FUNDAMENTALS OF NURSING

I. Nursing Theorists

Faye Abdellah Identification of 21 Nursing Problems

Lydia Hall Care, Core and Cure (3 C’s)
Virginia Henderson Identification of the 14 Basic Needs
Imogene King Goal Attainment Theory
Madeleine Leininger Transcultural Nursing
Myra Levine Four Conservation Principles
Florence Nightingale Environmental Theory
Betty Neuman Stress Reduction
Dorothea Orem Self-Care and Self-Deficit
Rosemarie Parse Human Becoming
Hildegard Peplau Interpersonal Relations Model
Martha Rogers Science of Unitary Human Beings
Callista Roy Adaptation Model
Jean Watson Human Caring

Metaparadigm for Nursing Theories: CHEN (Client, Health, Environment, Nursing)

II. CHAIN OF INFECTION

Six links

· Host (susceptible)

· Agent

· Reservoir

· Entry (mode of)

· Transmission (mode of) –direct, vehicle, vector

· Exit (mode of)

Surgical vs Medical Asepsis

Surgical = sterile free from ALL microorganisms

Medical = clean free from pathogenic microorganisms

III. ISOLATION PRECAUTIONS

Standard Precautions (Universal precautions)

· Applies to ALL body fluids, secretions, blood, non-intact skin and

excretions except sweat

· Includes hand washing, wearing clean gloves, mask and gown

Transmission Based Precautions

· Airborne used for clients with illnesses transmitted by airborne

droplets (less than 5 microns)

- Examples: Tuberculosis, Chickenpox, Measles

- Place client in private room but if no private room is available

place client in a room with another client infected with the
same microorganism

- Wear N95 respirator

· Droplet used for clients with illnesses transmitted by droplet

nuclei ( greater than 5 microns)

- Examples: Diptheria, Pertussis, Meningitis, Mumps

- Wear mask when working within 3 feet from the client

IV. PERSONAL PROTECTIVE EQUIPMENT (PPE)

Sequence of removing PPE

1. Gloves
2. Mask
3. Gown
4. Eyewear

V. INSERTION OF NASOGASTRIC TUBE

· Measure length of tube tip of the nose to the tip of the earlobe to the xiphoid
process

· Position High Fowlers position with neck hyperextended

· Lubricate tip of tube with water soluble lubricant

· Instruct the client to swallow or drink from a straw while the tube is being
inserted

· STOP and remove the tube if client becomes cyanotic or coughs

· Placement- check

- Aspirate gastric secretions measure pH

- Auscultate and inject air into the tube (whooshing sound)

- X-ray best measure to determine proper placement (initial placement)

· Secure tube using tape to the bridge of the clients nose and to the clients
gown
VI. TUBE FEEDINGS

Position: Fowlers position

Assessment: Check patency of tube and Aspirate residual contents

before feeding (if 100 ml or more than 50% of last feeding withheld
and check)

For feeding bags: Hang bag from infusion pole HEIGHT: 12 inches

Complications: Dumping syndrome, aspiration pneumonia, diarrhea,

hyperglycemia, nausea and vomiting

VII. INTESTINAL OSTOMIES

Assessment: color should be bright red

( not purple, bluish, pale, etc.), peristomal skin, amount

and type of feces (Ileostomy liquid feces / acidic,
ascending semi-liquid, transverse semi formed,
descending and sigmoidostomy formed feces / aromatic
and smelly)

Empty bag when it is 1/3 - ½

Apply a barrier (i.e. Karaya gum) over the skin around the
stoma to prevent skin breakdown

Control Odors (deodorizers, charcoal disks, prevent odor-

causing foods)

Complications: Fluid and Electrolyte imbalance, skin

breakdown, constipation, infection
VIII. ENEMAS

Classified into FOUR: Cleansing, Carminative, Retention

and Return Flow

Position: Left Lateral position

Protection: Wear clean gloves

Lubrication: lubricate with water soluble lubricant

Insertion: Insert 3-4 inches (adult), 2-3 inches (children)

Administration: administer gradually

IX. URINARY CATHETERIZATION

 Sterile technique

 I nsertion

Male Female
Position Supine (legs Supine (with knees
slightly abducted) flexed and
externally rotated)
Penis at 90 degree
angle
Length to be 6-9 inches 2-3 inches
inserted
Length of 40 cm 22 cm
catheter

(Adult)
X. TRACHEOSTOMY

Position: (during insertion) Fowler’s position

Use: Sterile gloves

Time: 2-3 minutes between suctions when possible,

suction applied for 5-10 seconds to minimize oxygen loss

Clean with: After removing the inner cannula it is soaked

in full strength hydrogen peroxide to moisten and
loosen dried secretions. After cleaning the cannula, it
should be rinsed with sterile normal saline to remove
traces of hydrogen peroxide from the cannula before
replacing it and securing it in place again.

When changing the ties: tie one end of the new tie to the
eye of the flange while leaving old ties in place

Before tying the tapes: be able to put two fingers under

the tapes before tying it

Parts: Inner cannula, outer cannula and obturator

Object at bedside: Obturator (for reinsertion), suction

machine/apparatus (for removing secretions)
XI. CHEST PHYSIOTHERAPY (PVP)

-done before meals (but not immediately before meals) or 2

hours after meals

-increase fluid intake to liquefy secretions

Percussion

Vibration

Postural drainage

XII. ANTIEMBOLISM STOCKINGS

Indication: to prevent thrombophlebitis by promoting

venous return from the legs

The client must be measured to ensure proper fit of the

stockings

When to apply: during the morning before the client gets

out of bed (elevate for at least 15 minutes)

When to remove: remove 20-30 minutes every 8 hours

Assess skin for breakdown

XIII. BLOOD TRANSFUSION

FIRST:
 Check if properly typed and cross matched

Gauge of needle: g #18

Drop factor: 10 gtts/min (1st 30 mins.)

Duration: RBC’s and whole blood – 4 hours, FFP

Fresh frozen plasma, platelets – not more than 20
minutes

Rate: KVO

IVF: Plain NSS

Monitor: vital signs (every 15 minutes for 1st hour), any

adverse reactions

When reaction happens: STOP the transfusion and

notify the physician

Common blood transfusion reactions:

Anaphylactic reaction – s/sx: rashes and hives

Hemolytic reaction – s/sx: flank/back pain

Pyrogenic reaction – s/sx: fever, headache

Cardiogenic reaction - s/sx: dyspnea

 XIV. CHEST TUBES

What to do if:

Tube becomes disconnected from the bottle – place

end of tube in a bottle with NSS

Tube becomes disconnected from the client – cover

wound with sterile dressing

Water seal has vigorous bubbling – there is a leak –

clamp tube nearest the client (intermittent bubbling –
normal, vigorous/continuous bubbling-abnormal)

Transporting the client – bottle below chest level and

upright

XV. PAIN

Study: Gate control theory (Substantia gelatinosa)

Analgesics, patient controlled analgesia (PCA),

transcutaneous electrical nerve stimulation (TENS),
imagery, massage

Pain assessment (some common indicators)

MI Crushing pain, (someone sitting in my

chest), radiates from chest to back
Angina Stab-like pain, , radiates from chest to
jaw to left shoulder and arm
Hypertension / hypertensive crisis Pounding pain
Ectopic pregnancy Knife-like pain
Gastric ulcer Gnawing pain
UTI Flank pain
Pancreatitis Radiates from Left upper quadrant to left
shoulder

XVI. ASSISTIVE DEVICES

CANES - opposite the affected leg (C-O-A-L)
- angle is 20 to 30 degrees
- the length should permit the elbow to slightly flex

WALKERS - Hand bar below the clients waist and the elbow is slightly flexed

CRUTCHES - Angle of elbow flexion – 30 degrees

-weight of the body should be borne by the arms not the axilla to
prevent CRUTCH PALSY

- Crutches are placed 6 inches in front and 6 inches laterally

- the feet should be slightly apart, hips and knees extended and
back is straight

- Four point gait – right crutch, left foot, left crutch,
right foot

- Three point gait – right and left crutch with weak
leg, stronger leg

- Two point gait- right crutch and left foot together, left
crutch and right foot

- Swing to gait- move both crutches forward, lift body

weight and swing to crutches

-Swing through gait - move both crutches forward, lift

body weight and swing through beyond the crutches

- Going up the stairs (remember: all good people go

to heaven) – when going up, lift (good) unaffected
leg first followed by the crutch, affected leg.
XVII. SPECIAL DIETS

DIET DISORDER
Low carbohydrate Dumping syndrome
Low protein Renal failure, Acute glomerulonephritis, uremia,
anuria
High protein Nephrotic syndrome
Low sodium Heart failure, CVD’s, Nephrotic syndrome
High fiber Constipation, hyperlipidemia
Low residue Bowel inflammation ( diverticulitis and
ulcerative colitis)
Acid/Alkaline ash (depending on the lab analysis of the stones)

Retard renal calculi formation

Clear liquid Following acute vomiting or diarrhea
Full liquid Gastrointestinal upsets, progression from clear
liquids
Gluten-free For clients with Celiac disease
Tyramine-free To prevent fermented and processed foods for
clients taking MAOI’s
Purine restricted Gouty arthritis, uric acid stones

XVIII. DEGREES OF BURNS

Superficial
 Partial Thickness

- area involved: epidermis

- tingling, erythema, minimal or no edema

 D eep Partial Thickness

- area involved: epidermis, dermis

- w/ PAIN, hyperesthesia, BLISTERS, edema, weeping

surface, mottled and red base

 F
 ull Thickness

- area involved: epidermis, dermis, may involve

subcutaneous and connective tissue, muscle
and bone
 - PAIN FREE, shock, dry, PALE, WHITE leathery or
charred skin, broken skin with fat exposed, edema

XIX. PRESSURE ULCERS (STAGES

Stage 1 ERYTHEMA(redness), elevated temperature, patient

complains of discomfort

Stage 2 Skin breaks, abrasions, BLISTERS, shallow crater,

edema, infection may develop

Stage 3 ulcer extends into the subcutaneous tissue, necrosis and

drainage, infection develops

Stage 4 - ulcer extends into the muscle and bone, deep pockets of
infection develop

XX. VITAL SIGNS

 TEMP PR RR BP

NV (Adult) 36.0- 60-100 bpm 12-20 bpm 120/80 mmHg

37.5 0 C
Oral-2-3 mins Ang PET Mo Breath Sounds: -cover about 2/3 of the
limb
Rectal – 2-3 mins A- pical Stridor- shrill and
(most accurate) harsh ( laryngeal Position: sitting
P-ulmonic obstruction)
Axillary – 6-9 Release valve on cuff
mins (least E-rb’s pt. Wheeze – high carefully -2-3 mmHg/sec
accurate) pitched/musical
T-ricuspid (Asthma) Wait 1-2 min before taking
Tympanic another BP
M- itral Volume:
BP erroneously high-
Others: Hypoventilation-slow
Cuff too narrow, arm
and shallow unsupported, no rest
Brachial – BP (Respiratory acidosis
before assessment, cuff
–pursed lip) wrapped loosely, deflating
Apical – used too slowly (high diastolic),
for children belowHyperventilation-deep assessing immediately
3 y/o and rapid (Respiratory after a meal
alkalosis – brown
paper bag) BP erroneously low- cuff too

wide, arm above heart level

Monitor in clients Bleeding, taking Anxious, receiving Cardiac problems, DM, RF

who are/has: digitalis, has DVT morphine and
immunosuppressed or Magnesium sulfate
, receiving chemo, thrombophlebitis
etc

10 HERBAL PLANTS (Advocated by DOH)

Lagundi Asthma, cough, fever Bayabas For washing wounds,

mouthwash/gargle,
toothache

Yerba Buena Pain, headache, Akapulko Anti-fungal

stomachache, toothache,
menstrual and gas pain

Sambong Anti-edema, anti- Ulasimang Bato Lowers uric acid

urolithiasis

Tsaang Gubat Diarrhea, Bawang For hypertension/

stomachache toothache

Niyug-niyugan Anti-helminthic Ampalaya To lower blood sugar levels