1.
Fundamentals
of Nursing
By. Nurse AMY

2.
Suchman’s Five Stages of Illness
•Symptom experience
•Assumption of the sick role
•Medical care contact
•Dependent client role
•Recovery or rehabilitation

3.
Body defenses
- These are the methods used by the body to protect itself from
invasion of disease producing substance.
• Primary
• Secondary
• Tertiary

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.
Prevention
•Primary
•Secondary
•Tertiary

6.
Nursing
• Art
• Science

7.
•Florence Nightingale
•Virginia Henderson- first modern
nurse to define nursing
•ANA

8.
PhasesofNurse-ClientRelationship
•Orientation
•Working Phase
•Termination

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.
Factors Affecting Body temperature
•S
•H
•A
•D
•E
•E

11.
Types of Fever
•1. intermittent
•2. Remittent
•3. Relapsing
•4. Constant

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.
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.
Methods of Temperature taking
•Oral
•Rectal
•Axillary

15.
2. Pulse
Apical
Peripheral Pulses:
Temporal femoral
carotid popliteal
brachial post. tibial
radial dorsalis pedis
ulnar

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.
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.
PE

19.
Physical Assessment
•Inspection
•Palpation
•Percussion
•Auscultation

20.
•INTEGUMENTARY
•HEENT
•CHEST
•GASTROINTESTINAL
•GENITO-URINARY
•MUSCULAR

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.
inspect
• Color
• Symmetry
• lesions

23.
Oxygenation
•Assessment
•color,
•level of consciousness,
•vital signs,
•presence of cough,
• nature of sputum and
•energy level

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.
•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.
•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.
Metaparadigm
•Person
•Environment
•Health
•Nursing

28.
Philippine Nursing Act of 2002
•BON- power to create
•PNA- coordinate
•Basis: code of governance

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.
Article 2: Nurses and People
•Confidentiality
•Autonomy
•Respect
•Safety

31.
Article 3: Nurses and Practice
•Aspect of care
a.Moral
b.Legal
c. Professional Dimension

32.
Article 4: Nurses and Co- worker
•Establishment of linkages
Article 5: Nurses, Society and
Environment
•Maintain peaceful environment

33.
Article 6: Profession
•Member of APO
•Involved in voluntary education
•Maintain Loyalty to the profession

34.
Article 7: Administrative penalties
• Effective July 14, 2002