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Fundamentals-of-nursing-lecture-Notes-PDF
Selected Nursing Concepts (NUR 116)
Northern Virginia Community College
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FUNDAMENTALS OF NURSING
By nclexnursing
OVERVIEW
I. THEORETICAL FRAMEWORK of NURSING PRACTICE
A. Nursing B. Concepts of Health and Illness C. Concepts of Stress D. Homeostasis E. Adaptation F. Adaptation to Stress – Physiological Response (Hans Selye) G. Physiologic Indicators of Stress
II. COPING STRATGIES (COPING MECHANISMS) A. 2 Types of Coping Strategies B. Relaxation Techniques
III. PSYCHOLOGICAL RESPONSE A. Task – Oriented Behaviors B. Defense Mechanisms C. Common Defense Mechanisms
IV. TYPES of NURSING DIAGNOSES A. Formulating the Nursing Diagnosis B. Collaborative Problems
V. METHODS USED for ASSESSMENT A. Collection of Data: Objective and Subjective
VI. DOCUMENTING and REPORTING A. Guidelines for Good Documentation and Reporting B. Documentation C. Documentation Systems D. Nursing Care Plan (NCP) E. KARDEX F. Nursing Discharge / Referral Summaries
VII. PHYSICAL EXAMINATION A. Purposes B. Preparation of Examination C. Order of Examination D. Skills in Physical Assessment E. Examples of Adventitious Breath Sounds
VIII. THE COMMUNICATION PROCESS A. Modes of Communication B. Verbal Communication
C. Nonverbal Communication D. Factors Influencing the Communication Process E. Therapeutic Communication Technique F. Barriers to Communication G. Phases of the Helping Relationship
PRINCIPLES and PRACTICE of NURSING CARE
IX. PRINCIPLES of ASEPSIS and INFECTION CONTROL
A. Chain of Infection B. Modes of Transmission C. Course of Infection D. Inflammation E. Immune Response F. Nosocomial Infection G. Factors Increasing Susceptibility to Infection H. Diagnostic Tests Used to Screen for Infection
X. THEORIES OF PAIN A. Specific Theory B. Pattern Theory C. Gate Control Theory D. Current Developments in Pain Theory
XI. TYPES OF PAIN
A. Acute Pain B. Chronic Pain
XII. PAIN ASSESSMENT A. TOOLS/INSTRUMENTS USED B. A B C D E method of pain assessment C. P Q R S T assessment for pain perception D. Pain History
ADMINISTRATION OF MEDICATIONS
XIII. DRUG NOMENCLATURE and FORMS A. Names B. Classification C. Forms D. Types of Drug Actions E. Principles in Administering Medications
XIV. BASIC HUMAN NEEDS A. Abraham Maslow B. Maslow’s Characteristics of a Self–Actualized Person
XV. MEETING OXYGENATION NEEDS
As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia Henderson: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health. It’s recovery, or to a peaceful death that the client would perform unaided if he had the necessary strength, will or knowledge.
Help the client gain independence as rapidly as possible.
1. CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE
Theorist Description
FLORENCE NIGHTINGALE
Developed the first theory of nursing. Focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.
HILDEGARD PEPLAU
Introduced the Interpersonal Model. She defined nursing as a therapeutic, interpersonal process which strives to develop a nurse-patient relationship in which the nurse serves as a resource person, counselor and surrogate.
FAYE ABDELLAH Defined nursing as having a problem-solving approach , with key nursing problems related to health needs of people; developed list 21 nursing problem areas
IDA JEAN ORLANDO
Developed the three elements – client behavior, nurse reaction and nurse action – compose the nursing situation. She observed that the nurse provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness.
MYRA LEVINE Described the Four Conservation Principles. 1. conservation of energy 2. conservation of structured integrity 3. conservation of personal integrity 4. conservation of social integrity
DOROTHY JOHNSON
Developed the Behavioral System Model. 1. Patient’s behavior as a system that is a whole with interacting parts 2. how the client adapts to illness 3. goal of nursing is to reduce so that the client can move more easily through recovery.
MARTHA ROGERS Conceptualized the Science of Unitary Human Beings. She asserted that human beings are more than different from
the sum of their parts; the distinctive properties of the whole are significantly different from those of its parts.
DOROTHEA OREM
Emphasizes the client’s self care needs ; nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs.
IMOGENE KING Nursing process is defined as dynamic interpersonal process between nurse, client and health care system.
BETTY NEUMAN Stress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of prevention
SISTER CALLISTA ROY
Presented the Adaptation Model. She viewed each person as a unified bio-psychosocial system in constant interaction with a changing environment. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function and interdependent relations during health and illness.
LYDIA HALL Introduced the notion that nursing centers around three components: person(core), pathologic state and treatment(cure) and body(care).
JEAN WATSON Conceptualized the Human Caring Model. She emphasized that nursing is the application of the art and human science through transpersonal caring transactions to help persons achieve mind-body-soul harmony, which generates self- knowledge, self-control, self-care and self-healing.
ROSEMARIE RIZZO PARSE
Introduced the Theory of Human Becoming. She emphasized free choice of personal meaning in relating to value priorities, co-creating of rhythmical patterns, in exchange with the environment and contranscending in many dimensions as possibilities unfold.
MADELEINE LENINGER
Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition
2. ROLES AND FUNCTION OF A NURSE
a. Caregiver – the caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client’s
a. Characteristics i. A concern for the individual as a total system ii. A view of health that identifies internal and external environment iii. An acknowledgment of the importance of an individual’s role in life
A dynamic state in which the individual adapts to changes in internal and external environment to maintain a state of well being
b. Models of Health and Illness
i. Health-Illness Continuum (Neuman ) – Degree of client wellness that exist at any point in time, ranging from an optimal wellness condition, with available energy at its maximum, to death which represents total energy depletion. ii. High – Level Wellness Model (Halbert Dunn) – It is oriented toward maximizing the health potential of an individual. This model requires the individual to maintain a continuum of balance and purposeful direction within the environment. iii. Agent – Host – environment Model (Leavell ) – The level of health of an individual or group depends on the dynamic relationship of the agent, host and environment Agent – any internal or external factor that disease or illness. Host – the person or persons who may be susceptible to a particular illness or disease Environment – consists of all factors outside of the host iv. Health – Belief Model – Addresses the relationship between a person’s belief and behaviors. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies.
Four Components The individual is perception of susceptibility to an illness The individual’s perception of the seriousness of the illness The perceived threat of a disease The perceived benefits of taking the necessary preventive measures
v. Evolutionary – Based Model – Illness and death serves as a evolutionary function. Evolutionary viability reflects the extent to which individual’s function to promote survival and well-being. The model interrelates the following elements: Life events Life style determinants Evolutionary viability within the social context Control perceptions Viability emotions Health outcomes
vi. Health Promotion Model – A “complimentary counterpart models of health protection”. Directed at increasing a client’s level of well being. Explain the
reason for client’s participation health-promotion behaviors. The model focuses on three functions: It identifies factors (demographic and socially) enhance or decrease the participation in health promotion It organizes cues into pattern to explain likelihood of a client’s participation health-promotion behaviors It explains the reasons that individuals engage in health activities
II. Illness – State in which a person’s physical, emotional, intellectual, social developmental or spiritual functioning is diminished or impaired. It is a condition characterized by a deviation from a normal, healthy state.
a. 3 Stages of Illness i. Stage of Denial – Refusal to acknowledge illness; anxiety, fear, irritability and aggressiveness. ii. Stage of Acceptance – Turns to professional help for assistance iii. Stage of Recovery (Rehabilitation or Convalescence) – The patient goes through of resolving loss or impairment of function
b. Rehabilitation i. A dynamic, health oriented process that assists individual who is ill or disabled to achieve his greatest possible level of physical, mental, spiritual, social and economical functioning. ii. Abilities not disabilities, are emphasized. iii. Begins during initial contact with the patient iv. Emphasis is on restoring the patient to independence or regain his pre-illness/predisability level of function as short a time as possible v. Patient must be an active participant in the rehabilitation goal setting an din rehabilitation process.
c. Focuses of Rehabilitation i. Coping pattern ii. Functional ability – focuses on self-care: activities of daily living (ADL); feeding, bathing/hygiene, dressing/grooming, toileting and mobility iii. Mobility iv. Integrity of skin v. Control of bowel and bladder function
C. Concepts of Stress I. Stress (Theory by Hans Selye) a. Non specific response of the body to nay demand made upon it b. Any situation in which a non specific demand requires an individual to respond or take action
II. Characteristics of Stress a. Stress is not nervous energy. Emotional reactions are common stressors
b. Stress is not always the result of damage to the body
Stressor
Epinephrine Tachycardia ↑ Myocardial contractility ↑ Blood clotting ↑ Metabolism
Norepinephrine ↓ Blood to kidney ↑ Renin
Cotisone Protein catablism Gluconeogenesis
Stage of Resistance
Shock Phase
nervous system to pain. It is an adaptive response and protects tissue from further damage. The response involves a sensory receptor, a sensory nerve from the spinal cord, and an effector muscle. An example would be the unconscious, reflex removal of the hand from a hot surface.
ii. Inflammatory Response – is stimulated by trauma or infection. This response localizes the inflammation, thus revenging its spread and promotes healing. The inflammatory response may produce localized pain, swelling, heat, redness and changes in functioning.
c. Three Phases of Inflammatory Response i. First Phase – Narrowing of blood vessels occurs at the injury to control bleeding. Then histamine is released at the injury, increasing the number of white blood cells to combat infection.
ii. Second Phase – It is characterized by release of exudates from the wound
iii. Third Phase – The last phase is repair of tissue by regeneration or scar formation. Regeneration replaces damaged cells with identical or similar cells.
II. General Adaptation Syndrome (GAS) or Stress Syndrome – characterized by a chain or pattern of physiologic events. a. 3 Stages i. Alarm Reaction – initial reaction of the body which alerts the body’s defenses. SELYE divided this stage into 2 parts: The SHOCK PHASE The COUNTERSHOCK PHASE ii. Stage of Resistance – occurs when the body’s adaptation takes place; the body attempts to adjust with the stressor and to limit the stressor to the smallest area of the body that can deal with it. iii. Stage of Exhaustion – the adaptation that the body made during the second stage cannot be maintained; the ways used to cope with the stressors have been exhausted
10
action, the stage of resistance and the stage of exhaustio
n.
Adaptation Stage of Exhaustion
↓ ↓
Rest Death
b. c. d. e. f. g. h. i. j. STRESSORS stimulate the sympathetic nervous system, which in turn stimulates the hypothalamus. The HYPOTHALAMUS releases corticotrophin releasing hormone (CRH). During times of stress, the ADRENAL MEDULLA secretes EPINEPHRINE & NOREPINEPHRINE in response to sympathetic stimulation. Significant body responses to epinephrine include the following: i. Increased myocardial contractility, which increases cardiac output & blood flow to active muscles ii. Bronchial dilation, which allows increased oxygen intake iii. Increased blood clotting iv. Increased cellular metabolism v. Increased fat mobilization to make energy available & to synthesize other compounds needed by the body.
G. Physiologic Indicators of Stress a. Pupils dilate to increase visual perception when serious threats to the body arise.
b. Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism.
c. The heart rate & cardiac output increase to transport nutrients and by-products of metabolism more efficiently.
d. Skin is pallid because of constriction of peripheral vessels, an effect of norepinephrine.
e. Sodium & water retention increase due to release of mineralocorticoids, which results in increased blood volume.
f. The rate & depth of respirations increase because of dilation of the bronchioles, promoting hyperventilation.
c. Self-Control (discipline) – assuming a manner of facial expression that convey a sense of being in control or in change.
d. Suppression – consciously and willfully putting a thought or feeling out of mind
e. Fantasy – (daydreaming) – likened to make believe. Unfulfilled wishes & desires are imagined as fulfilled, or a threatening experience is reworked or replayed so that it ends differently from reality.
2. COPING STRATEGIES (COPING MECHANISMS)
Coping – dealing with problems & situations or contending with them successfully.
Coping Strategy – innate or acquired way of responding to a changing environment or specific problem or situation.
According to Folk man and Lazarus, coping is “the cognitive & behavioral effort to manage specific external and/ or internal demands that are appraised as taxing or exceeding the resources of the person”.
A. Coping Strategies: 2 Types I. Problem-focused coping – efforts to improve a situation by making changes or taking some action II. Emotion-focused coping – does not improve the situation, but the person often feels better.
Coping strategies are also viewed as: a. Long-term coping strategies – can be constructive & realistic b. Short-term coping strategies – can reduce stress to a tolerable limit temporarily but are in the end of ineffective ways to deal with reality. Coping can be adaptive or maladaptive : B. Adaptive Coping – helps the person to deal effectively with stressful events & minimizes distress associated with them. C. Maladaptive Coping – can result in unnecessary distress for the person & others associated with the person or stressful event.
*Effective coping results in adaptation; ineffective coping results in maladaptation. The effectiveness of an Individual’s coping is influenced by a number of factors: The number, duration & intensity of the stressors Past experiences of the individual Support systems available to the individual Personal qualities of the person
*If the duration of the stressors is extended beyond the coping powers of the individual, that person becomes exhausted and may develop increased susceptibility to health problems.
*Reaction to long term stress is seen in family members who undertake the care of a person in the home for a long period. This stress is called caregiver burden & produces responses such as chronic fatigue, sleeping difficulties & high BP.
*Prolonged stress can also result in mental illness.
D. Relaxation Techniques – used to quiet the mind, release tension & counteract the fight or flight responses of General Adaptation Syndrome (GAS). I. Breathing Exercises II. Massage III. Progressive Relaxation IV. Imagery V. Biofeedback VI. Yoga VII. Meditation VIII. Therapeutic Touch IX. Music Therapy X. Humor & Laughter
3. PSYCHOLOGICAL RESPONSE
Exposure to a stressor results in psychological and physiological and physiological adaptive responses. As people are exposed a stressors, their ability to meet their basic needs is threatened. This threat whether actual or perceived, produces frustration, anxiety and tension. Psychological adaptive behaviors assist the person’s ability to cope with stressors. These behaviors are directed at stress management and are acquired through learning and experience as a person identifies acceptable and successful behaviors.
Psychological adaptive behaviors are also related to as COPING MECHANISMS. It involves:
A. Task – Oriented Behaviors – Involve using cognitive abilities to reduce stress, solve problems, resolve conflicts and gratify needs. It enables a person to cope realistically with the demands of a stressor.
Three General Types I. Attack Behavior – Is acting to remove or overcome a stressor or to satisfy a need II. Withdrawal Behavior – Is removing the self physically or emotionally from the stressor III. Compromise Behavior – Is changing the usual method of operating, substituting goals or omitting the satisfaction of needs to meet other needs or to avoid stress.
B. Defense Mechanisms – Unconscious behaviors that offer psychological protection from a stressful event. They are used by everyone and help protect against feelings of worthlessness and anxiety. Frequently activated by short-term stressors and usually do not result in psychiatric disorders.
5. METHODS USED for ASSESSMENT
A. Collaboration of Data: Objective & Subjective
I. Review of clinical record a. Client records contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations
b. Reviewing the client’s record before beginning an assessment prevents the nurse from repeating questions that the client has already been asked and identifies information that needs clarification.
II. Interview a. The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support. b. The goals of an interview are to develop a rapport with the client and to collect data c. An interview has 3 major stages i. Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self – introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time. ii. Body: during this phase, the client responds to open and closed- ended questions asked by the nurse. iii. Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process.
d. Types of questions i. Closed questions used in directive interview Re____ short factual answers; e. “Do you have pain?” Answers usually reveal limited amounts of information Useful with clients who are highly stressed and/or have difficulty communicating
ii. Open-ended questions used in nondirective interview Encourage clients to express and clarify their thoughts and feelings; e. “How have you been sleeping lately?’ Specify the broad area to be discussed and invite longer answers Useful at the start of an interview or to change the subject
iii. Leading questions Direct the client’s answer; e. “You don’t have any questions about your medications, do you?” Suggests what answer is expected
Can result in client giving inaccurate data to please the nurse Can limit client choice of topic for discussion
III. Nursing History a. Collection of information about the effect of the client’s illness on daily functioning and ability to cope with the stressor (the human response)
b. Subjective data i. May be called “covert data” ii. Not measurable or observable iii. Obtained from client (primary source), significant others, or health professionals (secondary sources). iv. For example, the client states, “I have a headache”
c. Objective data i. May be called “overt data” ii. Can be detected by someone other than the client iii. Includes measurable and observable client behavior iv. For example, a blood pressure reading of 190/110 mmHg.
IV. Physical assessment a. Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion b. A body system format for physical assessment is found below:
V. Psychosocial assessment a. Helpful framework for organizing data b. A suggested format for psychosocial assessment is found below:
General assessment Integumentary system Head, ears, eyes, nose, throat Breast and axillae Thorax and lungs Cardiovascular system Nervous system Abdomen and gastrointestinal system Anus and rectum Genitourinary system Reproductive system Musculoskeletal system
Vocation/education/financial Home and Family Social, leisure, spiritual and cultural Sexual Activities of daily living Health Habits Psychological
B. Documentation – anything written or printed that is relied on as a record of proof fro authorized persons.
Purposes of Records: I. Communication II. Planning Client Care III. Auditing Health Agencies IV. Research V. Education VI. Reimbursement VII. Legal Documentation VIII. Health Care Analysis
C. Documentation Systems I. Source – Oriented Record a. The traditional client record b. Each person or department makes notations in a separate section or sections of the client’s chart c. It is convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information d. Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s history sheet & progress notes e. NARRATIVE CHARTING is a traditional part of the source-oriented record
II. Problem – Oriented Medical Record (POMR) a. Established by Lawrence Weed b. The data are arranged according to the problems the client has rather than the source of the information.
The four (4) basic components: i. Database – consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physician’s history, social & family data ii. Problem List – derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved iii. Plan of Care – care plans are generated by the person who lists the problems. Physician’s write physician’s orders or medical care plans; nurses write nursing orders or nursing care plans iv. Progress Notes – chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet for notes. Numbered to correspond to the problems on the problem list and may be lettered for the type of data
Example: SOAP Format Or SOAPIE and SOAPIER
S – Subjective data O – Objective data A – Assessment P – Plan I – Intervention E – Evaluation R- Revision Advantages of POMR: It encourages collaboration Problem list in the front of the chart alerts caregivers to the client’s needs & makes it easier to track the status of each problem.
Disadvantages of POMR: Caregivers differ in their ability to use the required charting format Takes constant vigilance to maintain an up-to-date problem list Somewhat inefficient because assessments & interventions that apply to more than one problem must be repeated.
III. PIE (Problems, Interventions, and Evaluation) a. Groups information in to three (3) categories b. This system consists of a client care assessment floe sheet & progress notes c. FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional health patterns d. Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes
IV. Focus Charting a. Intended to make the client & client concerns & strengths the focus of care b. Three (3) columns for recording are usually used: date & time, focus & progress notes
V. Charting by Exception a. Documentation system in which only abnormal or significant findings or exceptions to norms are recorded b. Incorporates three (3) key elements: i. Flow sheets ii. Standards of nursing care iii. Bedside access to chart forms
VI. Computerized Documentation a. Developed as a way to manage the huge volume of information required in contemporary health care b. Nurses use computers to store the client’s database, add new data, create & revise care plans & document client progress.
Fundamentals-of-nursing-lecture-Notes-PDF
Course: Selected Nursing Concepts (NUR 116)
University: Northern Virginia Community College
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