the needle pierces the skin, grasp the lower end of
patient while only the area to be injected is exposed. the syringe barrel with your non dominant hand to
Step 14: stabilize the syringe. Move your dominant hand to the end
- Select an appropriate injection site. Inspect the skin surface of the plunger. Do not move the syringe.
over the injection site for bruises, inflammation, and edema. - Rationale: Smooth manipulation of the syringe
- Rationale: Injection sites should be free of abnormalities that reduces the patient’s discomfort from needle
may interfere with medication absorption. Injection sites that movement.
are used repeatedly can become hardened from c) Pull back on the plunger. If no blood appears, inject the
lipohypertrophy (increased growth in fatty tissue). Do not medicine slowly, at a rate of 1 mL per 10 seconds.
inject an area that is bruised or shows signs associated with - Rationale: Aspiration of blood into the syringe
infection. indicates intravenous placement of the needle. A slow
- Intramuscular injection: Note the integrity and size of the injection rate reduces the chance of pain and tissue
muscle and palpate for tenderness or hardness. Avoid these trauma.
areas. If injections are given frequently, rotate the injection d) Wait 10 seconds, and then smoothly and steadily
sites. Use the ventrogluteal site if possible. withdraw the needle and release the skin. Apply gentle
- Rationale: Unless contraindications exist for this site, the pressure with dry gauze if desired.
ventrogluteal site is the preferred injection site for adults and - Rationale: A wait of 10 seconds allows time for the
children but for infants the vastus lateralis site should be used. medication to absorb into the muscle before you
Step 15: remove the syringe and prevents the medication from
- Assist the patient to a comfortable position: > Intramuscular leaking back out through the track created by the
injection: Position the patient depending on the site chosen needle.
(e.g., have the patient sit, lie flat, lie on one side, or lie prone). Step 22:
- Rationale: The position of the patient can reduce strain on the - Withdraw the needle while wiping an alcohol swab or gauze
patient’s muscle and minimize the discomfort of the injection. gently over the injection site.
Critical Decision Point: - Rationale: Support of tissue around the injection site
- Ensure the patient’s position is not contraindicated by a minimizes the patient’s discomfort during withdrawal of the
medical condition. needle. Dry gauze may minimize the patient’s discomfort
Step 16: associated with the use of alcohol on nonintact skin.
- Relocate the injection site using anatomical landmarks. Step 23:
- Rationale: Injection into the correct anatomical site prevents - Apply gentle pressure. Do not massage the injection site.
injury to nerves, bones, and blood vessels. Put on a bandage if needed.
Step 17: - Rationale: Massage may cause underlying tissue damage.
- Clean the injection site with an antiseptic swab. Touch the Step 24:
swab to the center of the site and rotate outward in a circular - Assist the patient to a comfortable position.
direction for about 5 cm. - Rationale: Helping the patient to a comfortable position
- Rationale: The mechanical action of the swab removes gives the patient a sense of well-being.
secretions containing microorganisms.

Aki & Kaye 15 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

Step 25: • Record the patient’s response to medications in the nurses’

- Discard into a puncture-and leak-proof receptacle the notes and report to prescriber if required.
uncapped needle or the needle enclosed in safety shield IMs
and attached to the syringe. Do not recap the needle. • Needle: 1-1.5in 22-25g
- Rationale: Proper needle disposal prevents injury to • Spread the skin to ensure firmness.
patients and health care personnel. Recapping the needle • 90°angle
increases the risk of needle-stick injury. • Insert needle quickly, dart-like fashion.
Step 26: • ALWAYS aspirate prior to injection.
- Remove disposable gloves and perform hand hygiene. • Remove needle quickly in the same direction as insertion.
- Rationale: Proper hygiene reduces the transmission of Ventrogluteal Site
microorganisms.
- Recommended
Step 27: - Uses: Adults & Children over 7 months
- Stay with the patient for 3–5 minutes to observe for any - Needle: 1 –1.5in, 21-22g
allergic reactions. - Vol: 4ml (SAH) refer to agency policy
- Rationale: Severe anaphylactic reaction is characterized by - Landmarks: In side lying position c upper leg flexed
dyspnea, wheezing, and circulatory collapse and is a life- 1. Heel of opposite hand on head of greater trochanter.
threatening emergency. 2. Thumb in groin.
Step 28: 3. Index finger on anterior superior iliac spine.
- Inspect the injection site, noting any bruising or induration. 4. Third finger spread laterally along crest to form ‘V’.
- Rationale: Bruising or induration indicates a complication 5. Palpate for well-developed muscle in site.
associated with the injection. Document your findings and
notify the patient’s health care provider. Provide a warm
compress to the site.

Unexpected outcomes Related Interventions

1. Raised, reddened, or hard -Notify the patient’s health care
zone (induration) around provider.
intradermal test site. -Document the patient’s
sensitivity to the injected
allergen or the positive test if
tuberculin skin testing was
completed.

2. Hypertrophy of skin. -Do not use this site for future

injections.

3. Signs and symptoms of -Follow the institutional policy Deltoid site

allergy or side effects. or guidelines for the - High Risk, small muscle close to radial nerve and artery
appropriate response to adverse - Uses: Adults, immunizations
drug reactions. - Needle: 1 –1.5in, 21-22g
-Notify the patient’s health care - Vol: 1ml
provider immediately. - Landmarks: Place two fingers side by side below the acromion
-Add allergy information to the process. The side of your distal finger determines the top of
patient’s medical record the triangle. The tip of the triangle is in the same plane as the
axillary fold.
4. Complaints of localized pain, -Assess the injection site.
numbness, tingling, or -Document your findings.
burning sensation at injection -Notify the patient’s health care
site, indicating possible provider.
injury to nerve or tissues

Recording and Reporting

• Chart the medication dose, route, site, time, and date of
injection on the MAR immediately after giving medication, as
per agency policy.
• Document if the scheduled medication is withheld and record
the reason as per agency policy.
• Report any undesirable effects from the medication to the
prescriber.

Aki & Kaye 16 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

Dorsolateral Site 13. Place hand in non-dominant hand of the patient.

- High risk of hitting sciatic nerve, blood vessel or bone, not 14. Remove needle cap and holds syringe at 15 degrees angle from
recommended. skin with bevel up.
- Uses: Adults & children 15. Stretch the skin and tell the patient that he/she will feel a prick
- Needle: 1 –1.5in as needle is inserted.
- Vol: 4ml (SAH) refer to agency policy.
- Landmarks: Prone position c toes pointed inward.
• Palpate posterior iliac spine & draw imaginary line to the
greater trochanter of femur.
• This line is lateral & parallel to the sciatic nerve, the
injection sit is lateral & superior to this line.
• Visual calculation alone can result in an injection placed
too low!
Intradermal Injection
- It is the introduction via needle of tiny amounts of fluid into
layers of skin.
- It provides a local, rather than systemic effect.
- For diagnostic purposes (allergies and sensitivities to drugs)
- For administering tuberculin testing
- Syringe used is 1ml tuberculin syringe because of a very small
amount of drug needed.
16. Inject the solution intradermally and just enough to form a
- Needle used is a short (1/4 to 5/8 inch), fine gauge (g25-27). wheal.
Indications: 17. Remove the needle quickly but gently at the same angle used
• Syringe is positioned at15˚ angle. for injection.
• Small volumes, usually 0.01 to 0.05ml, are injected 18. Wipe with dry cotton ball but do not press the injection site.
because of the small tissue space. 19. Encircle the site correctly and write the time when to check the
- Most used site: injection site to determine reaction to the drug. Check the site
• Inner surface of the forearm. after 30 minutes.
• Subscapular region of the back can be used as well as the 20. Document the result and findings (If the result is positive, refer
deltoid region. to the doctor)
Procedures Subcutaneous Injection
1. Prepare all the equipment: - Administered in the loose connective tissue, the layer of skin
• 1cc syringe, disposable needle (aspirating needle), directly below the dermis and epidermis, collectively referred
• Sterile water, to as the cutis.
• Drug to be tested, - Subcutaneous administration may be abbreviated as SC, SQ,
• Wet and dry cotton balls sub-cu, sub-Q, SubQ, or subcut.
• Black/blue ballpen. - Subcutaneous tissue has few blood vessels drugs injected by
2. Wash hands and observe appropriate infection control SC are for slow, sustained rates of absorption.
measures. - SC -slower than intramuscular injections; faster than
3. Introduce yourself and verify the client’s identity. intradermal injections.
4. Explain to the client what you are going to do, why it is - Subcutaneous injection sites
necessary and how the client can cooperate. • outer area of upper arm.
5. Prepare needed materials aseptically. • The abdomen, from the rib margin to the iliac crest and
6. Check the label of the drug three times. avoiding a 2-inch circle around the navel. This has the
7. Prepare the medication to be used for skin testing (e.g ampule fastest rate of absorption among the sites.
or vial) • Front of the thigh, midway to the outer side, 4 inches
• Aspirate 0.9cc of distilled water/sterile water and 0.1cc of below the top of the thigh to 4 inches above the knee. This
the drug using the tuberculin syringe with the aspirating has a slower rate of absorption than the upper arm.
needle. • Upper back.
• Mix the drug and the distilled water in the syringe. • Upper area of the buttock, just behind the hip bone. This
• Replace the aspirating needle with g25 needle. has the slowest rate of absorption among the sites.
• Expel excess air. Equipment
• Place the syringe on the tray together with the wet and dry • A 25 (Orange) to 31 gauge thick,
cotton balls. • 3/8" to 1" long needle can be used. The size is determined by
8. Once With Patient the amount of subcutaneous tissue present, which is based on
9. Confirm again patient’s identity. patient build.
10. Locate the appropriate site for skin testing. • The 3/8" and 5/8" needles are most commonly used.
11. Cleanse the medial surface of the forearm by using firm, • Suitable for small volume (0.5ml to 1ml ); water-soluble.
circular motion from inner to outer portion.
12. Allow the skin to dry before injecting the drug.

Aki & Kaye 17 of 19

 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

Procedure
- Subcutaneous injections are inserted at 45.
a 5/8" needle is usually inserted at 45 degrees.
Medication is administered slowly, about 10 seconds/milliliter.

Materials
• Patient’s Medication record and chart
Oral Medications
- Safest • Prescribed medication
- Most convenient • Medication cup
- Least expensive • Optional: mortal and pestle for crushing pills, drinking straw,
- Patient are conscious and able to swallow applesauce or jelly for crushed pills (for children / elders)
Forms of Oral Medication • Patient’s water, juice or milk
• Tablet • Drug Handbook
• Enteric-coated tablets Steps
• Capsules 1. Verify the order on the patient’s medication record by
• Syrups checking it against the doctor’s order.
- If discrepancies exists, check another reference source for
• Elixirs
information
• Oils, powders, granules – these require special preparation.
• Kardex
• Liquid suspensions • Pharmacist
• Physician
2. Check if the patient has allergies to drugs or food by checking
the ….
• Hx & Physical findings,
• patient care plan, Kardex
• pt. wristband for allergies
3. Wash hands
4. Check the label on the medication three times before
administering it to the patient.
- when taking the medication from the shelf before pouring
the medication into the cup before returning the
medication to the shelf.
• For unit-dose medication. check the label again at the bedside
after pouring it and before discarding the wrapper.
Things to consider:
Patients with difficulty in swallowing whole tablets or capsules.
- cut the tablet into smaller doses or opening the capsule to
release the powder or granules.
Special considerations:
Patients with difficulty in swallowing whole tablets or capsules.
- Enteric-coated medication and extended/sustained-release
medications should never be broken.
Some prescribed doses require splitting a tablet to obtain the
desired dose of the medication (e.g., half of a tablet or 1.5 tablets).
- Divide a large, scored tablet into two equal pieces by
grasping both sides of the tablet and breaking at the
scored line.
- For un-scored tablets, place the tablet evenly into a pill
cutter and quickly close the device to ensure that the tablet
cuts evenly.
- Dispose of remaining partial doses according to
institutional policy if partial dosing is required.
Aki & Kaye 18 of 19
 FUNDAMENTALS OF NURSING PRACTICE LABORATORY: 1ST YEAR SUMMER MIDTERM

- If cutting and/or breaking tablets for patients with

difficulty swallowing, place all medication pieces into a
medication cup.
Oral capsule preparation for patients who are unable to swallow a
capsule.
- will require obtaining a soft food (i.e., puree or pudding)
from the nutrition room.
- To empty the contents of the oral capsule medication,
grasp both ends of the capsule, twist and pull gently, and
empty the contents into a medication cup.
- Be careful not to lose any of the medication.
- Carefully spoon 2-3 tablespoons of soft food into the
medication cup containing the capsule contents.
- This will facilitate administration and will help to mask
the taste of the medication.
Measuring liquid medication
- To pour liquids, hold the medication cup at eye level. Use
your thumb to mark off the corrective level on the cup
- Set the cup down & read the bottom of the meniscus at
eye level to ensure accuracy.
- If too much…discard…do not return to the bottle.
- If a medication, such as liquid digoxin, requires a precise
measurement, an oral syringe should be used to withdraw
the medication from the mediation cup.
- If a single-dose liquid medication container is used,
dispose of the remaining volume according to institutional
policy.
5. Confirm patients identify by ….
Asking name
Checking the name
Bed number on his wristband
6. Asses the patient’s condition, including level of consciousness
& vital signs, as needed & indicated by the particular
medication.
7. Assist patient in a sitting position.
• Hand medication cup and glass of water to patient.
• Name drug, describe its use, and answer any questions.
• Review with the patient any side effects or adverse effects
associated with the medication.
8. Give the patient his medication and liquid, as needed &
indicated, to aid swallowing, minimize adverse effects, or
promote absorption. Ask the patient to take a small sip of
water to ensure he/she is able to swallow without difficulty.
9. Ensure patient swallows’ medication.
- However, Should the patient refuse the medication, ensure
that he/she is aware of the potential
physiological/psychological impact.
of the refusal on his/her health and recovery.
10. Stay with the patient until he has swallowed the drug.
- If he seems confused or disoriented, check his mouth to Hiwalay po ung reviewer ng Lecture and Laboratory. Masyado
make sure he has swallowed it. kasing mahaba kaya pinaghiwalay ko HAHAHA at thank you kay
11. Once done…Handwash/ sanitize. kaye, dahil may katulong na rin ako dito sa paggawa ng reviewer
12. Document/record kaya mabilis namin to natapos hohoho. Good luck sa exam natin!!
- dose, route, date, and exact time administered with your – Aki
initials.
- Any assessments required prior to administration should
be included.
13. Return and reassess the patient’s response within 1 hour after
giving the medication.

Aki & Kaye 19 of 19

 NCMA113 LECTURE & LABORATORY – SUMMER FINAL 2021
- Granular and roughly cuboidal.
Coverage: - Cover – 5% of alveolar surface.
• Oxygenation - Secrete pulmonary surfactant.
• Suctioning - This is important in reduction of surfaces tension of
• Bowel elimination and Enema the lungs to prevent the development of lung collapsed.
• Urinary Catheterization
Respiratory Process
• Concepts and Principles of Partnership,
• Ventilation or breathing
Collaboration and Teamwork.
- the movement of the air into and lungs.
• Death and Dying - Process of inhalation and exhalation.
• Therapeutic Communication • Respiration – process of gas exchange between individual and
environment (Udan, 2004)
OXYGENATION • Gas Exchange – intake of oxygen and the excretion of carbon
Discussed by Prof. Aida V. Garcia, MAN, RN dioxide.
During Inspiration
- Diaphragm descends in the abdominal cavity causing lungs to
have negative pressure and;
- (-) intrapulmonary pressure because of this it will;
- Air draws from greater pressure into lesser pressure (to equalize
the pressure with the atmospheric pressure)
- Once it’s inside the lungs air will move to;
• Trachea
• Bronchi
• And alveoli

o Nose – serves as humidifier including warmth’s and filters the Alveolar-Capillary Gas Exchange
air as we breath in. then diff. sinuses which provide resonance - Diffusion of oxygen and carbon dioxide between the alveoli and
the sounds we produce. pulmonary capillaries.
- Air diffuses into capillaries.
o Pharynx – further subdivided to nasopharynx, oropharynx, and
laryngopharynx.
o Larynx – also known as the voice box.
o Epiglottis – helps prevent developing aspiration because it stays
open during the time of breathing and during the time of
swallowing it closes.
o Lungs – consist of left and right lung. The smaller is the left
lung because it consists of two lobes only. The right lung has
three lobes. Transport of oxygen and Carbon Dioxide
Alveoli - The oxygen will be transported from the lungs to the tissues so
- Smallest functional unit of respiratory system. that it will be able to oxygenate the diff. tissues, or the cells of
- Alveolar cells: the tissues and carbon dioxide will be transported from the
a) Type I Pneumocyte tissues back to the lungs and outside the body.
- Squamous and extremely thin. Diaphragm and intercostal muscles relax
- Cover – 95% of alveolar surface. - During the end of inhalation, the lung will be recoiled, when the
- Involved in gas exchange. lungs recoiled the pressure of the lungs will become higher than
b) Type II Pneumocyte the atmospheric pressure.
AKE 1 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

- The air inside the lungs will move from the lungs going outside
the body.

Types of Respiration
• External respiration - is gas exchange with in external
environment and usually happens in alveoli in the lungs. Inspiratory Reserve Volume (IRV)
• Internal Respiration – took place in the cellular level so that - Extra air inhaled beyond tidal volume. Breathing more than the
involve the gas exchange bet. the blood and the body cells. usual
- 3000 ml
- Halimbawa kapag umakyat ka ng 50th floor ng building
kailangan mo ng extra air
Expiratory Reserve Volume (ERV)
- Extra air exhaled beyond the tidal volume.
- 1,100ml
- The amount of extra air that can be exhaled beyond the tidal
volume.
Residual Volume (RV)
- Remains in the lungs after forceful exhalation
- 1,200 ml
- Ito yung iniiwan ng lungs mo kahit galing ka sa forceful
exhalation.

Lung Capacity
- Total amount of air that your lungs can hold
- Total Lung Capacity
• Total of volumes (TV + IRV + ERV+ RV)
• 5,800 ml

Muscle
- Normal breathing, we used;
1) Rib Muscle
2) Diaphragm
- They are the one to contract and relaxes for inhalation and
exhalation to happen.
- We do it for 16 times.
- RR – around 14 to 20 cycles in a minute but in other book the
RR is around 16-20 cycles in a minute
- Eupnea – Normal Breathing Pattern

Lung Volume & Lung Capacity Acessory Muscle

• Lung Volume – volume of gas in lungs during respiratory - Inspiration
cycle also called respiratory volume • Sternocleidomastoid
• Tidal Volume – (V or TV) • Scalene Muscle
- Air w/ each normal breathing - Expiration
- 500ml or 5ml – 10ml /kg • Abdominal
- Volumes – depends on the gender and age of the client • Internal Intercostal

AKE 2 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

Respiratory Control Centers Late s/s of Hypoxia

• Medulla Oblongata – sends signals to muscles. (innervates • Decreased respiratory rate (bradypnea) bcs of the fatigue
respiratory muscles this are rib muscles and diaphragm) happening in the respiratory muscles
• Pons – controls rate/no. of times of breathing • Bradycardia
• Dyspnea, retractions
• Decreased systolic BP
• Cyanosis
Note: during this marereverse ung early s/s

Caring for Patients with Impaired Oxygenation

- Assessing respiratory status:
• Color of skin and mucous membranes
• Respiratory effort
• Cough (dry or productive?)
• Chest appearance
• Oxygenation status
• Oxygen saturation

Factors that Influence Respiratory Function Nursing Diagnoses

• Age (in children mas mabilis ang RR nila compare to adults) • Ineffective breathing pattern – ventilation not adequate. (so
• Environment (living in high altitude mas thin air so mas nagging tachypnea or bradypnea)
madami ang kanilang rr including depth of their breathing other • Ineffective Airway Clearance – inability to clear obstructions.
is work environment like working with asbestos mas prone mag (ex. Pt. have sticky phlegm)
develop ng respiratory disease) • Impaired Spontaneous Ventilation – not able to maintain
• Lifestyle (those who are into smoking is usually affected) breathing.
• Health status (problems connected to the spinal column will • Activity Tolerance – insufficient energy. (s/s: weakness,
affect the inervation of respiratory muscles or anemia will dec. fatigue)
the ability of our body to transport o2) • Risk for Activity Intolerance – possible insufficient energy.
• Medications (dec. respirations like sedatives used in surgery) • Impaired Gas Exchange – Alveolar-capillary membrane
• Stress (may make the person to hyperventilate) changes.

Abnormal Respiratory Patterns SUCTIONING: OROPHARYNGEAL AND

• Tachypnea (rapid rate) – more than 20 breaths per minute. Seen NASOPHARYNGEAL
in patient with fever, metabolic acidosis hypoxemia and in pain. Discussed by Prof. Sharon B. Cajayon MAN, RN
• Bradypnea (abnormally slow rate) – less than 12-14 breaths. - Aspirating secretions through a catheter connected to a suction
Seen in pt. who took morphine or sedatives. machine or wall suction outlet.
• Apnea (cessation/ absence of breathing) - Upper airway suctioning:
• Kussmaul’s breathing- deep rapid and labor breathing usually • Oropharyngeal suctioning (pag tatanggal or pag excrete ng
seen in pt. with diabetic and ketoacidosis secretions sa bibig)
• Cheyne-Stokes Respirations- seen in pt. with drug overdose • Nasopharyngeal suctioning (pag tatanggal or pag excrete
or increased intracranial pressure which is characterized by ng secretions sa ilong)
gradual inc. and dec. and there are few sec. of apnea - 2 types of suction machine:
• Biot’s Respiration – shallow breathing and interrupted by • Wall mounted machine- we can see this on the wall
apnea. Seen in pt. with central nervous system disorder.
• Portable suction machine- we can see this on the bedside
• Hypoxemia – reduced oxygen levels in the blood. (so konti lang
where we can turn it on or off when needed.
makakarating sa parts ng body)
Note: We need suction catheter to remove, release or excrete
• Hypoxia – low levels of oxygen in the tissues of your body. secretions.
Impaired Oxygenation Purposes
Early s/s of Hypoxia • To remove secretions that obstruct the airway.
• Restlessness (agitation) • To facilitate ventilation.
• Tachypnea • To obtain secretion for diagnostic purposes.
• Increased depth and rate of respiration • To prevent infection that may result from accumulated
• Slight increase in systolic BP secretions.
Note: prior to lumala case ng pt. agapan na dpt put the pt. in semi Assess for clinical signs
fowlers pos. suction, and oxygenation. • Restlessness/ anxiety (nakita mo ung pt. na super pagod at
hindi komportble)

AKE 3 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

• Gurgling sound during respiration (sobrang dami ng

secretions kaya may noise na kapag humihinga)
• Adventitious breath sound (merong ibat ibang abnormal - Yankauer Tube – used only to suction oral cavity and its
breath sounds) reusable. (mas makapal ito)
• Change in mental status Skin color (kanina ok lang pt. tapos
biglang hirap na huminga at nag karron din ng changes of skin
color to assess this check the lips and finger nails kung may
nagkakaroon na ng poor oxygenation)
• Rate and pattern of respiration (normal adult respiratory rate
is 12-20cpm)
• Pulse rate and rhythm Sizes
Indications for Suctioning
• Adult – French # 12 to 18
• "Noisy breathing" (feeling mo maraming plema, naririnig mo
• Children – Fr # 8 to 10
kahit walang stethoscope ang pag hinga ng pt. if naka connect
• Infants – Fr # 5 to 8
naman si patient sa mechanical ventilator tutunog ito ibig
Suction device
sabihin kailangan na isuction ang pt.)
Wall unit Portable unit
• Audible or visual signs of secretions in the tube. (nakikita mo
Suction pressure Suction pressure
sa tube na nag i-in and out na ung secretions, marami na ding
-Adult – 100 to 120 mmHg -Adult – 10 to 15mmHg
saliva sa oral cavity nya) -Child – 95 to 110mmHg -Child – 5 to 10mmHg
• Signs of respiratory distress. (hirap huminga si pt. at mataas -Infant – 50 to 95mmHg -Infant – 2 to 5mmHg
ang respiratory rate)
• Suspicion of a blocked or partially blocked tube. (tignan if Things to remember:
na dislodge ang tube ng patient) • Do not force through nares during insertion. (like kpag nag
• Inability by the child to clear the tube by coughing out the sasuction kana at ayaw na pumasok wag ng pilitin. Use sterile
secretions. (kung conscious ang pt. pwede mo siyang paubuhin technique in suctioning bawal hawakan ang tube)
para ma clear or ma-expectorate niya ang mga plema pero kung • Length of insertion:
unconscious si pt. hindi nila kayang dumura so kailangan mag a) Oropharyngeal
perform tayo ng suctioning) - Measure from tip of the nose to angle of mandible.
• Vomiting. (wag idikit sa pt. skin kase malalagyan ng m.o, used
• Desaturation on pulse oximetry. (normal oxygen saturation of marker to mark the tube)
the patient is 95-100% kapag nag 94 na kailangan na isuction) b) Nasopharyngeal
Conduct a risk assessment. - Adult: 16cm (5-6 inches)
• Patients with a recent head or neck injury. (dapat tamang pso. - Older children: 8 to 12cm (3 to 5 inches)
And pagiingat sa pt.) - Infants and young children: 4 to 8 cm (2 to 3 inches)
• Geriatric (65 and above) and pediatric patients, who have - Hyper oxygenate first prior suctioning.
more fragile airways. (Vulnerable client or fragile have fragile - (before suctioning client i-hyper oxygenate muna siya,
airways) meaning lagyan mo muna ng oxygen before suctioning
• People with cognitive or mental health conditions that make kase hihigop ka ng air in doing suctioning)
it more difficult for them to understand the procedure and • Suction Time:
cooperate. (We have to assess them para makipag cooperate - Each suction: 10-15 seconds
sila) - Interval or in-between suction: 30 sec- 1 min
• Patients with loose dental. (tingnan ung mga pt. na may - The maximum suction time should only be 15 seconds.
pustiso baka malunok nila or malaglag) - After suctioning, re-oxygenate the patient.
• Patients with a difficult airway o history of suctioning - Whole procedure: maximum of 5 minutes
complication Patients with bradycardia Patients with - Prolonged suctioning increases the risk of hypoxia and
hypoxia. (before conducting suctioning we need to interview other complications.
them) - (kung may naririnig kapang secretion at mag suction ka ulit
kailangan may interval time at maximum suction time is 15
Suction Catheter seconds only kpag sumobra kappa dun it may lead to
Types hypoxia or other complications, after suction re-oxygenate
1. Open tipped pt and re-suction if needed)

2. Whistle tipped
- Less irritating to respiratory tissues
- More effective for removing thick mucus plugs.
AKE 4 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

5. Open sterile basin and fill which approximately 100 ml of

sterile normal saline solution or water.
6. Open lubricant and squeeze small amount onto sterile catheter
package.
- Naso – water soluble lubricant
- Oro – sterile water or NSS
7. Apply gloves.
- Oropharyngeal – clean gloves
- Nasopharyngeal – sterile gloves
8. Pick up suction catheter with dominant hand without touching
non-sterile surface.
Procedure
9. Pick up connecting tubing of the suction apparatus with non-
1. Greet and identify the patient. (tandaan na dpt tama ang pt.
dominant had and connect it to the catheter.
mo, allow cliet to state his name but if he is unconscious look
10. Place tip of catheter into sterile basin and suction a small
at his ID bracelet or ID bun but if not ask the clients name)
amount of NSS. To check the patency of the tubing.
2. Ask patient's name and check pt's id bracelet Determine the
11. Apply suction by placing the thumb over the suction control.
patient need for suctioning: (meron kabang naririnig?
12. Measure the catheter to be inserted. Make a mark.
Restless ba? Etc.)
Note: tandaan na ung dulo ng suction tip ay naka connect sa suction
- audible secretions during respiration
machine at ung unsterile hand pwedeng humawak sa dulo ng suction
- adventitious breath sounds
tip kase mag iintermittent suctioning ka tapos mag apply ka sa butas
3. Explain the procedure – to allay anxiety and tell the
ng suction tube ng lubrivant para maka higop siya ng saline sol. look
importance of suctioning that this procedure will relieve
for the patency of the tube then put it to the lubricant and do
breathing problems.
intermittent suctioning to see the patency of the tube lastly, measure
4. Wash hands.
it to the pt. and make a mark
5. Provide client's privacy. (close the door, discuss to the
relatives what u are going to do) Oropharyngeal Suctioning
6. Check the nares (naso) and mouth (oro) using penlight. 1. Remove 02 mask if present but keep it near the patient’s
7. Position appropriately. 2. Insert catheter gently into patient’s mouth
Unconscious Patient 3. Do not apply suction during insertion – it may cause trauma in
Lateral position and the patient is facing you. mucous membrane. (mag sa suction ka lang kapag nasa loob na
- This position allows the tongue to fall forward not to obstruct ung tube pero kapag wla pa wag mo muna i-oon)
the catheter for insertion and facilitates drainage of secretion. 4. Suction intermittently moving around the mouth including
Conscious Patient pharynx and gum line.
Semi - Fowler’s Position with: 5. Advance the catheter about 4-6inch.
- Head turned to one side for oral suctioning. 6. Apply suction for only 5-10 second along one side of the mouth
- For nasal suctioning with the neck hyperextended. to prevent gagging.
- This position facilitates the insertion and prevent aspiration. 7. Slowly remove the catheter in a rotational manner

Prepare the Materials Suction Airway – Nasopharyngeal

1. Suction tube (size), gloves, towels, gauze pad, sterile water, • Lubricate distal 6-8cm (2-3 inches) of catheter tip with water-
goggles, emesis basin (calibrate suction machine based on soluble lubricant.
pressure needed) • Remove 02 device with on-dominant hand while using
2. Set up the suction gauge. dominant hand insert catheter into the nares.
- Prevent trauma to mucous membrane. • Have patient take a deep breath and gently insert the catheter
3. Place towel/ sterile drape on the chest. downward and advance to pharynx (ipa-inhale and exhale muna
ang patient).
• Apply intermittent suction 5-10 seconds.
• Non-sterile finger in the suction part.
• Sterile hand in the suction catheter.
• Alternate nares for repeat suctioning.
• Apply intermittent suction while slowly withdrawing catheter
in rotating between thumb and fore finger.

Suction Airway – Oropharyngeal

• Encourage the patient to cough and repeat suctioning if needed.
4. Open appropriate suction kit or catheter using sterile technique. Replace 02 mask.
Note: use one hand first because your other hand will touch or hold
unsterile materials
AKE 5 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

• Rinse catheter with saline or water from basin with suction until BOWEL ELIMINATION
cleared from secretions. Discussed by Prof. Rosanna P. Suva, MAN, RN
• Cleans the catheter by wiping odd thick secretions with gauze Factors that affect Bowel elimination
pad or rinse catheter and connecting tubing with normal saline - Regular elimination of bowel waste products is essential for
or water until cleared. normal body functioning.
• During suction, if the patient coughs, withdraw the catheter - Understanding normal elimination and factors that promote,
immediately flush catheter after each solution with sterile water. impede, or cause alteration in elimination help a nurse manage
• Assess for need to repeat suctioning procedure. patient’s elimination problem.
• Ask patient to deep breath and cough. - Alteration in bowel elimination are often early signs and
symptoms of problems in gastrointestinal system.
• Limit suctioning to 5 minutes.
Scientific Knowledge Base
• If using yankauer catheter, place in a clean, dry area for reuse
- The GI tract is the series of the hallow mucous membrane-lines
with suction turned off.
muscular organs.
• Disconnect the catheter form connecting tubing. - These organs absorb fluid and nutrients, prepare food for
• Turn off the suction machine. absorption, and use by body cells, and provide temporary
• Dispose catheter rolled inside the used gloves and discard in storage of feces.
appropriate receptacle. - The GI tract absorb high volume of fluids, making fluids and
• Remove towel and place in laundry or remove the drape and electrocyte balance a key function of the GI system.
discard. - The GI also receive secretions from the gallbladder and
• Reposition the patient to promote client’s comfort. pancreas.
• Do oral hygiene/ nasal hygiene.
The GI System
• Discard all soiled materials.
- Each individual has intake of food through the:
• Evaluate patient.
• Mouth
• VS: RR, HR, lung sounds to assess effectiveness of suctioning,
• Pharynx
level of anxiety, oxygen saturation.
• Esophagus
• Return the head of the bed.
• Stomach
• Obtain specimen if required (sputum trap)/gene expert.
• Small intestine
• Wash hands and document
• Large intestine
• Rectum
Complications Of Suctioning
• Anus
• Hypoxia
• Airway trauma
• Psychological trauma
• Pain
• Bradycardia
• Infection
• Ineffective Suctioning may cause STRESS.

Stomach
- The stomach performs 3 tasks:
1) Storage of swallowed food and liquid.
2) Mixing of food with digestive juice.
3) Regulates emptying of its contents into the small intestine.
- The stomach produces and secretes:
• Hydrochloric acids
• Mucus
• The enzyme pepsin
• Intrinsic factor

AKE 6 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

o Hydrochloric acids and pepsin – help digest the protein - The colon absorbs a large volume of water which up to 1.5
o Mucus – help protect the stomach, mucosa from acidity and the meters, a significant amount of sodium and chloride daily.
enzyme activity - The amount of water absorbs depends on the speed at which the
o Intrinsic factor – is for absorption of vitamin B12. colonic content moves.
o Chyme – mixing of food and Digestive juices. It is the partly - Normally the fecal matter becomes soft formed or semi-solid
fluid which passes from the stomach to the small intestine mass.
consisting of gastric juices and partly the digested food. - If the peristalsis is abnormally fast, there is less time to water to
Small Intestine be absorbed and the stool will be watery.
- It facilitates both digestion and absorption. - If the peristaltic contractions slow down water continues to be
- Measure of 6 meter or 20 feet long. absorbed and the hard mass stool forms resulting to constipation.
- Chyme comes into the small intestine as a liquid material and Anus
mixes with digestive enzymes. - The body expel feces and flatus from the rectum through the
- Three Section of Small Intestine: anus.
• Duodenum - The anal canal contains a rich supply of sensory nerves that
- Approximately 20 to 28 centimeters or 8 to 11 inches allow people to tell when there is solid, liquid, or gas that needs
long. to be expelled and aids in maintaining continence.
- Continues to process fluids from the stomach. - Note:
• Jejunum • Normally defecation is painless, resulting in passage of soft,
- Approximately 2.5 meter or 8 feet long. formed stool.
- Absorbs carbohydrates and protein. • Straining while having a bowel movement indicates that
• Ileum the patient may need changes in diet (ibig sabihin baka
- Approximately 3.7 meters or 12 feet long. kulang sya ng fiber) or should increase the fluid intake
- Absorbs water, fats, and the bile salts and absorbs (dagdagan ang pag inom ng water or damihan ang pagkain
certain vitamins and irons. ng gulay or prutas) or that there is an underlying disorder
o Duodenum & Jejunum in GI function.
- Absorbs most nutrients and electrolytes from small
intestine. Factors Influencing Bowel Elimination
- Digestive enzymes and bile enter the small intestine Age
from pancreas and the liver to further breakdown • Infants
nutrients into usable by the body. - have a smaller stomach capacity, less secretion of digestive
NOTE: enzymes, and more rapid intestinal peristalsis (mas
- The digestive process is greatly altered when small intestine madalas mag defecate kaysa sa adults).
function is impaired. • Adolescents
- Condition such as inflammation, infection surgical resection, or - experience rapid growth and increase metabolic rate.
obstruction disrupt peristalsis, reduce absorption, or block the • Older Adults
passage of fluid, resulting in electrocyte and nutrients - may have decreased chewing ability. Partially chewed food
deficiencies. is not digested as easily. Peristalsis declines. This impairs
Large Intestine a.k.a Colon (Lower GI Tract) absorption by the intestinal mucosa.
- Length is 1.5 to 1.8 meters (5-6 feet) - Muscle tone in the perineal floor and anal sphincter
- Primary organ of bowel elimination weakens which sometime causes difficulty in controlling
- Six Division of Large Intestine: defecation.
1) Cecum Diet
2) Ascending colon • Regular daily food intake helps maintain a regular pattern of
3) Transverse colon peristalsis in the colon.
4) Descending colon • Fiber in the diet provides the bulk in the fecal material.
5) Sigmoid colon • Bulk-forming foods such as whole grains, fresh fruits, and
6) Rectum vegetables help remove the fats and waste products from the
- The digestive fluid enters the large intestine by waves of body with more efficiency.
peristalsis through the ileocecal valve. • Some of these foods such as cabbage, broccoli or beans may
- Ileocecal valve – a circular muscle layer that prevents also produce gas, which distends the intestinal walls and
regurgitation back into the small intestine increases colonic motility (observe a balance diet, always
- The muscular tissue of the colon allows to accommodate and include vegetables, fruits, and meat to help the fecal material to
eliminate large quantities of waste and gases or the flatus be expelled smoothly).
- Functions of Large Intestine: Fluid Intake
1) Absorption • A fluid intake of 3L per day for men/ 2.2L per day for women
2) Secretion is recommended. (If it is not contraindicated – something (such
3) Elimination as a symptom or condition) that makes a particular treatment or
procedure inadvisable.)
AKE 7 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

• Reduced fluid and fiber intake slows passage of food through Pregnancy
the intestine and results in hardening of stool contents, causing • As the pregnancy advances, the size of the fetus increases, and
constipation. (an adequate fluid intake such as vomiting affect pressure is exerted on the rectum.
the character of the feces) • A temporary obstruction created by the fetus impairs passage of
Physical Activity feces.
• Physical activity promotes peristalsis, whereas immobilization • Slowing of peristalsis during the third trimester often leads to
depresses it constipation.
• Encourage early ambulation as illness begins to resolve or as • A pregnant woman’s frequent straining defecation or delivery
soon as possible after surgery to promote maintenance of may result in formation of hemorrhoids (almuranas).
peristalsis and normal elimination Medications
• Weakened abdominal and pelvic floor muscle impair the ability • Many medications prescribed for acute and chronic conditions
to increase intra-abdominal pressure and control the external have secondary effect on patient’s bowel elimination patters.
sphincter • For example:
• Muscle tone sometimes weakened or loss of a result of long- - Opioid analgesics – slows peristalsis and contractions,
term illness, spinal cord injury, or neurological diseases that often resulting in constipation.
impaired nerve transmission - Antibiotics – decreases intestinal bacterial flora, often
• As a result of these changes the abdominal pelvic floor muscle resulting in diarrhea.
there is an increased risk of constipation (galaw galaw din mga • It is important for the nurse and client to be aware to this
mare! Wag puro higa at upo HAHA) possible side effects and use appropriate measure to promote
Psychological Factors healthy bowel elimination. Some indications are used primarily
• Prolonged emotional stress impairs the function of the almost for the action on the bowel, and we promote defecations such
body system as laxatives (to soften stools), Cathartics (promote peristalsis).
• During emotional stress, the digestive process is accelerated, • If laxative is needed from regular evacuation from the rectum a
and peristalsis is increased fiber laxative is the first type to be used. Patients need to avoid
• Side effects of increased peristalsis include diarrhea and regular use of sinemet laxative bcs the intestines often becomes
gaseous distention dependent on it.
• If a person becomes depressed, the autonomic nervous system Diagnostic Test
may slow impulses that decreased peristalsis, resulting in • Involving visualization of GI structures often a require a
constipation prescribes bowel preparation (e.g., laxatives and/or enemas,
• Several disease GI tracts are elaborated by stress including labatiba in tagalog) to ensure that the bowel is empty.
ulcerative colitis, irritable bowel syndrome, certain gastric and • Usually, patients cannot eat or drink several hours before
duodenal ulcers. examination (NPO nothing per orem) such as endoscopy,
Personal Habits colonoscopy, or other testing that require visualization of the GI
• Personal elimination habits influence bowel function. tract. (sisilipin lower or upper GI)
• Individuals need to recognize the best time for elimination. • Following the diagnostic procedures changes in elimination
o Mas convenient ang tao mag defecate sa sariling banyo. such as increased gas or loose stool often occur until the pt.
o A busy works schedules sometimes prevent the individual resume normal eating pattern.
from responding appropriately to the urge to defecate.
Common Bowel Elimination Problem
o Disrupting personal habits and causing possible alteration
Constipation
such as constipation.
- Is a symptom, not a disease, and there are many possible causes.
Position During Defecation
- Improper diet, reduced fluid intake, lack of exercise, and certain
• Squatting is the normal position during defecation.
medications.
• Lean forward, exert intraabdominal pressure, and contract the
- Signs of constipation include infrequent bowel movement (less
gluteal muscles.
than 3 per week) and hard, dry stools that are difficult to pass.
• For immobilized patient in bed, place the patient in supine (If - When intestinal motility slows, the fecal mass becomes expose
pwede). If not – a patient’s condition permits, raise the head of to the intestinal wall over time and most of the fecal water
the bed to help him or her to a more normal sitting position on content is absorbed. Few waters are left to soften and lubricate
a bedpan, enhancing the ability to defecate. the stool. Passage of a dry and hard stools often causes rectal
Pain pain or constipation.
• Normally the act of defecation is painless - Constipation is a sig. source of discomfort assess the need for
• However, several conditions such as hemorrhoids; rectal intervention before defecation becomes painful or the stool is
surgery; anal fissures, which are painful linear splits in the impacted.
perineal area; and abdominal surgery result in discomfort Impaction
- In these instances, the patient often suppresses the urge to - Fecal impaction results when a patient has unrelieved
defecate to avoid pain, contributing to the development of constipation and unable to expel the hardened feces retained in
constipation the rectum.

AKE 8 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

- In case of severe impaction, the mass extends up into the Bowel Diversion
sigmoid colon. - Certain diseases or surgical alteration make a normal passage of
• If not resolved or removed, severe impaction results in an intestinal contents throughout a small and large intestine
intestinal obstruction. difficult or inadvisable. When these conditions are present, a
- Obvious sign of impaction is the inability to pass a stool for temporary or permanent opening (stoma) is surgically created
several days, despite the repeated urge to defecate. by bringing a portion of the intestine out through the abdominal
- Patient who are debilitated, confuse or unconscious are most at wall.
risk for impaction. They are dehydrated or too weak or unaware - These surgical openings are called an ileostomy or colostomy,
for the need to defecate, and the stools will become too hard and depending on which part of the intestinal tract is used to create
dry to pass. the stoma.
- If you suspect of impaction, gently perform a digital Ostomies
examination of rectum, and palpate for impacted stool. - The location of ostomy determines stool consistency. (kung
Diarrhea saan naka locate ang kanyang ostomy yan ang mag dedetermine
- An increase in the number of stools and the passage of liquid, kung yan ay formed or liquid)
unformed feces. (Watery nag kakaroon ng LBM). - A person with sigmoid colostomy ibig sabihin un ay nasa
- It is associated with disorders affecting digestion, absorption, sigmoid colon and will have a more formed stool.
and secretion in the GI tract. Transverse Colostomy
- Intestinal contents pass through the small intestine and large - Stool will be thick liquid to soft consistency.
intestine too quickly to allow for the usual absorption of fluid - Kapag ang ostomy naman ay nasa transverse colon.
and nutrients.
- Irritation within the colon results it increase mucus secretion. Diagnostic Test – visualization of the bowel
As a result, feces become watery, and patient often has Colonoscopy
difficulty controlling to urge to defecate. - An exam used to detect changes or abnormalities in the large
- Excess loss of colonic fluid results to dehydration with fluids intestine.
and electrolytes or acid base imbalance if the fluid is not - The large colon and sometimes a portion of the lower small
replaced. bowel are visualized and may be biopsied
- Nursing care: is that the cause needs to determine and treated.
Provide good perineal care after each stool and apply moisture
barrier if indicated. Properly wash anus and perineal area. Care
giver should use good hand hygiene.
Incontinence
- The ability to control passage of feces and gas from the anus
- Incontinence harms a patient’s body image. The embarrassment
of soiling clothes often leads to social isolation. (hindi
macontrol ang pagtae so nagkakaroon ng poop ang clothes)
- Physical conditions that impair anal sphincter function or large- Sigmoidoscopies
volume liquid stools cause incontinence - The sigmoid colon and rectum are visualized and may be
Flatulence biopsied. (same procedure but up to the descending colon)
- Also known as Farting. - This procedure usually under anesthesia.
- A buildup of gas in the digestive system that can lead to
abdominal discomfort. (Fullness, pain, cramping)
- Normally intestinal gas escapes through the mouth (belching)
or the anus (passing the flatus)
Hemorrhoids
- Are dilated, engorged veins in the lining of the rectum. They are
either external or internal
- External hemorrhoids – are clearly visible as protrusions of skin.
- Internal hemorrhoids – occur in the anal canal and may be
inflamed or distended.
- Increase venous pressure resulting from straining at defecation,
pregnancy, heart failure and chronic liver illnesses such as
congestive factors can cause hemorrhoids. Assessment
- Nursing care: when cleansing the perineal area, moist wipes is • Obtain – obtain diet and medication history
more comfortable alcohol-free wipes. Application of prescribed
• Identify – identify signs and symptoms associated with altered
ointments and creams maybe used but it should always be
elimination patterns
prescribed.
• Determine – impact of underlying illness activity patterns, and
diagnostic bowel elimination

AKE 9 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

Note: Interview client and obtain the nursing history. Determination Types of Enema
of the usual elimination pattern ito ung gaano kadalas sa isang araw - According to purpose:
or anong oras ang kanyang pag defecate, sasabihin ng client ang 1. Cleansing enema – to remove feces
itsura ng kanyang stool, identify routines like exercise, food intake, a) High enema – cleans as mush of the colon, you must
having changes in appetite, daily fluid intake, medication, consume 1000 ml of solution, 12-18 inches.
socialization. b) Low enema – rectum and sigmoid colon, 500 ml of
solution, 12 inches.
Patient Teaching 2. Carminative enema – to expel flatus 60-80ml.
• Encourage the patient to set aside time to defecate 3. Retention enema – introduces OIL (mineral oil, olive oil,
- Hanggat maaari ung pattern of elimination or pagpunta sa cottonseed or VCO) or medication into the rectum and the
c.r ay parepareho everyday kung umaga yan after taking sigmoid colon, at least 30 minutes.
bfast tumatae or Sometimes after a meal works the best
• If not contraindicated or restricted, encourage the client to drink Types of solution for Cleansing Enema
plenty of fluids and to consume a diet high fiber to prevent Hypertonic
constipation • Constituents: 90-120mL of solution e.g., sodium phosphate.
- Exercise (Galaw galaw pag may time! Whoo HAHAHA) • Action: draws water in the colon. (nag lalagay ng tubig sa
colon)
ENEMA (Labatiba) • Time to effect: 5-10 mins (no. of min. can vary to the client if
Discussed by Prof. Rosanna P. Suva, MAN, RN hindi na niya kaya stop it)
- An enema is solution introduced into the rectum and large
• Adverse effect: retention of sodium.
intestine.
Hypotonic
- Purposes:
• Constituents: 500-1000mL of tap water
• Relieve constipation, fecal impaction, and flatulence (utot).
• Action: distends colon, stimulates peristalsis, and softens feces.
• To soften hard fecal matter.
• Time to effect: 15-20 mins
• Administer medication.
• Adverse effect: fluid and electrolyte imbalance, water
• Prepare for diagnostic procedures and surgery.
intoxication.
Note: Colonoscopy is the visualization of the lower GI tract.
Isotonic
Endoscopy is the visualization of the upper GI tract.
• Constituents: 500-1000 ml of normal saline (9ml of salt to
Normal Characteristics of Stool 100ml water)
- Color: • Action: distends colon, stimulates peristalsis, softens feces,
• Normal – brown • Time to effect: 15-20mins
• Abnormal: • Adverse effect: possible sodium retention
o Melena – black tarry stool (in upper GI) Soap suds
o Hematochezia – stool with fresh blood (in lower GI) • Constituents: 500-1000ml (4-8tbps of mild soap or castile soap
o Steatorrhea – stool with excessive fats. to 1000 ml water)
- Odor – aromatic • Action: irritates the mucosa, distends the colon.
- Consistency – forms, soft, semi-solid, and moist • Time to effect: 10-15 mins
- Shape – cylindrical • Adverse effect: irritates and may damage the mucosa.

Materials
• Waterproof pad or rubber sheet
• IV pole
• Enema can or bag
• Rectal tube
• Water soluble lubricant
• Bedpan
• Towel
• Clean gloves
• Clamp

Contraindications
- Appendix are inflamed.
- Diverticulitis – infection or inflammation of pouches that can
form in your intestines. Pouches are called diverticula.
- Pregnant mothers on their third trimester.
- Clients with cardiac problem.

AKE 10 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

Procedure - Urine is the waste product coming from our body.

1. Verify the doctors order of administering enema to the client - Once the urine is formed in the kidneys, it moves through the
2. Prepares the needed materials and solutions collecting ducts into calyces of the renal pelvis and from there
3. Performs handwashing before and after the procedure into the ureters.
4. Identifies patient and explain the procedure - The urinary bladder is a hollow muscular organ that serves as a
5. Provides privacy to the client throughout the procedure reservoir for urine and as the organ of excretion.
6. Places the waterproof pad under the client’s buttocks - The urethra extends from the bladder to the urinary meatus.
7. Positions the client in the left Sim’s position - Nephrons is the functional units of the kidney.
8. Prepares the irrigation can, tubing and solutions hangs the - Acc. To national kidney foundation normal GFR 60-90ml/min.
enema cannon the IV stand about 18-24 inches above the level - Older people have lower GFR because of age.
of the patient’s rectum - In adult normal GFR is more than 90 and it declines with age.
9. Lubricates the rectal tube and allows a small amount of solution - Functional units of kidneys:
to flow through the tubing into the bedpan (para maiwasan ang • Glomerular filtration rate = 120mL/ min
hangin sa tube and to check patency, dpt iprime muna tubing • Kidney form 0.5 to 1 mL/ min = 60 mL/hr
lagyan small amt of sol. ganern) • 1500mL/ day of urine
10. Don’s glove and lift the upper buttock of the patient o Adult: 60-120 mL/hr; 720-1440 mL/day
11. Insert the tube slowly and smoothly around 3-4 inches into the o Child 300-1500 mL/day
patient’s anus - Habang tumatanda, bumababa un production ng GFR
12. Administer the solution slowly. If the pt complains of fullness
or pain, use clamp to stop the flow for 30 seconds, and then
restart the flow at a slower rate
13. Closes the clamp after all the solutions has been administered
or when the client cannot hold anymore and wants to defecate
14. Removes the rectal tube and places it in a disposable towel
15. Encourages the patient to retain the enema solution
16. Assist the patient with the necessary cleansing
17. Makes the patient comfortable
18. After care of the unit and materials used
19. Document the procedure done, record the kind and amount of
stool and solution used and the character of the return flow.
Remember:
• To reduce defecation, enema solutions must cause Detention
and Irritation in the intestinal mucosa.
• The client must be placed in left sim’s position. Characteristics of Urine
• Minimum heigh of the Enema can is 12” above the rectum • Odor: aromatic – upon voiding
and a maximum height of 24” above the rectum.
• pH: slightly acidic (4.6-8; average 6) (hydrogen ion
• Insert rectal tube about 3-4 inches for adult clients concentration of urine can vary more than 1,000 folds from a
• Abdominal cramps may indicate giving of too much solution. normal law of 4. 5 to maximum of 8. Diet can influence pH like
meats lower the pH whereas citrus fruits, vegetables and dairy
URINARY CATHETERIZATION products raises the pH level. High or low pH can lead to
Discussed by Prof. Vilma R. Miguel disorders such as development of kidney stones or
Urinary system Anatomy osteomalacia)
- Consist of organs that produce an excrete urine from the body. • specific gravity: 1.010 – 1.025 (SG- is the weight of a liquid
- Components of urinary system include the kidneys, ureters, compared to pure water. Any solute added to water will increase
bladder, and urethra. its SG. In other term SG is Measure of quantity of solutes for
- The paired kidneys are situated on either side of the spinal volume of a solution and traditionally easier to measure than
column, behind the peritoneal cavity. They are primary osmolarity. Urine will always have SG than pure water)
regulators of fluid and acid base balance in the body.
• Color of urine: amber/ straw
- Kidneys are responsible for removing waste products, drugs,
• Transparency of urine: clear
and excess fluid from the body.
• Characteristics of urine changes depending on the influences
- Blood enters the kidney and goes to the millions of the
such as water intake, exercise and env. temp, nut. intake etc.
functional units to filter the blood. These units are called
nephrons consist of glomerulus and tubule. Blood is then • Color and odor are descriptors of hydration state ex. Few
filtered in the glomerulus, and remaining fluid goes to the tubule exercise and sweat urine will turn darker and produce slight
and has water or chemicals either added or removed depending odor even when we drink plenty of water. Athletes are advised
on requirement. It requires 500-1000mL of water a day as a to consume water until urine is clear this is good advice
minimum to support this elimination processes. however it takes time for the kidneys to process body fluids and
store in the bladder another way of looking at this is that the
AKE 11 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

quality of the urine produced is an average over the time it takes Urine components
to make the urine. In producing clear urine it may take only a • Normal urine consists of 96% water and 4% solutes.
few minutes if you are drinking a lot of water or several hours • Organic solutes include urea, ammonia, creatinine and uric
if you are working outside and not drinking much. acid.
• Urea is the chief organic solute. Sodium chloride is the most
abundant inorganic salt.

Urination
- Micturition, voiding and urination all refer to the process of
emptying the urinary bladder.
- Urine is a liquid by product of the body secreted by the kidneys
through a process called urination/ voiding/ micturition.
Factors affecting voiding:
• Fluid and food intake. (marami intake marami output)
• Medications (taking vit. Can make urine yellowish)
• Pathologic conditions (like diabetes)
• Surgical and diagnostic procedures
• Psychosocial factors (kapag stress nakakawiwi)
• Growth and development
• Muscle tone and activity
Altered urine production:
• Polyuria: 100 mL/hr or 2500 mL/day (other term: diuresis.
There is a large vol. of urine aleast 3,000 mL)
• Oliguria: < 30 mL/hr or < 500 mL/ 24hr (urine output that is
less than 400 mL/ 24 hr or less than 17 mL/ hr in adults)
• Anuria: 0 -10 mL/ hr (a- absence. Defined as urine output that
is less than 100 mL/ hr of 0 mL in 12 hrs)
• There are several conditions can cause abnormal components to
be excreted in urine or present as abnormal characteristics of
urine they are mostly referred to as suffixes urea or uria
• Normal urine 1,000-1,500mL
Altered urine elimination:
• Frequency – voiding at frequent intervals that is more often
than usual.
• Nocturia – increase frequency at night that is not a result of an
increased fluid intake. (voiding of two or more than two times
per night)
• Urgency – feeling that the person must void immediately.
• Dysuria – painful urination. (difficulty and pain in urinating,
urinary tract infection is the cause of this, and is common in
women bcs our ureter is shorter than male. In male the common
is urethritis or the inflammation of the urethra and certain
prostate conditions are frequent causes of painful urination)
• Hesitancy – delay in initiating voiding. urinary hesitancy
(decrease in force of extreme in urine and is common seen in pt.
with large prostate in male and UTI in female)
• Enuresis – repeated involuntary urination in children at night.
• Pollakiuria – frequent, scanty urination. (frequent urination at
day time 3 to 4 times/hr. also known as benign idiopathic
urinary frequency, refers to frequent day time urination in
children 3-5 years old, teenager with no specific cause)
• Urinary Incontinence – considered as a symptom, not a
disease. (loss of bladder control like when sneezing or coughing
there is leakage)
a) Functional – involuntrary, unpredictable passage of
urine.

AKE 12 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

b) Reflex, (spastic bladder) this happens when the bladder • Recommend good handwashing and proper perineal care.
fills with urine and an involuntary reflex causes it to (reduces skin irritation and risk of ascending infection)
contract in an effort to empty. • Pour warm water over perineum or have the client sit in a warm
c) Stress – leakage of <50 mL urine due to intra-abdominal bath to promote muscle relaxation. (begin bladder retraining)
pressure • Apply hot-water bottle to the lower abdomen.
d) Total – continuous, unpredictable • Turn on running water within hearing distance. (para mainduce
e) Urge – an occasional sudden desire to urinate with large pagwiwi)
volume urine loss; can also exist without incontinence. • Timing
• Urinary retention with overflow – dribbling incontinence that • Relieve physical or emotional discomfort. (kapag dnaka relax
results when the bladder is greatly distended with urine because dna kakawiwi)
of an obstruction. (you can empty your bladder, you may need • Assist clients to have the urge to void immediately. (kapag
to urinate but have troubled starting urinate and completely nawiwi si pt. paihiin na)
emptying the bladder) more common in male than women.
• Offer toileting assistance at usual times of voiding.
• Neurogenic bladder – describes any voiding problem related • Positioning.
to neurologic dysfunction. (may problema sa spinal cord,
• Dangle fingers to warm water
symptoms: dribbling stream when urinating , inability to fully
• Crede’s Manuever: applying pressure to suprapubic area.
empty the bladder, there is straining during urination or pinipilit
(should be used with cautions bcs it may precipitate autonomic
mag wiwi, loss of bladder control, increase urinary tract
dysreflexia)
infection, leaking urine, difficult det. when bladder is full)
Managing UI
• Urinary retention – accumulation of urine in the bladder as
Continence (bladder) training
much as 3L with associated inability of the bladder to empty
- Bladder training – requires that the client postpone voiding,
itself.
resist or inhibit the sensation urgency, and void according
to a timetable rather than according to the urge to void. The
Assessment
goal is to lengthen the intervals between urination to
Nursing history:
correct the clients habit of frequent urination.
a) Data about voiding patterns and habits, any problems in
- Habit training – also referred to as timed voiding or
voiding, about past or present problems involving the
schedules toileting. There is no attempts to motivate the
urinary system. (hematuria- blood in the urine)
client to delay voiding if the urge occurs. Prompt voiding
b) Data about any problems that may affect urination.
supplements the habit training by encouraging the client to
Possible diagnosis use the toilet and reminding the client when to void.
• Urinary incontinence - Pelvic muscle exercise (PME) – referred to as perineal
- Functional incontinence – reflex incontinence – stress muscle tightening or Kegel’s exercise. Strengthen
incontinence – total incontinence – urge incontinence. pubococcygeal muscles can increase the incontinent
• Impaired/ altered urinary elimination. females ability to start and stop the stream of urine.
• Urinary retention Managing urinary retention
- Urinary catheterization (last resort)
• High risk for infection
• Self-esteem disturbance (like stress incontinence na may Catheterization
leakage tapos naaamoy na sarili so bumababa self-confidence - It is the insertion of a hollow tube through the urethra into the
nila) bladder to urethra to drain urine. (we have latex and silicon.
• High risk for impaired skin integrity (like diabetic pt. Allows to drain the bladder for collection it also may be used to
lumalabas wiwi sa balat) inject liquids that is used for treatment or diagnosis for bladder
• Social isolation (bcs of embarrassment they avoid others) conditions. Nurse or doc. performs the procedure)
• Self-care deficit: toileting - Self-catheterization is applied just like others kukuha lang ng
Note: problem pa lang ang ibinibigay dito wala pa yung cause and urine sample straight catheterization ang gagamitin but with doc.
symptoms order)
- Maybe used in place for long periods of time.
Nursing interventions - Ex. Of chronic catheterization is the indwelling catheter for 3
Note: in maintaining urinary elimination we have to do the weeks to 1mos. We also have intermittent catheterization or
following interventions single used catheter can be removed once we get the urine.
• Promoting normal fluid intake (we know that sufficient - Purposes:
hydration promotes urinary elimination and it aids in preventing • To relive discomfort due to bladder distention or provide
infections) gradual decompression of distended bladder.
• Maintaining normal voiding habits (huwag mag pigil) • To assess the amount of residual urine if the bladder
• Relaxation empties incompletely. (residual urine- kapag nakaihi na
• Allow client sufficient time to avoid. (huwag madaliin si client) tska i-kacatheter para Makita kung gaano kadami ung
natira sa bladder niya)

AKE 13 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

• To obtain urine specimen

• To empty the bladder completely prior to surgery.
• To facilitate accurate measurement of urinary output for
critically ill clients whose output needs to be monitored
hourly.
• To provide for intermittent or continuous bladder drainage
and irrigation
• To prevent urine from contacting an incision after perineal
surgery. (kase pwedeng ung urine mag contaminate sa
incision sa site kay kinacatheter siya)
• To manage incontinence when other measure has failed.
Types of catheters
According to the number of lumens:
• Straight catheter (non-retention)
- Single lumen tube
• Two-way Catheter (foley, Retention) Materials
- Double lumen catheter • Latex
• Three-way Catheter - Can be used for 2-3 weeks.
- Triple lumen catheter used in bladder irrigation. - Assess client for latex-allergy.
- Bakit tatlo? Kasi andyan un pag iinflatan ng balloon • Silastic (pure silicone or silicone-coated)
para hindi matanggal un catheter once na pumasok - For long term use (2-3months)
doon sa bladder. Pangalawa – connection ng tubing - Expensive
para doon sa drainage. Other one na lumen, - Silicone is fast becoming the material of choice as critics
paglalagyan ng mga irrigating solutions. claim the production, use and disposal of PVC materials
Note: create toxic chemicals. Silicone is also clear, meaning
− The colored one is the inflation of the patients and medical providers can see the urine easily. In
balloon. terms of flexibility, it sits somewhere between PVC and
− Nasa gitna process for cytolysis’ latex. As silicone is totally free of latex, it is also a
preferable choice for those with a latex allergy. The
− May buong opening or pangatlo un ung
material is also smooth, and some brands even have an
connection ng urine bag
antibacterial coating applied.
• Silver allov (Polyvinyl chloride - PVC)
- Can be used for 4-6weeks soften at body temperature and
more.
- Comfortable use.
- Wala ng ganito ngayon ang kapalit na nito ay PVC
• Polyvinyl chloride - PVC
- synthetic plastic polymer or are the translucent, they allow
to see the color of the urine easily.
- also firm, but fairly flexible for easy insertion. As PVC
materials are usually (but not always) latex-free, they are
preferred by those who have a latex allergy.
- Among the three materials, latex is the most flexible due to
the material being thermo-sensitive, meaning that it will
warm up to the surrounding temperature and, as such,
become more flexible in a 2000 study by the American
Family Physician organization.

Possible complications
• Inability to catheterize.
• Urethral injury – by inflating balloon before ensuring correct
catheter placement in the bladder.
• Infection
• Psychological trauma
• Hemorrhage – trauma sustained during insertion or balloon
inflation. (dapat mag advance ng 2 inches paar hindi mag
karoon ng trauma sa trigan spinchter ni bladder)

AKE 14 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

• False passage – by injury to the urethra; wall during insertion.

• Urethral strictures – following damage to the urethra – long
term problem.
• Paraphimosis due to failure to return foreskin to normal posit
following catheter insertion. (para sa mga kalalakihan na hindi
na bumabalik ung mga fore skin ng kanilang penis)

Complications of Catheterization
• The main complications are tissue trauma and infection. After
48 hours of catheterization, most catheters are colonized with
bacteria, thus leading to possible bacteriuria and its
complications. Catheters can also cause renal inflammation,
nephron-cysto-lithiasis, and pyelonephritis if left in for
prolonged periods.
• The most common short term complications are inability to
insert catheter, and causation of tissue trauma during the
insertion. Special considerations
• The alternatives to urethral catheterization include suprapubic 1. Invasive procedure
catheterization and external condom catheters for longer 2. Strict asepsis
durations. 3. Perineal care
4. Size of catheter
a) Male: French 16-18 (Fr. 8-10 Child, Fr. 5-8 Infant)
b) Female: French 12-14
5. Position:
a) Male – frog-like position or supine;
b) Female – dorsal recumbent.
6. Urinary meatus
a) Male – sa mismong opening na nung penis
b) Female – sa female is under the clitoris
Suprapubic Tube Placement 7. Length of catheter insertion:
- most indication is urinary retention when urethral a) Male: 6-9 inches
catheterization is not feasible. b) Female: 3-4 inches
- This includes benign prostatic hypertrophy or lumaki
prostate ng mga kalalakihan, may false urethral passages,
morbid obesity, urethral strictures, bladder neck
contracture and genital malignancy
- Urogenital trauma causing urethral destruction and severe
damage are common indication
- Suprapubic tube placement for the long term diversion of
the urine in cases of neurogenic bladder is also sometimes
indicated.

Urinary elimination
• Condom catheter: - Retract the labia minora.
- Can be used by men with incontinence. (lalo na sa may mga - Front-back isang deretsyo lang.
dementia) - Above symphysis to avoid irritation or pagkiskis ng
- There is no tube placed inside the penis. Instead, a condom- pinoscrotal junction.
like device is placed over the penis. - Inner thigh to avoid trigans spincter. Mostly appropriate in the
- A tube leads from this device to a drainage bag. The left inner thigh kase mas madalas ngagamit ang kanan.
condom catheter must be changed every day. - Sterile drapes ipangtatakip sa sterile field ang naka exposed
- Considerations: proper way to apply condom catheter lang is the genitals.
a) Frequency of checking. (ang tinitinganan dito is kung Materials
paano ikabit dahil pag masyadong masikip baka may • Catheter
edema) • Betadine
b) Frequency of changing. • Urine bag
c) Attach to where part of the body? • KY jelly (lubricant before insert catheter)
- How to use external condom catheters: • Syringe (10mL)
• Sterile water (do not use saline bcs it may crystalize)
AKE 15 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

• Forceps Male Catheterization

• Sterile cotton balls 1. Assess the patient’s need for catheterization and refer patient to
• Kidney basin (as receptacle) the doctor.
• Sterile drape 2. Verify the doctor’s order for catheterization.
• Tape to secure the catheter. (micropore tape) 3. Prepare the necessary materials.
4. Perform hand washing.
5. Identifies the patient and explains the procedure.
6. Positions the patient properly and ensures patient’s privacy.
7. Applies aseptic technique during the entire procedure.
8. Opens the catheterization kit aseptically.
9. Add materials to the kit ensuring sterility the whole time.
10. Dons first glove and fills the syringe with distilled water.
11. Dons second glove and applies sterile drapes to the patient.
12. Grabs the penis firmly behind the glans with the non-dominant
hand and retracts the foreskin of the uncircumcised male.
13. With the dominant hand, uses sterile forcep to pick up swabs.
Cleans first from the meatus and then wipe the tissue
surrounding the meatus in circular motion using a new swab for
each stroke.
14. Picks up the catheter and places the drainage end of the catheter
Procedures
in the urine receptacle using uncontaminated hand.
Female catheterization
15. Lubricates the insertion end or tip of the catheter.
1. Assess the patient’s need for catheterization and refer patient to
16. Lifts the penis to a position at 90 degrees angle and inserts the
the doctor.
catheter until urine flows.
2. Verify the doctors order for catheterization.
17. Connects the catheter to the urine bag and ensures that emptying
3. Prepare the necessary materials.
base of the bag is closed.
4. Perform hand washing.
18. Inflates the balloon by injecting 5-10cc of distilled water and
5. Identifies the patient and explains the procedure.
checks the anchor.
6. Positions the patient properly and ensures patients privacy.
19. Tapes the catheter with non-allergenic tape at the lower
7. Applies aseptic technique during the entire procedure.
abdomen of the patient.
8. Opens the catheterization kit aseptically.
20. Removes drapes and makes the patient comfortable.
9. Add materials to the kit ensuring sterility the whole time.
21. Disposes soiled materials properly.
10. Dons first glove and fills the syringe with distilled water.
22. Accurately records the procedure done.
11. Dons second glove applies sterile drapes to patient.
Reminders:
12. With the non-dominant hand, separates the labia minora with
the thumb and index finger. Never removes fingers until • Left left, right right. Left-handed nurse must stand on the left
catheter is inserted. side of the patient.
13. With the dominant hand, uses sterile forceps to pick up swabs. • Grasp catheter 2-3 inches
Cleans first from the meatus downward and then on either side • As nurse inserts catheter – client inhales deeply and exhales
using a new swab for each stroke. • Sterile water in balloon not NSS
14. Picks up the catheter and places the drainage end of the catheter • If urine flows, do not stop, insert 2 inches further into the
in the urine receptacle using uncontaminated hand. bladder.
15. Lubricates the insertion end or tip of the catheter. • What to do when a urinary catheter accidentally inserted to
16. Gently inserts the catheter in the direction of the urethra until vagina? – do not remove the catheter in vagina para may
urine flows. (tell the pt. to hinga po ng malalim or relax) plaatandaan na meron na sa vagina, you have to acquire one
17. Connects the catheter to the urine bag and ensures that emptying ng panibago, mag insert ulit. Maintain aseptic technique.
base of the bag is closed. Method to see urinary meatus in female is paubuhin ng bagya.
18. Inflates the balloon by injecting 5-10cc of distilled water and
checks the anchor. (before u inject the distilled water, mag
advance ng 1-2 inches)
19. Tapes the catheter with non-allergenic tape at the thigh of the
patient.
20. Removes drapes and makes the patient comfortable.
21. Disposes soiled materials properly.
22. Accurately records the procedure done. (record the time anong
oras natapos? Natolerate ba ni client ung procedure?
Characteristic ng output sa urine?)

AKE 16 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

CONCEPTS AND PRINCIPLES OR PARTNERSHIP, - As defined by ANA (American Nurses Association), (1992)
COLLABORATION, TEAMWORK refers to the collegial working relationship with another health
Discussed by Prof. Norilyn Limchanco care provider in the provision of patient care.
Terminologies - Interprofessional and interprofessional process in which nurses
Collaborative Health Care comes together to form a team to solve a patient care and to
- A comprehensive care provided to the clients through the provide a comprehensive service and to deliver the highest
collaborative efforts and expertise of each member of the health quality of care to our patient and to their families.
team. - There is an impact of collaborative relationship to patient, team
- It is defined as health care professionals assuming of member and organization.
complementary roles and cooperative lead working together • Patient – improve the care transition
through sharing responsibility, problem solving and making • Team member – improve collaborative relationship
decisions to formulate and caring out plan for patients care. • Organization – improves outcomes
- It is also involved in professional coordinating their care with
another team.
- to avoid redundancy, deficits, and errors na karaniwang
naeencounter sa duty
Partnership
- A collaborative relationship between two or more parties based
on trust, equality, and mutual understanding for the
achievement of a specified goal.
- Brings together 2 or more party, so that they can benefit from
the expertise, resources, and power of each team.
- Goal: to enhance efficiency and quality of the services.
Twinning
- Coined by the Tropical Health Education Trust (THET)
- "The establishment of a formal link between a specified
department/ institution and a corresponding
department/institution., to facilitate an accurate assessment of
need and consequently to ensure effective mutual collaboration
at all levels."
- This diagram is an example of a member of the healthcare team
- This is a development model that uses institution partnership
individualize care for the client based on their expertise of their
and peer relationship to benefits both sides. It emphasizes the
own discipline
professional exchanges and monitoring for the effectiveness of
- We can notice in this diagram that there are different healthcare
sharing information, knowledge, and technologies.
teams and each team have care of plan to the patient
- Ex. There are times na nag kaka conflict or overlapping sa care
plan provided doon na papasok ang teamwork to solve the
problem.
- Hindi rin naman lahat ng problem ni patient ay kinokolaborate.
Teamwork
- when two or more people are interacting interdependently with
a common purpose, working toward measurable goals that
benefit from leadership that maintains stability while
encouraging honest discussion and problem solving.
- To ensure the patients satisfaction during health care
implementation, we need to embrace the teamwork approach.
- It requires good communication skills and collaborative care
coordination. It is increasing the nursing workplace satisfaction.
- Combination of the actions of different group of people to
achieve common goal in effective teamwork.
- This is an example of modern integrated healthcare delivery - Importance:
system made possible by partnership between the individual
• Decreases the level of stress to the patient.
agencies or institutions
• Positive outcomes.
- In here we can see through partnership na nag kakaroon ng good
• Reduce the number of issues related to burnout.
health services ang mga patient.
Collaboration • Efficiency of the services.

AKE 17 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

Common Principles Related to Partnership, Collaboration, - It is an individual and family’s behavior and perception that is
Teamwork measured in response to nursing interventions.
Effective Communication - Top 7 of health care outcomes that are measured:
- Involves commitment of both parties to meet regularly, 1. Mortality
understand each other’s professional roles and appreciating 2. Safety of care
each other as individuals, sensitivity to differences in their 3. Remission
communication styles yet being focused on a common ground: 4. Patient’s experience
the client’s needs. 5. Effectiveness of care
- The process of exchanging knowledges, ideas, thoughts and 6. Timeliness of care
information that would help to fulfill the best possible services. 7. Efficient use of medical imaging
- “Less about talking, and more about Listening” Decision Making
- Listening – you also understand the emotions of the speaker that - Involves shared responsibility of the team for the outcome.
he/she is trying to convey to have a effective communications. - An important aspect is for the interdisciplinary team to focus on
- 5 keys: the client’s priority needs and organizing interventions
1. Be positive accordingly.
2. Be listener - This is a series of decisions including obtaining subjective and
3. Be an echo objective data, implementation of action and evaluation of data
4. Be a mirror to achieve the desired outcome to our client.
5. Be real - Technique we should follow:
Clear Roles and Expectations 1. Always be pro active
- Must be related to team member’s functions, responsibilities, 2. Keep asking question
and accountabilities, thus optimizing the team’s efficiency 3. Know team inside out
through division of labor. 4. Think before you act
- Ex. In hospital we have kanya kanyang healthcare team na may 5. Never take chances that you are not sure about something.
mga responsibilities and accountabilities.
Mutual Respect and Trust KEY AREAS OF RESPONSIBILITY FOR BSN
- Mutual respect when two or more people show, feel honor, or GRADUATES
esteem toward one another. (CHED Memo. No. 5, Series of 2008)
- Trust is confidence in the actions of another person which must • Nurses also play the role of collaborators, them being part of
expressed verbally and non- verbally. the health care team. Therefore, they must develop this
- Can be attained through openness and honesty. competency as they assume their professional practice. The
- This is very important in the work place because you can apply importance of the concepts of collaboration and teamwork had
it or put it in practices to provide safe and effective care for the been given emphasis with their inclusion in the Key Areas of
patients. Responsibility for BSN graduates (CHED Memo. No. 5, Series
- We should learn to listen to gain rapport to the client. of 2008) with the corresponding core competencies that every
Shared Goals nurse should demonstrate.
- There must be a clear purpose that are mutually agreed upon by • 11 keys areas of responsibility for BSN graduates:
the group, which should reflect patient and family priorities, and 1. Safe and quality of nursing care
can be clearly articulated, understood, and supported by all team 2. Communication
members. 3. Collaboration
- We know that health care provider work in variety of set from 4. Teamwork
hospital, surgery and doc. offices and even in large companies 5. Health education
so in each settings we have kanya kanyang team na may 6. Legal responsibility
common share goal which is to provide and deliver good service 7. Ethico moral responsibility
to the client. 8. Human factors and Record management
- 5 professional goals as nurses: 9. Quality improvement
1. To provide excellent patient centered care 10. Management and Resources of environment
2. Increase technologies skill 11. Personnel and professional development
3. Focus on continuing education • Collaboration and teamwork core competency:
4. Develop continuing education 1. Establishes collaborative relationship with colleagues and
5. Become an expert other members of the health team.
Measurable Processes and Outcomes 2. Collaborates plan of care with other members of the health
- These include the protocols and procedures necessary for team
orderly and systematic delivery of care thus, providing a means
for reliable and timely feedback on successes and failures in
both the functioning of the team and achievement of the team’s
goals.

AKE 18 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

Program Outcomes for BSN Graduates 5) Actual loss – recognize and verify with others. (ex. Dati
(CHED Memo. No. 15, Series of 2017) kang mayaman tapos biglang mahirap so magiging
- This specifies the core competencies of BSN graduates, and the dependent ka sa iba tapos ung iba magsasabi sayo sa mga
program specifications like program roles and goals. nawala sayo)
Program Outcomes Grief
- Collaborate effectively with inter-, intra-, and multi- - total response to emotional experience related to loss.
disciplinary and multi-cultural teams. (kalungkutan/intense sorrow)
- With the program outcomes, it describes the broad aspects of 1) Abbreviated grief – when a person finds it necessary to
the behavior, knowledge and skills that develop over the move on (short lived grief ex. Si lola nawalan ng partner
duration of time and experience of our BSN graduates. pero may mga apo sya so madali siyang nakaka move on
Performance Indicators kase nalilibang siya)
- It evaluates the success of particular activity like ensure intra- 2) Anticipatory grief – a feeling of grief occurring before an
agency, inter-agency, multi-disciplinary and sectoral impending loss. The impending loss is the death of
collaboration in the delivery of health care. someone close due to illness. (upcoming death of someone
- Implement strategies, approaches to enhance/support the special ex. Sa family na diagnose ng stage 3 cancer si tatay
capability of client/care providers to participate in decision at ina-anticipate nung family nya na mamamatay na siya)
making by the inter professional team. (Through this na-aaply 3) Dysfunctional grief – a failure to follow the predictable
natin yung concept ng team work and collaborations) course of normal grieving to resolution (acc. To Elizabeth
- Maintain a harmonious and collegial relationship among we have five stages of grief so kapag na stock up ka sa isang
members of the health team for effective, efficient, and safe stage ng grief we call it dysfunctional)
client care. Bereavement
- Coordinate the tasks/ functions of other nursing personnel - subjective response to by loved one.
(midwife, BHW and utility worker). - It is a period of mourning or state of intense grieving.
- Collaborate with GOs, NGOs, and other socio civic agencies to - Talagang nagluluksa at ayaw lumabas ng kwarto.
improve health care services, support environment protection Mourning
policies and strategies, and safety and security mechanisms in - behavioral response.
the community. (dito naman papasok si partnership and - expressions of grief or intervention of grief.
collaboration) - kadalasan ung mga close friend mo or family na nakaka alam
- Participate as a member of a quality team in implementing the ng griefing mo sila ung makakapag provide ng help for you to
appropriate quality improvement process on identified cope up.
improvement opportunities.
- In here it integrates all the relevant concepts and principles in Dying
given health and nursing situations to achieve good services for - On the point of death.
the client. - Irreversible cessation of the circulatory, respiratory and brain
Note: function.
- This is the process of approaching death.
• Collaborative- working of two or more parties. Putting heads
- As a nurse we have to apply autonomy means the right of the
together in taking care of the patient.
patient to choose what kind of treatment, procedure of death he
• Partnership- association of two or more people as partner this is
wants.
similar with collaboration and cooperation.
• Teamwork- combine actions of group of people. Death
- The cessation or permanent termination of all the biological
DEATH AND DYING functions that sustain a living organism.
Discussed by Prof. Norilyn Limchanco - End of life/ existence in the world.
Terminologies - The phenomenal which commonly bring about death includes:
Loss • Aging
- something of value is gone. • Poisoning
- Process of losing someone or something. • Malnutrition
1) Personal loss – impact of life changing. (ex. Self-esteem, • Disease
security and confidence) • Suicide
2) Perceived loss – person experience the loss (ex. Adults
• Homicide
rejecting by his/her family, it my lead to loss of security or
• Drug intoxication
big changes to social status)
• Starvation
3) Maturational loss – predictably occur during the life cycle
(ex. Person unable to cope up to natural process of • Dehydration
development) • Accident or major trauma resulting in fatal injury.
4) Situational loss – unexpected or traumatic event. (ex. Loss
of partner, sudden death of pet)

AKE 19 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

Development of the concept of Death Kubler-Ross 5 Stages of Grief (DABDA)

Age Beliefs and attitudes (Psychiatrist Elizabeth Kubler-Ross 1969)
- Does not understand concept of death. 1. Denial
- Infant’s sense of separation forms basis for - Shock and disbelief.
later understanding of loss and death. - Pretending that the loss is not exist. (hindi nangyari, ayaw
Infancy – 5 tanggapin or ayaw pag usapan ung namatay)
- Believes death is reversible, a temporary
years
departure, or sleep. 2. Anger
- Emphasizes immobility and inactivity as - Hostility and resentment
attributes of death. - Blaming others
- Understands that death is final. 3. Bargaining
- Believes own death can be avoided. - Looking for a way out
5-9 years - Associates’ death with aggression or violence. - What if? You may feel guilt
- Believes wishes or unrelated actions can be - Madalas maririnig ung “what if” na word
responsible for death. 4. Depression
- Understands death as the inevitable end of life. - No longer able to deny, patients experience sadness and
- Begins to understand own mortality, loss.
9-12 years - Isolation and loneliness
expressed as interest in afterlife or as fear of
death. - Nag mumukmok lang at nag sasarili sa kwarto
- Fears a lingering death. May fantasize that 5. Acceptance
death can be defied, acting out defiance - Acceptance of the inevitability of death with peace and
through reckless behaviors (e.g., dangerous detachment.
driving, substance abuse). - Letting go of what once was. Can be good or bad.
- Seldom thinks about death but views it in
12-18 years Indications of death
religious and philosophic terms.
• Total lack of response to external stimuli
- May seem to reach “adult” perception of death
• No muscular movement, especially breathing
but be emotionally unable to accept it.
- May still hold concepts from previous • No reflexes
developmental stages. • Flat encephalogram (brain waves)
- Has attitude toward death influenced by • In the hospital one of the reliable source of physician in
18-45 years declaring death is the ECG or the flat line means there is no
religious and cultural beliefs.
- Accepts own mortality. electrical activity in the heart.
- Encounter’s death of parents and some peers. Physiological Needs of Dying Persons
45-65 years - Experiences peaks of death anxiety. Problem Nursing care
- Death anxiety diminishes with emotional
- Fowler’s position: conscious clients
well-being.
- Throat suctioning: conscious clients
- Fears prolonged illness. - Lateral position: unconscious clients
Airway
- Encounter’s death of family members and clearance - Nasal oxygen for hypoxic clients
peers. - Anticholinergic medications may be
65+ years
- Sees death as having multiple meanings (e.g., indicated to help dry secretions
freedom from pain, reunion with already
- Open windows or use a fan to circulate air
deceased family members).
Air hunger - Morphine may be indicated in an acute
• Infancy- they don’t know what death is. episode
• 5- 9 years- naiintindihan na nila ung kamtayan or katapusan, so - Frequent baths and linen changes if
kapag tinanong nila tayo dpat iexplain natin ito ng mabuti at diaphoretic
totoo - Mouth care as needed for dry mouth
• 9- 12 years- nagsisimula na ang death ay un-avoidable, nag Bathing/
- Liberal use of moisturizing creams and
start na magdalamhati o malungkot kapag may namatay. hygiene
lotions for dry skin
• 12- 18 years- the concept of death is almost similar to adult - Moisture-barrier skin preparations for
already incontinent clients
• 18- 45 years- Malaki ung factor ng paniniwala at faith nila in - Assist client out of bed periodically, if able
terms of death - Regularly change client’s position
• 45- 65 years- tanggap na sa sarili nila na lahat ng tao ay doon - Support client’s position with pillows,
papunta, so madali na silang nakaka cope up Physical blanket rolls, or towels as needed
• 65+ years- hindi na sila takot mamatay, ang kinakatakot nila is mobility - Elevate client’s legs when sitting up
mag hirap pa sila bago sila mamatay - Implement pressure ulcer prevention
program and use pressure-relieving surfaces
as indicated
AKE 20 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

- Antiemetics or a small amount of an - Change stroke respiration- abnormal breathing characterized by

Nutrition alcoholic beverage to stimulate appetite progressive deeper breathing pawala ng pawala hanggang sa
- Encourage liquid foods as tolerated mawala na ung breathing nya or apnea
- Dietary fiber as tolerated Sensory impairment
Constipation - Blurred vision
- Stool softeners or laxatives as needed
- Skin care in response to incontinence of - Impaired senses of taste and smell.
urine or feces - Visual and auditory hallucination
- Bedpan, urinal, or commode chair within - Hearing sensation – pinaka last
easy reach - Due to chemicals in the body kaya sila nag kaka hallucinations
- Call light within reach for assistance onto
Urinary Pronouncement of Death
bedpan or commode
elimination • Absence of the carotid pulses
- Absorbent pads placed under incontinent
client; linen changed as often as needed • Pupils are fixed and dilated
- Catheterization, if necessary • Absent heart sounds
- Keep room as clean and odor free as • Absent breath sounds
possible • Asystole or Flat line – there is no electrical activity in the heart.
- Check preference for light or dark room
Religious Beliefs
- Hearing is not diminished; speak clearly
- Spiritual support is of great importance in dealing with death.
Sensory/ and do not whisper
- Malaking factor sa tao ung belief to cope up.
perceptual - Touch is diminished, but client will feel
Sociocultural Definitions of Death
changes pressure of touch
- Different cultures view death in diverse ways.
- Implement pain management protocol if
- Customs and expectation also differ in ritual of bereavement
indicated
and mourning.
- Even within a culture there is diversity in the view of death.
Signs of impending Clinical Death
- May kanya-kanyang paniniwala and beliefs.
Loss of Muscle Tone
- Relaxation of the facial muscles (e.g., the jaw may sag) Post Mortem Changes
- Difficulty speaking Pallor mortis
- Difficulty swallowing and gradual loss of the gag reflex. - First stage of death
- Decreased activity of the gastrointestinal tract, with subsequent - Paleness of death
nausea, accumulation of flatus, abdominal distention and - Almost immediately after death a body of a person with light
retention of feces, especially if narcotics or tranquilizers (may skin will begin to grow very pale. This is caused by a lack of
cause the relaxation of an organ that may cause retention) are blood in the capillary region of the blood vessel.
being administered. Algor Mortis
- Possible urinary and rectal incontinence due to decreased - Second stage of death
sphincter control. - Cool of death
- Diminished body movement. Due to loss of activity - After death a human body will no longer be working to keep
- Impending- means upcoming warm, and as a result will start cooling.
Slowing of the Circulation - About an hour postmortem (after death) a human body will have
- Diminishes sensation decreased around 2 degrees Celsius and will continue to
- Mottling and cyanosis of the extremities decrease one degree Celsius until it reaches the temperature of
- Cold skin, first in the feet and later in the hands, ears and nose. the environment around it.
(The client, however may feel warm if there is a fever) Rigor Mortis
- Slower and weaker pulse - Third stage
- Decreased blood pressure. - Death stiffness
- a dying person kase bumabagal heartbeat so bumabagal din ung - About three hours after death a chemical change in the muscles
flow ng blood at ung blood papunta sa brain is not enough so of a human corpse causes the limbs of the corpse to become stiff
not enough din ung pang supply sa iba pang mga organs so and difficult to move.
hihina ang mga ito.
Changes in Respirations Postmortem Care
- Rapid, shallow, irregular or abnormally slow respirations. • Needs to be done promptly, quietly efficiently and with dignity.
- Noisy breathing, referred to as the death rattle, due to collecting (kapag naka duty dpt nakikidalamhati tayo)
of mucus in the throat • Straighten limbs before death, if possible place head on pillow
- Mouth breathing dry oral mucous membranes. (kase kapag hindi mo ito inayos kailangan pa siyang baliin kpag
- Dying person: 50-60 breaths per min (progressively decreasing) inembalsa)
• Remove tubes
• Replace soiled dressings

AKE 21 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

• Pad anal area Non-Verbal Communication

• Gently wash body to remove discharge (hindi maiiwasan na ma - Uses gestures, facial expressions, and body movements.
pupu ang pt. kapag nag cpr) - Also includes physical appearance, eye contact, posture, gait
• Place body on back with head and shoulders elevated. and many more.
• Grasp eyelashes and gently pull lids down. Written Communication
• Insert dentures - Uses any forms of written materials such as books, magazines,
• Place clean gown on body and cover with clean sheet. (after and any written materials.
natin magawa lahat pwede ng tawagin ang relatives) Percentage of Communication Methods
• Note time of death and chart • Verbal and Non- Verbal Communication occur currently. The
• Notify attending physician majority is Non-verbal, why? It is because verbal
• Chart any special directions communication comprises only 10% and non-verbal is 90%.
• Notify family members • Note: Action Speaks Louder Than Words (It is this for this
• Allow time with loved one reason that when interacting with others, particularly to your pt.
• Gather eyeglasses and other belongings (ibalik ang gamit sa you should observe not only what they are (client) saying, but
relative at papirmahin ang relative na tumaggap nung gamit) more or so with his/her non-verbal communication.
• Prepare necessary paperwork for body removal
• Call funeral home (or other appropriate personnel) for body New Form of Communication
transport Electronic Communication
• Note on chart - Highly beneficial to people, organizations, or industry if it is
- What personal artifacts were released with the body? managed effectively.
- What belonging were released? - Method that we used in online classes.
- Who received the belongingness? - Playing an increasing role in nursing practice. Many health care
agencies are moving toward electronic medical records where
• Tag or provide body identification as per policy.
nurses document their assessments and nursing care.
Nursing responsibilities - The nurse ability to established effective communication in
To the patient nursing is imperative and providing the best care and patient
• Nurses need to take time to analyze their own feelings about. outcomes possible.
• Understand that you may experience grief. - Communication is an integral part of the helping relationship
• Nurses must be strong to control their feelings to be able to Effective Communication of Nurses
tolerate pain, illness, and death, and to keep their distance. able to:
• Provide relief from illness, fear, and depression. • Collect assessment data
• Help clients maintain sense of security. • Initiate interventions
• Help accept losses. • Evaluate outcomes of interventions
• Provide physical comfort. • Initiate change that promotes health
To the family • Prevent safety and legal problems associated with nursing
• Explain procedures and equipment practice
• Prepare them about the dying process. • Effective communication is essential for the establishment
• Involve family and arrange for visitors of a nurse-client relationship.
Components
• Encourage communication
Trust
• Provide daily updates
- Development of trust is the key factor in establishing
• Resources
therapeutic relationship or vital step in the recovery process.
• Do not deliver bad news when only one family member is
Genuine Interest
present. (ideally two or more)
- when the nurse is comfortable with himself or herself,
aware of his or her strengths and limitations, and clearly
THERAPEUTIC COMMUNICATION
focused, the client perceives genuine person showing
Discussed by Prof. Dr. PA Maroma
genuine interest.
Communication
- The nurse should be open and honest and display congruent
- In nursing is vital to quality of nursing care.
behavior.
- Communication is the exchange of information, ideas, thoughts,
or feelings, between two or more people. Empathy
- It is the basic components of human relationship including nursing. - The ability to perceive the meanings and feelings of the
Mode of Communication client and to communicate that understanding to the client.
Verbal Communication - One of the essential skills a nurse must develop.
- Uses methods such as talking and listening. - Both the client and the nurse give a “gift of self” when
- Could also be form of writing, reading, storytelling or any forms empathy occurs.
of communication that uses words. - Essential skills must nurse be developed.

AKE 22 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

Acceptance (Positive Required) Factors that Influence the Communication Process

- Is not just being nice to others. Personal Space
- It is a principle of action in which a nurse perceives and - It is the distance people prefer in interactions with others.
works with the pt. as what he really is accepting his - Communication alters w/ the 4 distances:
congenial and uncongenial qualities, constructive and 1. Intimate – 0 to 1 ½ feet
destructive attitude and positive and negative feelings - Characterized by body contact
while maintaining a sense of pt’s innate worth. - ex. Cuddling a baby or assessing pt. who is blind.
Therapeutic Use of Self 2. Personal – 1 ½ to 4 feet
- Is forming a trusting relationship that provides comfort, - Characterized by nurse-patient interaction and
safety, and non-judgmental acceptance of clients to help providing nursing care.
them improve their health status. 3. Social – 4 to 12 feet
- It requires self-awareness and use of effective - Communication is formal.
communication techniques. - Characterized by group discussion, classes, meetings,
etc.
Communication 4. Public – 12 feet and beyond
- Is a process it consists of certain steps which each step - Characterized by conferences, tournaments, or other
constitutes the essential of effective communication. public activities.
- Goals of communication process is to influence others and Boundary
facilitates change. - Are the defining limit of individual to keep clear boundaries the
- It is a two-way process involving the sending and receiving a nurse must maintain the professional boundary bet. the nurse-
message. patient relationship.
• Sender – is the source/encoder who wishes to communicate - Respect the client’s boundaries.
the message (magbibigay ng mensahe or content) - Physical boundaries
• Message – is being said or written the body language that - Social boundaries
accompanies the word in how it is being transmitted - Personal boundaries
(mensahe o yung content) - Material boundaries
• Receiver – is the decoder who will perceive what is the Gender
sender intended to relate. (ang tatanggap o tumatanggap ng - Man and women communicate differently, and they may
mensahe) interpret the same communication in a different manner.
• Feedback – is the return response of the receiver. (tugon)
Values and Perception
- Communication can be described as helpful or unhelpful.
Values
• Helpful – when it encourages sharing information,
- Standards that influence behavior.
thoughts, or feelings bet. two or more people
Perception
• Unhelpful – when it hinders or blocks transfer of
- Personal view of events.
information and feelings.
- Each person has unique personality traits values and life
When Communicating in a face-to-face manner
experiences each will perceive and interpret messages and
Pace and Intonation
experiences in a different way.
- Manner of speech, rhythm, and tone of voice
Interpersonal Attitude
Simplicity
- Communicated convincingly and rapidly to others.
- Commonly understood words.
- Attitude such as caring, warmth, respect and acceptance
facilitate communication whereas lack of interest and coldness
Clarity
inhibit communication.
- Saying precisely what is meant. Attentive Listening Congruence
Brevity
- Is listening actively and mindfulness and using all senses and
- Using fewest words possible
paying attention to what the client is saying, doing or feelings.
Timing and Relevance - Communication is congruent when verbal and non-verbal
- Involves in the sensitivity clients’ needs and concerns. communication harmonize with each other.
Credibility Helping Relationship
- Means the worthiness of beliefs, trust worthiness and - A therapeutic nurse pt relationship is defined as a helping
reliability. relationship that is based on mutual trust, respect, nurturing,
- Most importance criterion in communication. being sensitive to others and assisting with gratification of the
- Must consistent, dependable, and honest. pt’s physical, emotional, and spiritual needs through your
Humor knowledge and skills.
- Can be powerful tool in the nurse-patient relationship but
it must be use with care.
- To help the client adjust in difficult and painful situations.

AKE 23 of 24
 FUNDAMENTALS OF NURSING PRACTICE LECTURE &LABORATORY: 1ST YEAR SUMMER FINAL

Four Phases/Stages in a Helping Relationship Child

Pre-Interaction Orientation Phase - The nurse should use symbol words and the level of the child’s
- Begins with the nurse first contact with the patient. understanding.
- Gathering information; recognizing limitations and seeking - Maintain eye contact and same eye level with the child.
assistance as required. - Parents should be present during the interview as required.
- Client’s name, address, age, medical and social history. Highly Emotional Clients
- Nurse should consider her personal strength w/ working w/ the - The nurse needs a lot of patients.
client. - Should be respectful and accepting regardless on their mood
Introductory/Orientation Phase and behavior.
- Establishing a relationship develop trust and respect, setting, People of Different Culture
goals, and security within the nurse-client relationship. - The nurse should speak slowly and use different words to
Working Phase express same ideas.
- Working with client on the identified problems and evaluating - During the interview, the pt maybe reluctant to reveal personal
and modifying goals as appropriate information to strangers for various culture base reasons.
Termination Phase - The nurse should be aware of client’s culture and understand
- Summarizing or review with client, his progress and assessing variations in disease perceptions, family roles, and meaning of
his ability to handle problems independently. non-verbal communication such as eye contact, handshaking,
and other gestures.
Therapeutic Communications Techniques
− Facilitates communication and focus on patients concerns.
• Using silence (Offering self) Pinagsama ko na po ung Lecture and Laboratory. And may isa pa
• Providing general leads (Giving information) akong reviewer na galing sa section namin (Dash 10), Andon un
• Using open-ended questions (Giving recognition) mga diniscuss saamin, kaya kung gusto nyo ng additional info.
• Using touch (Clarifying time or sequence) Pwede nyo rin sya gamitin :)))
• Actively listening (Focusing)
• Seeking clarification (Reflecting) Good luck on your Exam! I know you will pass!
• Seeking consensual validation (Summarizing and planning)
Padayon Future Nurses!! 🩺🩺
Barrier to Communication - Aki
- Nurses need to recognized barriers or nontherapeutic responses
that affects effective communication. Failure to listen,
improperly decoding the client’s intended message, and placing
the nurse’s needs above the client’s needs are major barriers to
communication.

Non-Therapeutic Communication Techniques

− To become effective in communication you should be aware of
the techniques that could hinder the development of a
therapeutic relationship with patients.
• Stereotyping
• Agreeing and disagreeing
• Being defensive
• Challenging
• Probing
• Testing
• Rejecting
• Changing topics
• Unwarranted reassurances
• Giving personal opinion
• Approving and disapproving

Special Consideration when Communicating

Elderly
- The nurse should consider the hearing ability of the clients.
- The nurse should speak clearly and clarify statements, as
necessary.
- Interview the client with significant others if he/she is confused
or forgetful.
AKE 24 of 24