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Fundamentals of Nursing lecture.pptx

  1. 1. Fundamentals of Nursing By. Nurse AMY
  2. 2. Suchman’s Five Stages of Illness •Symptom experience •Assumption of the sick role •Medical care contact •Dependent client role •Recovery or rehabilitation
  3. 3. Body defenses - These are the methods used by the body to protect itself from invasion of disease producing substance. • Primary • Secondary • Tertiary
  4. 4. Tissue and wound healing • Affected by person’s general condition- age, nutritional status, blood supply to the area, extent of injury. Type of wound healing Type of wound How does it heal First Intention Minimal tissue damage Simple incision Without infection No separation of wound Results in minimal scar Second Intention Decubitus ulcer Wound edges do not join Spaces in between wound edges is filled with granulation tissue Third intention Dehiscence suture Results in scar and possible contraction of surrounding tissue.
  5. 5. Prevention •Primary •Secondary •Tertiary
  6. 6. Nursing • Art • Science
  7. 7. •Florence Nightingale •Virginia Henderson- first modern nurse to define nursing •ANA
  8. 8. PhasesofNurse-ClientRelationship •Orientation •Working Phase •Termination
  9. 9. Vital Signs 1. Temperature • Core • Surface *Factors that affects body heat production: a. B b. I c. T d. C e. H Mechanism of HEAT LOSS
  10. 10. Factors Affecting Body temperature •S •H •A •D •E •E
  11. 11. Types of Fever •1. intermittent •2. Remittent •3. Relapsing •4. Constant
  12. 12. •Decline of Fever 1. Crisis/ Flush/ Defervescent- excessive sweating and hot flushed skin due to sudden vasodilation. 2. Resolution of pyrexia by lysis- gradual return of body temperature
  13. 13. Nursing Intervention for Clients with FEVER 1. Monitor V/S especially temperature 2. Monitor WBC, Hct 3. Remove warm extra blanket when warm, provide when client have chills 4. Well balanced diet, increase fluid 5. MIO 6. IVF 7. Rest 8. Oral Hygiene 9. Cool circulating air 10. TSB 11. Antipyretics
  14. 14. Methods of Temperature taking •Oral •Rectal •Axillary
  15. 15. 2. Pulse Apical Peripheral Pulses: Temporal femoral carotid popliteal brachial post. tibial radial dorsalis pedis ulnar
  16. 16. •3. Blood Pressure= SV X PR Physiology of ARTERIAL BLOOD PRESSURE a. Pumping action of the heart b. Peripheral Vascular Resistance c. Blood volume d. Blood Viscosity
  17. 17. 4. Respiration • Newborn- 30-80 • 12 months- 20-40 • 2 years- 20-30 • 8 years- 15-25 • 16 years- 15-20 • Adult- 12- 20
  18. 18. PE
  19. 19. Physical Assessment •Inspection •Palpation •Percussion •Auscultation
  21. 21. Characteristics Normal Abnormality Color Infant: Yellow Adult: brown White/ clay Black or tarry Red Pale with fat Translucent mucus Bloody mucus Odor Pungent Noxious change Consistency Soft, formed Hard liquid Frequency Infant: 4-6x daily Adult: daily or 2-3 times a week Infants: >6x/ day or less than once every 1-2 days Adult: >3x/day or less than once a week Amount 150 g per day Shape Resembles the diameter of the rectum Constituents Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal mucosa and water. Blood, pus, foreign bodies, mucus, worms and excess fats
  22. 22. inspect • Color • Symmetry • lesions
  23. 23. Oxygenation •Assessment •color, •level of consciousness, •vital signs, •presence of cough, • nature of sputum and •energy level
  24. 24. •General Measures •Encourage exercise and activity. •Bedridden patients must be turned and positioned every 2 hours. •Encourage coughing and deep breathing at least every 2 hours for inactive and bedridden patients •Ensure adequate fluid intake
  25. 25. •The use of NEBULIZER •Methods of delivering medication directly to the respiratory tract. •Nebulizer breaks liquid into a mist of droplets which are inhaled.
  26. 26. •Incentive Spirometer •With the lips sealed around the mouthpiece, the patient takes a deep breath, holds, for 3 seconds and slowly exhales. •The spirometer indicates with a light or small plastic balls reaching an indicated level whether the patient has inhaled the desired volume.
  27. 27. Metaparadigm •Person •Environment •Health •Nursing
  28. 28. Philippine Nursing Act of 2002 •BON- power to create •PNA- coordinate •Basis: code of governance
  29. 29. Article 1: Preamble •Health is the fundamental right -Must be preserved at all cost a. Promotion of heath b. Prevention of Illness c. Alleviation of suffering d. Restoration of health
  30. 30. Article 2: Nurses and People •Confidentiality •Autonomy •Respect •Safety
  31. 31. Article 3: Nurses and Practice •Aspect of care a.Moral b.Legal c. Professional Dimension
  32. 32. Article 4: Nurses and Co- worker •Establishment of linkages Article 5: Nurses, Society and Environment •Maintain peaceful environment
  33. 33. Article 6: Profession •Member of APO •Involved in voluntary education •Maintain Loyalty to the profession
  34. 34. Article 7: Administrative penalties • Effective July 14, 2002

Notas del editor

  • Physical experience, cognitive, emotional
    Accept sick role, seek confirmation
    Validation of real illness
    Becomes dependent to healthcare
    Resume former roles.
  • skin, cilia, mucous membrane, tears, reflexes.
    Infla- inc. BF- leukocyte move to the area- phagocytosis- pus(from dead pathogen and tissue) healing
    Immune response- antigen, antibody.
    Autoimmunity- antibodies are produced against the body, rf, ra
  • True prevention, precede the disease, physically and emotionally healthy.. Exercise, smoking cessation, lifestyle changes.
    Early diagnosis- for at risk of developing complication and worsening condition. Screening, casefinding.
    Minimizing the effect, irreversible disease or disability.- treatment, rehabilitation.
  • Utilization of environment
    a. Goal oriented, Adaptable, Direct to the needs of individual, family and community.
    b. 1980: diagnosis and treatment of human responses to actual or potential problems.
    c. 1995: protection, promotion, optimization of health services and abilities.
    prevention of illness and injury
    alleviation of suffering
  • Trust building
    Management of emotion
    Environmental orientation

    Teach- Learn- Change

    Referral and Reintegration
    Evaluation of independence
    Synthesis of Learning
    Termination of relationship
  • *BMR
    Increase Temperature
    Thyroxine output
    Heart and Muscle activity
  • Stress
    Diurnal Variation
  • Discuss pulse generation.
    Cardiac output= SV X HR
    Factors: Age, sex, Fever, exercise, athlete, medication, hemorrhage, stress,
    Use when radial pulse is not accessible
    Physiological shock and cardiac arrest and circulation to the brain
    Bp measurement and circulation of lower arm
    Readily accessible
    Allen’s test
    Physiological shock and circulation of the leg
    Circulation of leg
    -9. circulation of the foot.
  • 30-40 mmHg- smooth and rounded contours
    Pressure is decrease the pulse feel weak and small- decrease stroke volume, as in heart failure, hypovolemia
    Strong and bounding rapid rise and fall, peak is brief- d/t increase stroke vol. decrease PR, fever, anemia hyper, AV fistula
    Increase in pulse with double systolic peak- ar,
    Regular, alternATAING sof and weak beat
    Normal beat with premature contraction
    Decrease altitude on inspiration
  • Hypertensive crises- emergency, urgency
    Orthostatic hypertension
  • Rate
    Hyperventilation- rapid, deep
    Hypoventilation- shallow
    Cheyne- stoke- deep with period of apnea
    Kussmaul- rapid, deep, labored breathing
    Pleural friction rub
  • Position, expose, confidentiality, comparison
    Light, deep 1-3 inches perpendicular
    Direct, indirect- plexor and pleximeter
    Ausculatation bell- low pitch bp s3, s4
  • Bronchial- trachea- high pitch low intensity
    Bronchoves- sternum and scapula- mod all
    Vesicular soft intensity, low pitch
  • Cyanosis- bluish- dec 02- lips, nail bed, skin
    Pallor- whitish dec. o2, face, conjunctiva, lips, nail beds, palms, sole
    Jaundice bilirubin dark skinned hard palate
    Primary lesion
    Macule- patch- less than and greater than 1 cm, flat
    Papule- plaque greater than 1 cm
    Nodule tumor
    Wheal- collection of edematous fluid
    Vesicle bullae
  • to help expand lungs, providing better oxygenation.
    to prevent pooling of secretion in the lungs
    to help with oxygenation and bringing up secretions.
    to keep secretions thin and thus esier to expectorate
  • Recipent
    Nternal and external
    Level of wellness
    Nursing care
  • Dean julieta sotejo- 1st to create in 1981