Fundamentals of Nursing

Nursing Theories

1. Faye Abdellah
Holistic delivery of health care to meet social, physical, intellectual, creative, emotional and spiritual needs of the
client and family (21 problems)

2. Lydia Hall
First introduced the nursing process

3. Virginia Henderson
To work independently with other health caregivers. Focus is on the independent satisfaction of 14 human needs
(complementary – supplementary)

4. Imogene King
According to her, nursing process is defined as a dynamic and interpersonal process between the nurse, client and
health care system (Goal Attainment Theory)

5. Dorothy Johnson
Focuses on how clients adapt to illness and how actual or potential stress can affect the ability to adapt. The goal of
nursing is to reduce stress so that the client can move easily toward recovery.

6. Madeleine Leininger
With her “Transcultural Care Theory”, caring is the central and unifying domain for nursing knowledge and practice.

7. Betty Neuman
According to her, the goal of nursing is to assist the individual, families and groups in attaining and maintaining a
maximal level of total wellness (Open Systems Approach)

8. Florence Nightingale
To facilitate the body’s reparative process by manipulating the environment. According to her theory, the client’s
environment is manipulated to include appropriate noise, nutrition, hygiene, light, comfort, socialization and hope.

9. Dorothea Orem
Orem proposed the “Self-Care Deficit” theory. Nursing care becomes necessary when the client is unable to fulfill
biological, psychological, developmental or social needs. The goal of nursing is to attain total self-care.

10. Hildegard Peplau

According to Peplau, nursing is a significant, therapeutic and interpersonal process and the goal is to develop
interaction between the nurse and the client.

11. Martha Rogers

Known as the “Science of Unitary Human Beings”, Rogers stated that the person is an irreducible whole, the whole
being greater than the sum of its parts. She also said that the client continuosly changes and coexists with the
environment.

12. Sister Callista Roy

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Her adaptation model is based on the physiological, psychological, sociological and dependence-independence
adaptive models.

13. Jean Watson

Her theory invlolves philosophy and the science of caring

Definitions of Nursing
• Diagnosis and treatment of human responses to actual or potential health problems 1
• Nursing Science – Cognitive brain of Nursing
• Nursing Esthetics – Art and heart of Nursing
• Nursing Ethics- Knowledge of professional standards of conduct
• Personal Knowledge – Conscious awareness of one’s own values

The Nursing Process

Nursing theory and process

NURSING PROCESS

• is the method used to assess and diagnose needs, plan and implement interventions, and evaluate the
outcomes of the care provided.
• is a process by which nurses deliver care to patients, supported by nursing models or philosophies.
• originally an adapted form of problem-solving and is classified as a deductive theory.

Characteristics of the nursing process

G Goal directed and client centered

U Universally applicable

D Dynamic and cyclic

I Interpersonal and collaborative

S Systematic

SKILLS (T-I-C)

Technical skills - Knowledge and skills needed to properly and safely manipulate and handle appropriate
equipment needed by the patient in performing medical or diagnostic procedures

Interpersonal skills - therapeutic communication, active listening, conveying knowledge and information,
developing trust or rapport-building with the patient, and ethically obtaining needed and relevant
information from the patient which is then to be utilized in health problem formulation and analysis.

Cognitive or Intellectual skills - analyzing the problem, problem solving, critical thinking and making
judgments regarding the patient's needs.

Phases of the nursing process

• Assessment (of patient's needs)

• Diagnosis (of human response needs that nursing can assist with)
• Planning (of patient's care)
• Implementation (of care)
• Evaluation (of the success of the implemented care)

Assessment Phase

PURPOSE: to identify the patient's nursing problems.

Models for data collection

• Gordon's functional health patterns

• Roy's adaptation model
• Body systems model
• Maslow's hierarchy of needs
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 • Initial Assessment-specified time after admission
• Focus or Ongoing Assessment- ongoing process integrated with nursing care
• Emergency Assessment- during any physiologic or psychologic crisis of the client
• Tome-Lapsed- several months after initial assessment

Diagnosis Phase

NURSING DIAGNOSIS - a standardized statement about the health of a client (who can be an individual, a family, or
a community) for the purpose of providing nursing care..

Structure of diagnoses

• Actual diagnosis - a statement about a health problem that the client has and the benefit from nursing care.
An example of an actual nursing diagnosis is: Ineffective airway clearance related to decreased energy as
manifested by an ineffective cough.
• Risk diagnosis - a statement about health problems that a client doesn't have yet, but is at a higher than
normal risk of developing in the near future. An example of a risk diagnosis is: Risk for injury related to
altered mobility and disorientation.
• Possible diagnosis - a statement about a health problem that the client might have now, but the nurse
doesn't yet have enough information to make an actual diagnosis. An example of a possible diagnosis is:
Possible fluid volume deficit related to frequent vomiting for three days as manifested by increased pulse
rate.
• Syndrome diagnosis - used when a cluster of nursing diagnoses are seen together. An example of a
syndrome diagnosis is: Rape-trauma syndrome related to anxiety about potential health problems as
manifested by anger, genitourinary discomfort, and sleep pattern disturbance.
• Wellness diagnosis - describes an aspect of the client that is at a low level of wellness. An example of a
wellness diagnosis is: Potential for enhanced organized infant behaviour, related to prematurity and as
manifested by response to visual and auditory stimuli.
Diagnosis Format (PES) 11
1. Problem Statement (altered, impaired, ineffective, acute and chronic)
2. Etiology (related to / secondary to)
3. Defining Characteristic (signs and symptoms)

Process of diagnoses

• Collect data - statistical data relevant to achieving a diagnosis.

• Cues/patterns - changes in physical status. (for example: lower urinary output)
• Hypothesis - possible alternatives that could have caused previous cues/patterns.

Validation - taking necessary steps to rule out other hypothesis, to single out one problem.

Diagnosis - making a decision on the problem based on validation.

Strategies - taking necessary action to solve the problem and/or to provide adequate nursing care.

Planning Phase

• In agreement with the patient, the nurse addresses each of the problems identified in the planning phase.
• For each problem a measurable goal is set. For example, for the patient discussed above, the goal would be
for the patient's skin to remain intact.
• The result is a nursing care plan.

NURSING CARE PLAN - outlines the nursing care to be provided to a patient. It is a set of actions the nurse will
implement to resolve nursing problems identified by assessment.

Characteristics of the nursing care plan

• focuses on actions to solve or minimize the existing problem.

• product of a deliberate systematic process.
• relates to the future.
• based upon identifiable health and nursing problems.
• holistic

Elements of the plan (3Ns)

• Nursing diagnosis with related factors and subjective and objective data

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 • Nursing outcome classifications with specified outcomes (or goals)
• Nursing interventions

Implementation Phase

• The methods of implementation must be recorded in an explicit and tangible format in a way that the patient
can understand should he wish to read it.
• Clarity is essential as it will aid communication between those tasked with carrying out patient care.

Evaluating Phase

PURPOSE: to evaluate progress toward the goals identified in the previous stages.

It is due to this stage that measurable goals must be set - failure to set measurable goals will result in poor
evaluations.

Nursing Documentation Formats

1. Nursing care plans – Traditional or standardized

2. Critical pathways – Managed care systems (interventions for specific diseases)

3) Kardex - Concise method of organizing and recording data about a client, making information readily accessible to
all health professionals

4) Progress notes

a. Narrative charting is a description (narration) of information and chronologic charting.

b. Soap format / soapier
c. Pie charting
d. Flowsheets (graphic or tabular) med., daily nursing care record
e. Clinical records (GCS, CVP)
f. Focus charting – Outlines occasions for nd activities of nursing care (data, action, response)

Ethics and Values

1. Morality of human behavior
2. Bio-ethics- applied to life
3. Code of ethics- standard of group’s ideals and values
4. Values- both intrinsic and extrinsic
5. Morals- principles and rules of right conduct, private and personal commitment defended in daily life
6. Ethics- professionally and publicly stated inquiry, or study of principles and values
7. Morals- standards of right and wrong
8. Intuitionism- notion
9. Autonomy- independence
10. Non-maleficence- do no harm
11. Beneficence- doing good
12. Justice- fairness
13. Fidelity- faithfulness and commitment
14. Veracity- truthfulness
15. Advocacy- informed support / enhance autonomy
16. Restraints- not instituted for the purpose of convenience and as a treatment of medical symptoms (false
imprisonment) both physical and chemical.
17. Informed consent- duration required not prn- alternative measures first
18. Remove Q2h for skin care and ROM- done to prevent harm or injury or complication if patient is disoriented
(SAFETY)

Incident Reports
1. Incident reports- statement of facts and patient’s physical response from unexpected occurrence that could affect
the client---sequence within 24 hours---risk manager
2. Telephone orders- repeat order to the AP and let him sign within 24 hours

Informed Consent

1. agreed upon 4. explanation

2. facts known 5. risk understood
3. treatment

Consent Considerations
1. OB, STD, Rehabilitation, Blood donation

(minor can give)

2. ER, Life threatening (implied)

Mentally-ill (incapable)
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Teaching and Learning
1. Andragogy vs Pedagogy
2. Dependence to Independent
3. Previous experience
4. Readiness to learn (developmental task) 3
5. Personal usefulness and value
6. Domains- cognitive, affective and psychomotor
7. A key element in the change process is trust
Desire + Acting - Compliance

STRESS
1. Gas – Alarm-Resistance-Exhaustion
2. Coping and stress management
3. Anxiety-
Mild – slight arousal and increased perception
Moderate- increased tension and selective inattention
Severe- decreased perception and focused energy
4. Panic- overpowering and loss of control

Loss, Grieving and Death

Death Concepts
1. 1-5Y.O – immobility and inactivity wishes and unrelated action responsible for action
2. 5-10 – final but can be avoided
3. 9-12 – understands own mortality and fears death
4. 12 – 18 – fears and fantasizes avoidance
5. 18-45 – increased attitude awareness
6. 45-65 – accepts mortality
7. Above 65 – multiple meanings, encounters and fears

SENSORY PERCEPTION AND COGNITION

1. Sensory deprivation
2. Sensory overload
3. Sensory deficits

Protecting Health: Universal Precaution

1. Strict Isolation

• highly transmissible diseases by direct contact and airborne routes of transmission

• Private room, gowns, mask, gloves, hand washing, double bagged techniques for soiled articles
• Diptheria (pharyngeal), Herpes Zoster, Varicella , Pneumonia (S. aureus, Strep. group A)
2. Respiratory Isolation-droplet transmission (3 feet)

• Private room, patient w/ same organism, mask, hand washing, labeled plastic bags for soiled articles
• H. influenza, measles, mumps, N. meningitidis
3. Tuberculosis/ AFB isolation-suspected / active TB

• Private room with negative pressure ventilation so that air room is vented outside, mask, hand washing,
bronchoscopy and dental examination postponed until 2 weeks of antibiotic therapy
4. Contact Isolation

• Infectious diseases or multiple resistant microorganisms that are spread by direct contact or close contact
• Private room, mask gown, gloves
• Diptheria (cutaneous), Herpes simplex, MRSA, Pediculosis, Scabies, Syphilis
5. Enteric Precautions

• infectious diseases transmitted through direct or indirect contact with infected feces.
• Hand washing, gloves, gowns worn only when handling contaminated objects with feces
• Aseptic meningitis, AGE, Hepatitis A , Typhoid fever, diarrhea (CDT )
6. Drainage / Secretions precautions

• patients with wound drainage or infected wounds

• Gloves, gowns indicated if clothing is likely to be contaminated burns
7. Universal Blood and Body fluids precautions

• blood-borne, body fluids pathogens (blood, semen, vaginal secretions, CSF, synovial fluid, pleural fluid,
peritoneal fluid, pericardial fluid, amniotic fluid and tissues. Gloves, mask, protective eye gears, gown,
contaminated needles not recapped and sharps in puncture resistant containers
• Aids, Hepatitis B and C, STDs

8. Reversed Isolation

• Patient is protected from pathogens and nosocomial infections by instituting reverse transmission precautions.
Burns and open wounds, patients with artificial airway, immunocompromised patients – leukemia, AIDS, steroid
therapy, radiation or cancer chemotherapy, medication effect of leukopenia or agranulocytosis
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Diagnostic Studies and Interpretation

DETERMINATION REFERENCE RANGE CLINICAL SIGNIFICANCE

Hematology

Bleeding Time 1 – 8 min. Prolonged in thrombocytopenia, defective platelet function

and aspirin therapy

Factor VIII assay 60 % - 140 % Deficient in classical hemophilia

Prolonged in deficiency of fibrinogen, factors II, V, VIII, IX,

X, XI And XII and in Heparin therapy
PTT 60 – 70 sec

PT 10-12 sec Prolonged by deficiency of factors I, II, V, VII, fat

malabsorption, severe liver disease, coumadin
anticoagulant therapy

INR 2-3 Used to standardize the prothrombin time and

anticoagulation therapy

Erythrocyte count M 4.6 – 6.2 x 1012/ L Increased in severe diarrhea and dehydration,
polycythemia, acute poisoning, pulmonary fibrosis
F 4.2 – 5.4 x1012/ L

Decreased in all anemia, in leukemia, and after

hemorrhage, when blood volume has been restored

ESR Westergren method < 15-20 mm / Hour Increased in tissue destruction, whether inflammatory or
degenerative, during menstruation and pregnancy and in
ESR Zeta Centrifuge acute febrile illness

< 0.40-0.60

Hematocrit M: 42- 54 % Decreased in severe anemia, anemia of pregnancy, acute

massive blood loss
F: 36 – 48 %

Increased in erythrocytosis of any cause and in dehydration

or hemoconcentration associated with shock

Hemoglobin M: 14 – 18 gm / dl Decreased in various anemia, pregnancy, severe or

prolonged hemorrhage, with excessive fluid intake
F: 12 – 16 gm / dl
Increased in polycythemia, chronic obstructive pulmonary
disease, failure of oxygenation because of CHF and
normally in people living at high altitudes

WBC / leukocytes 5,000–10,000/cu.mm Increased in various infections

Neutrophils 45 %– 73 % Neutrophils increased with acute infections, trauma or

surgery, leukemia, malignant disease, necrosis, decreased
Eosinophils 0%-4% with viral infections, bone marrow suppression, primary
bone marrow disease
Basophils 0% - 1%

Lymphocytes 20 %– 40 %
Eosinophils increased in allergies, parasitic disease,
Monocytes 2% - 8 % collagen disease, subacute infections, decreased with
stress, use of some medications

(ACTH, epinephrine, thyroxine)

Basophils increased with acute leukemia and following

surgery or trauma, decreased with allergic reactions, stress,
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 parasitic disease, use of corticosteroids

Lymphocytes increased with infectious mononucleosis, viral

and some bacterial infections, hepatitis; decreased in
aplastic anemia, SLE, immunodeficiency including AIDS

Monocytes increased with viral infections, parasitic disease,

collagen and hemolytic disorders, decreased with use of
corticosteroids, RA, HIV infection

Platelet count 150,000-450,000/cu. Increased in malignancy, myeloproliferative disease,

rheumatoid arthritis and post operatively
Mm
Decreased in thrombocytopenic purpura, acute leukemia,
aplastic anemia and during cancer chemotherapy

Prevention and Early Detection of Disease

HEALTH SCREENING

1. OB – GYNE / REPRODUCTIVE TESTS

2. UTZ-5 WKS CONFIRM PREGNANCY AND AOG
3. AMNIOCENTESIS – 16 WKS- DETECT GENETIC DISORDERS – 30 WEEKS – L/S RATIO (2-4 WKS RESULT)
(EMPTY Bladder)
4. OCT – (28 WKS) FHR DECELERATIONS – IV OXYTOCIN 15-20 MIN----3 CONTRACTIONS OBTAINED WITHIN
10 MINUTES- REACTIVE
5. NST– FHR ACCELERATIONS (32-34 WKS)– 2-MORE FHR ACCELERATION OF 15 BPM or MORE LASTING 15
SECS -20 MINS. AND RETURN OF FHR TO NORMAL/BASELINE – REACTIVE
6. DOPPLER TONE- 12 WEEKS (18 – 20 WKS-AUSCULTATION)
7. AFP-FETAL SERUM CHON- DETECT NEURAL TUBE DEFECTS – 16-18 WKS
8. CHORIONIC VILLI SAMPLING –FETAL ABNORMALITIES- 10-12 WKS

NEWBORN/ INFANT HEALTH SCREENING

1. PKU – GUTHRIE BLOOD TEST- EAT CHON FOR 2 DAYS MIN. (PHEONISTICS – DIAPER)
2. SICKLE CELL DISEASE –ABNORMALLY SHAPED HEMOGLOBIN
3. ELISA AND WESTERN BLOT
4. CARRIER SCREENING FOR CYSTIC FIBROSIS AND SWEAT CHLORIDE TEST

SCHOOL AGE
1. HEARING AND VISION TESTS
2. ALLEN PICTURE CARDS
3. SNELLEN CHART - 20/40 AT TODDLER AND 20/20 AT SCHOOL AGE
4. WEBER’S - SENSORINEURAL AND CONDUCTIVE
5. RINNE’S - CONDUCTIVE
6. DENTAL EXAM – STARTS AT 2 YEARS

ADOLESCENT
1. PPD – induration – 72 hours
2. BSE – (18-20 YRS.) post menstruation/ monthly
3. TSE – monthly (18-20 YRS)
4. Pelvic Exam with PAP Smear – if sexually active or 18 years old annually

ADULT/ELDERLY
1. HPN, DM, HEARING AND VISION
2. Prostate – annually at 40 years old
3. Ca check-ups – every 3 years = 20 years old; every year = 40 years old
4. Sigmoidoscopy - > 50 Y.O. = every 3-5 years
5. Fecal Occult Blood Test - > 50 YO = annually
6. Digital Rectal Exam - > 40 Y.O. = yearly
7. Pelvic Exam - 18-40 Y.O. = performed every 1 – 3 years with PAP TEST
8. Mammogram - 35 – 39 YO = once baseline
40 – 49 YO = every 2 years

50 YO– older = every year

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