FUNDAMENTALS OF NURSINGHISTORY OF NURSING

PERIODS OF NURSINGPERIODS OF NURSINGINTUITIVE NURSING/ PRIMITIVE NURSING/ INSTINCTIVE NURSING (Primitive times – 6th century)PRIMITIVE TIMES- Women practice nursing because of low status in society.- Took care of children and sick members of the family.- Personalistic cause of disease. - Sickness is due to active intervention of:

a. human – caused by witchcraft.b. non human – caused by ghosts.c. superhuman beings – caused by deities.

- Superstitious and believes in magic.- Slave society “slave nurses”- Wet nursing, take care of babies/children of their masters- Women also practices midwifery.- Masters/healers are the people who are responsible in decision making when it comes to health.6 th CENTURY - Founding of religious orders.3 Attributes of Nurses1. Self denial2. Devotion to hard work and duty.3. With spiritual calling.Main Guiding Principles1. “Love thy neighbor as thy self”.2. Parable of the Good Samaritan.

- Beneficence (doing good to others).2 Types of Beneficence1. Ordinary – doing good to others.2. Ideal – entails sacrifice.

APPRENTICE NURSING PERIOD (6th Century – 18th Century)6 TH CENTURY - founding of religious orders.- women practiced nursing.- Daughters of Charity/Sisters of Charity founded by St. Vincent de Paul and Augustinian Sisters.CRUSADES- Men practiced nursing.- Knights of St. Lazarus

a. established a standard among hospitals in Europe.b. took care of clients with skin problems like leprosy.

- Knights of St. John of Jerusalema. also known as Knights Hospitalers.b. founded hospitals.

18 TH CENTURY 1836- Theodore Fleidner reestablished order of Deaconesses.- Founded school of nursing in Kaisserwerth, Germany where Florence Nightingale was the most known student.1854-1856 (CRIMEAN WAR)- Florence Nightingale was known as the Lady with a Lamp.- Compiled the “Notes on Nursing: What it is and What is not” and became the first nurse theorist.

EDUCATIONAL NURSING PERIOD (18th Century – 20th Century)18 TH CENTURY - Florence Nightingale established a nursing school in St. Thomas Hospital in London which adopted the Nightingale System.- Made Florence Nightingale the mother of modern nursing.Philosophy of Nightingale System1. Government funds should be allotted to nursing education.

- earned her the title of being the first nurse political activist.2. Training schools of nursing should be in close affiliation.3. Professional nurses should train nurses.4. Nursing students should be provided with residence near their training hospitals.

- written orders of doctors insisted.- nurses should go with doctors during rounds.

LATE 20 TH CENTURY - Specialization in medicine.- Conceptualization of the role of clinical nurse specialist.- Increase clinical content of education (1900’s).

CONTEMPORARY PERIOD (21st Century)- Globalization of nursing.- Period after world war II.- Borderless nursing or transcultural nursing.- Professionalization of nursing.

PROFESSIONPROFESSION – a special calling that requires special, skills, knowledge and attitudes.7 CRITICAL ATTRIBUTES OF PROFESSION1. Specialized education2. Code of ethics3. Research of orientation4. Autonomy5. Body of knowledge6. Service orientation7. Professional Organization

SOCIALIZATION – process where a person learns the ways and means or skills, knowledge, attitudes of the group to which he belongs to.BENNER LEVEL OF PROFICIENCY1. Novice – student nurse entering a clinical setting where he has no experience at all.2. Advance – nurse who demonstrates a marginally acceptable performance: depends on rules and maxims.3. Competent – 2 – 3 years experience demonstrates organizational ability but lacks speed and flexibility of a proficient nurse.4. Proficient – concerned with long term goals, performance is fluid and flexible compared to competent nurse

- has a wholistic view of the client.5. Expert – no longer relies on maxims, performance is highly proficient, fluid flexible and has a wholistic view.

- has high perceptual acuity or a clinical eye.

DIMENSIONS OF NURSING1. Nursing Practice2. Nursing Education3. Nursing Research

FOCUS OF NURSING1. Health Promotion – improve clients well being.2. Health Maintenance3. Health Instauration – help clients with illness to recover.4. Care of the Dying – clients with cancer.

ROLE – patterns of behavior expected of person assuming a status/position in society or a group.TASK – specific activities required of a person.

PATIENT CLIENT- Has a disease- Very dependent on health

professional

- Not necessarily sick- Health promotion act till disease

prevention- Client collaborates with health

professional

LEVELS OF CLIENTELE1. Individual2. Family3. Community4. Population Groups – special groups with special needs attributed to the following:

a. Cultural characteristics – indigenous people.b. Developmental stagec. Occupation – commercial sex workers are more prone to STD’s.

ROLES OF NURSE1. Nurse Educator- 3 domains of learning

a. Cognitive – knowledge aspectb. Psychomotor – skillsc. Affective – interest/emotion

2. Caregiver- Attends to physical/emotional (mostly physical) needs of the client.3. Nurses as Leader- Process of influencing people to work towards the attainment of goals.4. Manager- Organizational goals/works within an organization.

PROCESS OF MANAGEMENTa. Planning (resources)b. Organizing (delegating tasks/tasking)c. Directing (motivating people)d. Controlling – evaluation of output against standards.

5. Client advocate – protects rights of clients.6. Change agent – improvement in organization.7. Researcher – research process8. Facilitator

THEORIESTHEORIES – relationship between concepts4 CONCEPTS OF NURSING THEORIES1. Individual/Person2. Nursing3. Health4. Environment

GOALS

INDEPENDENCEKNOWLEDGE

RESTORATION WILL

MAINTENANCESTRENGTH

PEACEFUL DEATH

NURSING THEORIESNURSING THEORIESA. GENERAL THEORIES1. NIGHTINGALE’S ENVIRONMENTAL THEORY- What nursing has to do is to put the individual in best position for nature to work on him.- Nursing Action: manipulation of elements in the environment to contribute to reparative process.10 ELEMENTS FOUND IN ENVIRONMENT1. Air – importance to have moving air in room of patient to contribute in proper ventilation.2. Light – patient should be near windows to be able to see sunlight and give hope.3. Health of houses – environmental sanitation.4. Cleanliness5. Beddings – change linens/beddings in patients room to promote comfort.6. Nutrition7. Variety – change in environment for patient.8. Ventilation – promote warming.9. Noise – due to nurses clothing or roaming around.10. Chattering hopes – deals with social aspect; nurse should be cautious with words when at bedside, talk about positive things.2. VIRGINIA HENDERSON’S DEFINITION OF NURSING- Assisting individuals sick or well in the performance of activity.- Role of nurse is complimentary.- Supplementary- Individual person is a whole, complete and individual being.

NURSE- PERSON INTERACTION

NURSES PERSON

ENVIRONMENT

14 BASIC COMPONENTS OF NURSING CARE1. Breathe normally2. Eat, drink adequately3. Eliminate body waste4. Move and maintain desirable posture5. Sleep and rest6. Select suitable clothes7. Maintain body temperature8. Keep body clean and well groomed9. Avoid dangers in environment10. Communicate with others11. Worship according to ones faith12. Work for accomplishment13. Participate in recreation14. Learn to satisfy the curiosity that leads to normal development

1-9 PHYSIOLOGIC

10 – 14 PSYCHOLOGICAL

12 – 13 SOCIOLOGIC

11 SPIRITUAL/MORAL

3. MARTHA ROGER’S SCIENCE OF UNITARY HUMAN BEINGSA. Nursing is humanistic scienceB. Parallel with Ludwig von Bertalanffy’s General System TheoryC. 5 assumptions about human beings

1. Man is a unified whole – whole not equal to sum of parts.2. Individual and environment are continuously exchanging matter and energy.3. Lifecycle evolves irreversibly and uni-directionally along space and time continuum.4. Life patterns identify individuals.5. Humans have the capacity for absorption and imagery, language and thought, sensation and emotion.

GENERAL SYSTEM THEORY- A set of interacting parts/ components with a boundary that filters the input and output from and to the environment.- Input and output: matter, energy, information.- Whole: physical, psychological, spiritual, intellectual.

4. DOROTHEA OREM’S SELF CARE DEFICIT THEORY- Man is an integrated whole, biologically, symbolically and socially.- Man is self reliant and responsible for self care.- Man is requisite for all.- Nursing is a service, art and technology.

3 SUB THEORIES1. Self Care – universal self care, developmental.2. Self Care Deficit – demands, capabilities, deficits.3. Theory of Nursing Systems – wholly compensatory, partly supportive-educative.

UNIVERSAL SELF CARE REQUISITES1. Sufficient intake of air2. Sufficient intake of water3. Sufficient intake of food4. Satisfactory eliminative functions5. Activity balanced with rest6. Time spent alone balanced with time spent with others7. Prevention of danger8. Being normal

DEVELOPMENT OF SELF CARE REQUISITES- Specialized expression of universal self-care requisites for development process.HEATH DEVIATION- Additional demands for health care due to illness, disease or injury.THEORY OF NURSING SYSTEM1. Wholly compensatory – nurse acts for patient.2. Partly compensatory – both nurse and patient.3. Supportive-Educative – patient able to perform self care.

B. SYSTEM THEORIES5. SISTER CALLISTA ROY’S ADAPTATION MODEL- Grounded on humanism.- Person is adaptive system with coping mechanism.- Goal of nursing is to promote persons adaptation.

STIMULI1. Focal - immediate2. Contextual – other internal and external factors3. Residual – may or may not have effect like attitudes and beliefs.

COPING MECHANISMS1. Regulator – neural – chemical – endocrine.2. Cognator – processed through cognition.ADAPTIVE MODES- Physiologic – adaptive mode- Self concept mode- Interdependence mode- Role function mode

- Adaptive/effective response- Maladaptive/ineffective response

6. IMOGENE KING’S GOAL-ATTAINMENT THEORY- Nursing is a process of human interaction between the nurse, client, each person perceive the other and situation and explore the means to achieve them.- Humans are open systems in constant interaction with their environment.- Nursing focus: human interact with the environment.- Nursing Goal: humanistic maintenance of individuals and groups.- Interacting components are personal, interpersonal, social.- Elements: interaction, communication, transaction role, stress.

COMPONENTS PERSONAL SYSTEM- Perception, self, growth and development, image, space, learning time.- Organization, authority, power, status, decision making.

7. BETTY NEUMAN’S HEALTH CARE SYSTEMS MODEL- Based on 2 components stress, reaction to stress.- Client (individual, group, community) is an open system in interaction with environment.4 CONCEPTSA. CLIENTFlexible – keeps system free from stressor reaction or symptom-matology.Line of Resistance – consist of internal defensive processes. Ex. Immune response.

B. ENVIRONMENT- Environment has potential to alter system stability due to internal and external stressors.

STRESSORS CAN BE1. Extra personal – unemployment, microorganisms, peer pressure, radiation.2. Inter personal – between 2 or more individual (parent expectations).3. Intra personal – anger, physical abilities, financial condition.

- Environment can also be source of resources that may help client cope with stressors.C. HEALTHD. NURSING- Primary: protection of normal line of defense.- Secondary: protection of basic structure by strengthening internal line of resistance.Ex. Treatment of symptoms, energy conservation- Tertiary: promotion of reconstitution by supporting existing strengths and resources.

8. DOROTHY JOHNSON’S BEHAVIORAL SYSTEMS MODELMans subsystem- Behavioral subsystem: addressed by nursing intervention.- Biological subsystem: addressed by medical intervention.Goal of Nursinga. demonstrate behavior commensurate to social demands.b. modify behavior to support biological needs.c. benefit from physicians skill and knowledge.d. demonstrate behavior that does not give evidence of unnecessary trauma.- Nursing focus: behavior modification to foster equilibrium.

C. INTERPERSONAL/CARING THEORIES9. HILDEGARD PEPLAU’S INTERPERSONAL RELATIONSHIP IN NURSING- purpose of nursing is to educate and to be a nurturing force to a patient for him to get a new view of himself.- interaction is a maturing force.

Nurse PatientCounselor – identify stressor (with a need)Resource Person – health educatorSurrogate – acts as caregiver

Congruent Goals

PHASE OF NURSE – PATIENT RELATIONSHIP1. Orientation – leveling off between nurse and client in term of expectation.2. Identification – selective response of the client to those who can meet his needs; affected by clients belief.3. Exploitation – client takes control of the situation by extracting help from nurse.4. Resolution – evaluation of care and discharge of client.

10. MADELEINE LEININGER’S TRANSCULTURAL CARE THEORY- Culture: way of life, total of all the material and non material’s produced by the people at their level of social development.- has universalities: same as other culture (hygiene, nutritional needs).- diversities: cultural peculiarities (caring ).

11. IDA JEAN ORLANDO’S DYNAMIC NURSE-CLIENT RELATIONSHIP- Types of nursing response: deliberate action(based on correct identification of patients needs) and automatic action.- nursing function is concerned with providing direct assistance to individuals in whatever setting to avoid, diminish, relieve individual’s sense of helplessness.- Nursing disciplined professional response.

12 JEAN WATSON’S PHILOSOPHY AND SCIENCE OF CARING- Nursing is the science of caring.- Caring is more healthogenic than caring.- Main focus of nursing is on curative factors that are derived from humanistic perspectives combined with a scientific base. 10 CARATIVE FACTORS1. Formation of a humanistic-altruistic value system.2. Faith – hope3. Cultivation of sensitivity to self and others.(First 3 factors are the foundations for caring)4. Establishing a helping trust relation5. Expression of feelings, both positive and negative.6. Research and systematic problem solving.7. Promotion of interpersonal teaching-learning.8. Provisions for a supportive, protective and corrective mental, physical, sociocultural and spiritual environment.9. Assistance with the gratification of human.10. Allowance for existential phenomenological factors.

D. CLIENT CENTERED THEORIES

13. FAYE GLEN ABDELLAH’S 21 NURSING PROBLEMS- Nursing in the use of the problem solving approach- Covert: psychological problem- Overt: obvious (physical manifestations of health problems)

CONSERVATION OF

- Energy

- Structural Integrity

- Personal Integrity

- Social Integrity

Importance of health

Perceived control of health

Perceived self efficacy

Depth of health

Perceived health status

Perceived benefits of health promoting behaviors

Perceived barriers of health promoting behaviors

Biologic

Interpersonal influences

Situational factors

Behavioral factor

Cues to action

14. LYDIA HALL’S THEORY OF CORE, CARE, CURE- Patient is composed of 3 elements: body, pathology, person- Nursing is helping clients move in the direction of self awareness- Nursing operates in all 3 elements- Core: the person, therapeutic use of self- Care: the body, intimate body care (nurturing component)- Cure: the disease, medical care (client advocate)

15. MYRA ESTRINE LEVINE’S FOUR CONSERVATION PRINCIPLES OF NURSING- Promotion of the wholeness of the person- By improving the clients patterns of adaptive response

Promotion of “wholeness” of the client towards health maintenance or health restoration.

CONSERVATION- Defends wholeness of living systems by ensuring their ability to confront change

16. NOLA J. PENDER’S HEALTH PROMOTION MODEL- Directed towards increasing the level of well being and self actualization of a given individual or group- Example: 6 – 8 hours of sleep- Disease prevention/Health protection: action directed towards decreasing the probability of experiencing illness by active protection of the body against pathological stressors.- Example: BCG vaccination

COGNITIVE PERCEPTUAL MODIFYING FACTORS FACTORS

LIKELIHOOD IN ENGAGING INHEALTH PROMOTINGBEHAVIORS

Ex. Mass media

Demographic character

HEALTHY LIFESTYLE- Adequate nutrition 3 times a day- Regular exercise 3 times a week- Not smoking- Moderate intake of alcohol

CONCEPT OF MANCONCEPT OF MANAtomistic – whole or sum of partsHolistic – the whole is not equal to the sum of partsPhysiologic – genetic character, organs and functioningPsychological – emotions, affect, rationality, mercifulSocio-cultural – socialization, family, languageIntellectual – perception, cognitionSpiritual – faith (unquestioning belief in someone, serves to unite humans), hope, charityCharity – outward expression of love for others

BASIC HUMAN NEEDS1. Universal2. Met in different ways3. Stimulated by external and internal factors4. Maybe differed5. Interrelated6. Priorities maybe altered

MASLOW’S HEIRARCHY OF NEEDS- Need: anything that is essential to the survival of man- Framework: basic need is something whose- Absence: may cause illness- Presence: prevent illness/signal health- Meeting unmet needs restore health

Physiologic- sex, nutrition, shelter, clothing, water, elimination, rest and sleepSafety and Security- physical freedom from harm, psychological knowing what to expect from others and what others expect from you.Love and Belongingness- nurturance with affectionSelf Esteem- persons sense of achievement and independence, competence, confidence and strengthSelf Actualization- not all people attain self actualization (attained by only 15%)- Accepts himself- Balance between rest and activity- Open mind- Positive outlook in life

HEALTH- Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

WELLNESS- State of well being- Subjective perception of balance, harmony and vitality engaging in attitudes and behaviors that enhance the quality of life and maximizes personal potential.

DIMENSION OF WELLNESS- Physical: ADL, fitness of organ structures and functioning- Spiritual: faith and hope- Intellectual: use knowledge for personal, family, social, career development- Emotional: able to manage stress, express feelings and emotions appropriately- Social: interact successfully with others, tolerant of people with different beliefs

MODELS OF HEALTH AND WELLNESSLEAVELL AND CLARKS AGENT – HOST ENVIRONMENT MODEL OR ECOLOGICAL

MODEL/EPIDEMIOLOGIC

Agent

Host Environment

DUNN’S HIGH LEVEL WELLNESS GRIDVery Favorable Environment

Protected poor health High level wellness ( in favorable environment) (in favorable environment)

HEALTH AXIS

Death PeakWellness

Poor health Energetic, High level wellness (in an unfavorable environment) (in an unfavorable environment)

Environmental axis Very Unfavorable Environment

Both physical and social cultural environment

TRAVIS ILLNESS – WELLNESS CONTINUUM

Wellness model

. . . . . .

Premature Death Disability Symptoms/Signs Awareness/ Education/ Growth High Level Wellness

Treatment Models

Neutral Point(no discernable illness or wellness)

- Movement to the right of the neutral point indicates high level of health and well being for an individual and this may be achieved through awareness and education and growth. In contrast, movement to the left of the neutral point indicates a progressively decrease state of health

HEALTH BELIEF MODELHEALTH BELIEF MODEL- Intended to predict whether individuals would or would not use preventive measure- Based on the motivational theory- Assumption: Good health is a motivation common to all people

ILLNESS- Highly personal state in which the person feels unhealthy or ill, may or may not be related to disease

DISEASE- Alteration in body function resulting in a reduction of capacities or a shortening of the normal lifespan

CAUSES OF DISEASE1. Genetic – inherited, genetic defects2. Developmental – resulting to exposure to virus or chemicals during pregnancy3. Biologic – microorganisms (virus, bacteria, protozoa, fungi) and their toxins and helminthes4. Physical – temperature extremes, electricity, radiation5. Chemical – alcohol, strong acid and base, drugs6. Mechanical – generalized tissue response to injury or irritation (trauma shearing force, friction)7. Physiologic and Emotional reaction to stress8. Faulty Chemical or Metabolic Processes – excessive or insufficient production of hormones, enzymes

IGUN’S 11 STAGES OF HEALTH SEEKING- Any activity undertaken by a person who feels ill in order to define his state of health and seek a suitable remedyStage 1: Symptom experienceStage 2: Self treatment or self medicationStage 3: Communication to othersStage 4: Assessment of symptomsStage 5: Sick-role assumptionCharacteristics of Sick Role

a. Expected to seek competent helpb. Expected to get well in the shortest possible time

c. Person is not blamed for his diseased. Exempted from usual task

Stage 6: ConcernStage 7: Efficacy of treatmentStage 8: Selection of treatmentStage 9: TreatmentStage 10: Assessment of effectiveness of treatmentStage 11: Recovery and rehabilitation

SUCHMAN’S 5 STAGES OF ILLNESSStage I: Symptom Experience- Person believes that something is wrong- Physical experience of the symptoms- Cognitive aspect: interpretation of the symptoms- Emotional response: fear or anxiety

Stage II: Assumption of Sick Role- People are excused from normal duties and role expectations- Clients are not held responsible for their condition- Clients are obliged to get well and resume normal activity- Clients are obliged to seek competent help

Stage III: Medical Care Contact- Seeking medical advice to ask for the following

o Validation of real illnesso Explanation of symptoms in understandable termso Reassurance that they will be fine or for a prediction of what the outcome would be

- Client may accept or deny diagnosisStage IV: Dependent Client Role- The client is dependent on the professional for help and give up their independence- Client accepts treatment plan

Stage V: recovery or Rehabilitation- Client relinquishes role and resumes former role and responsibilities- For permanent disability, this may require therapy to learn how to make major adjustments in

functioning.

CHARACTERISTICS OF NURSING PROCESSCHARACTERISTICS OF NURSING PROCESS1. Cyclic and dynamic rather than static2. Client centered – nurse organizes plan of care according to client problems rather that nursing goals3. Interpersonal and collaborative – depends on open and meaningful communication between client and

the nurse4. Universally applicable – can be used with clients of any age at any point of the wellness – illness

continuum and useful in a variety of settings5. Adaptation of problem solving techniques and system theory based on the scientific method6. It can be viewed as parallel to but separate from the medical process

ASSESSMENTASSESSMENT- Objective (physical exam) and subjective (nursing history)

SOURCES OF DATA1. Primary – client2. Secondary – relatives, members of health team

FOR NURSING HISTORY USE GORDON’S TYPOLOGY OF 11 FUNCTIONAL PATTERN1. Health perception – health management pattern – describes clients perceived pattern of health and

well being and how health is managed.2. Nutritional – metabolic pattern – describes pattern of food and fluid consumption relative to metabolic

need and pattern indicators of local nutrient supply.3. Elimination – describes pattern of excretory function (bowel, bladder and skin).4. Activity – exercise – describes pattern of exercise, activity, leisure and recreation5. Cognitive perceptual – describes sensory perceptual and cognitive system6. Sleep rest – describes pattern of sleep, rest and recreation.7. Self perception – self concept – self concept pattern and perceptions of self (body comfort, body

image, feeling state).8. Role relationship – describes pattern of role engagements and relationships9. Sexual reproductive – client patterns of satisfaction and dissatisfaction with sexuality: describes

reproductive pattern10. Coping stress tolerance – general coping pattern and effectiveness of the pattern in terms of stress

tolerance.11. Value belief – patterns of values, beliefs (including spiritual) or goals that guide choices of decisions.

NURSING DIAGNOSISNURSING DIAGNOSIS- Clinical judgment about an individual, family or community responses to actual and potential health problems- Professional nurses are responsible for making nursing diagnosis.- Nursing diagnosis describe a continuum of health states.

Actual Potential Health Healthy

Problem Responses

NURSING DIAGNOSIS MEDICAL DIAGNOSIS- Focus on identifying human responses to health and illness- Describe problems treated by nurses within the scope of independent nursing practice- Changes from day to day as client responses change

- Identifies disease- Describe problems for which the physician directs the primary treatment

- Remains the same for as long as the disease is present

6 TYPES OF NURSING DIAGNOSIS1. Actual nursing diagnosis – judgment about a clients response to a health problem at the time of assessment and is signified by the presence of associated signs and symptoms.

Format: 2 part (problem related to etiology) 3 part (problem, etiology and signs and symptoms format)

2. Risk nursing diagnosis – clinical judgment about a clients vulnerability to develop a problemFormat: 2 part statement (diagnostic label related to risk factors)

3. Possible nursing diagnosis – evidence about a certain problem is unclear and need to gather more data to support it

Format: 2 part statement4. Wellness nursing diagnosis – clinical judgment about an individual, family and community in transition from a specific level of wellness to a higher level of wellness

Format: potential + desired higher level of wellness Readiness for + higher level of wellness

5. Syndrome nursing diagnosis – comprises of a cluster of problemsFormat: 1 part statement (rape trauma syndrome)

6. Alfaro’s rule for a collaborative problem – focus on potential complicationsFormat: potential problem + related to + list of complications that may occur

First Priority – is any threat to the vital functions of breathing, heart beat, blood pressure.Medium Priority – health-threatening problems that may result in delayed development or cause destructive physical or emotional changes.Low Priority – problems that arise from normal development needs or those that require minimal nursing support.

OBJECTIVESOBJECTIVES- Should be SMART, client centered, statement of a single human responseEVALUATIONEVALUATION- Conclusion and supporting data - Goal met- Goal partially met- Goal not met

GROWTH- Physical change- Increase in size- Periods of very rapid growth rate: pre – natal, neonatal, infancy, adolescence

DEVELOPMENT- Increase in complexity of function and skill progression- The behavioral aspect of growth

PRINCIPLES OF DEVELOPMENT1 Growth and development are continuous orderly, sequential process influenced by maturational environment and genetic factors2. All humans follow the same pattern of growth3. The sequence of each stage is predictable although the time of onset, the length of the stage and the effects of each stage vary with the person.4. Growth and development occur in cephalocaudal direction.5. Growth and development occur in a proximal to distal direction6. Development occurs from simple to complex or from single acts to integrated acts.7. Development becomes increasingly differentiated, begins with generalized response and progresses to a skilled specific response.8. The pace of growth and development is asynchronous or uneven.

KOHLBERG’S STAGES OF MORAL DEVELOPMENTLEVEL AND STAGE

Level I: Pre Conventional (Egocentric Focus)Stage 1Punishment and obedience orientation (toddler – 7 years)Stage 2Instrumental – Relativist Orientation (4 – 12 years)

Level II: Conventional (Societal Focus)Stage 3Interpersonal concordance, good boy, nice girl (6 years thru adult years)Stage 4Law and order orientation (adolescent – adult)

Level III: Post Conventional or Principled Level (Universal Focus)Stage 5Social contract, legalistic orientation (middle age or older adult)

Stage 6Universal ethical principles (middles age or older adult)

- Activity is wrong if one is punished, activity is right if one is not punished.

- Action is taken to satisfy ones needs.

- Action is taken to please another and gain approvals.

- Right behavior is obeying the law and follow the rules

- Standard of behavior is based on adhering laws that protect the welfare and rights of others: violating the rights of others is avoided: personal values and opinions are recognized.

- Universal moral principles are internalized, person respects other humans and believes that relationship are based on mutual trust.

TYPES OF OLDER ADULT1. Young old (65 – 74) – adaptation to retirement and changing physical abilities, chronic illness may develop.2. Middle old (75 – 84) – adaptation to decline in speed of movement, reaction time and sensory abilities: increasing dependence in others.3. Old old (85 – over) – increase physical problems.

DEVELOPMENTAL TASK AND WHOLISTIC APROACH BY ROBERT HAVIGHURST

AGE PERIOD DEVELOPMENTAL TASKInfancy and Early Childhood

Middle Childhood

Adolescence

Early Adulthood (20 – 40 yrs)

Middle Age (Emptiness Stage)

Late Maturity

- Learning to walk, to taste solid foods, to talk, to control elimination of body wastes, sex differences and sexual modes- Learning to relate emotionally to parents, siblings and others- Learning to distinguish right from wrong and developing a conscience- Learning to form concepts of social and physical reality

- Learning physical skills for ordinary games- Building wholesome attitude towards oneself- Learning to get along with age mates- Learning an appropriate masculine or feminine social role- Developing fundamental skills in reading, writing and calculating- Develop concepts necessary for everyday living- Achieving personal independence

- Achieving new and more mature relations with age mates of both sexes- Achieving masculine/feminine social role- Accepting ones physique and using the body effectively- Achieving emotional independence from parents- Selecting and preparing for an occupation- Preparing for marriage and family life- Developing intellectual skills necessary for civic competence- Acquiring a set of values and an ethical system as a guide to behavior

- Selecting a mate- Learning to live with a partner- Starting a family and rearing children- Managing a home- Getting started in an occupation- Taking on civic responsibility- Finding a congenial social group

- Achieving adult civic and social responsibility - Establishing and maintaining an economic standard of living- Assisting teenage children to become responsible and happy adults- Developing adult leisure time activity- Accepting and adjusting the physiologic changes of middle age- Adjusting to aging parent

- Adjusting to decrease physical strength- Adjusting to retirement and reduced income- Adjusting to death of a spouse- Meeting social and civic obligations- Establishing satisfactory living arrangements

NURSE – CLIENT RELATIONSHIPNURSE – CLIENT RELATIONSHIP- Helping relationship for growth

PHASES OF NURSE – CLIENT RELATIONSHIPPhase I: Pre Interaction- No face-to-face interaction with client

Phase II: Introductory/Orientation- Rapport setting, contract setting, sets tone for rest of relationship- Testing behavior (orientation) resisting behavior (non compliance)

Phase III: Working- Implementation of nursing care plans- View as unique individuals- Employ decision-making and technical skills and communication skills

Phase IV: Termination- Characterized by ambivalence on both nurse and client- Discharge phase- Evaluation of care given by nurse

COMMUNICATIONCOMMUNICATION- Human function that enables people to relate with each other

MODESVerbal – spoken languageNon-Verbal – symbols, sign language

ELEMENTS OF COMMUNICATION1. Stimulus – reason why people communicate, motivation with each other (object, ideas, feeling) referent2. Message – idea, feelings and emotions3. Sender – also known as encoder, one that sends the message4. Channels – kinesthetic: tactile stimulus, visual: symbols, auditory: spoken language5. Receiver – decoder6. Feedback – answer to questions, whether receiver understood or not

FACTORS THAT AFFECT COMMUNICATION PROCESS1. Ability of communicator – ability to speak, hear, see and comprehend stimulus2. Perceptions – each has a unique trait, values, life experiences3. Personal space – distance people prefer in interactions with one another

Four distancesa. Intimate- Physical contact to 1 ½ feet characterized by body contact heightened sensation of body heat and smell, low vocalization- Threatening to clientb. Personal- 1 ½ feet to 4 feet- Less overwhelming than intimate distance- Usual distance between nurse and client- Best distancec. Social- 4 feet to 12 feet- Communication is non-formal- Allows more activity and movement back and forth- Often misused by nursed. Public- 12 feet and beyond- Individuality is lost- Mass health education

4. Territoriality – concept of space and things that an individual considers as belonging to the self

5. Roles and Relationships6. Time – events that precede and follow interactions7. Environment – environment is comfortable, communication is more effective8. Attitudes

THERAPEUTIC COMMUNICATION RATIONALEUsing silence

Providing general leads

Being specific and tentative

Using open ended questions

Using touch

Restating/Rephrasing

Seeking clarification

Clarifying time or Sequence

Offering self

Giving information

Acknowledging

Presenting reality

Focusing

Reflecting

Accepting pauses or silences without interjecting any verbal response

Using statements or questions that a. encourage client to verbalize b. choose a topic of conversation

Statements that are specific rather than general and tentative rather than absolute

Specify only topic to be discussed and invite answers longer than one or two words

Touch reinforces caring feelings, however, nurse should be sensitive to difference in attitude’s practice of clients self

Actively listening for the client’s basic message then repeats those thoughts and/or feelings in similar words.

Used when communication is rambling or when paraphrasing is difficult

Helping the client clarify an event situation or happening with respect to time

Suggesting ones presence, interest or wish to understand the client without making any demands that could make client comply to suggestion

A simple and direct manner, specific factual information

Giving recognition in a non judgmental way of a. change in behavior b. effort the client has made c. contribution to a communicator

Helping client differentiate real from unreal

Helping the client expand on and develop a topic of importance

The focus may be an idea or a feeling.Directing ideas, feelings, questions or content back to clients to enable them to explore their own feelings

Summarizing and Planning

Perception checking

Stating the main points of discussion to clarify relevant parts discussed

Verifies meaning of specific words than overall meaning of a message

NON THERAPEUTIC COMMUNICATION RATIONALEStereotyping

Agreeing and Disagreeing

Being defensive

Challenging

Probing

Testing

Changing topic

Unwarranted reassurance

Passing judgment

Giving common advice

Offering generalized and over simplified beliefs about groups of people

Akin to judgmental responses implies client is either right or wrong

Attempting to protect a person

Giving response that makes client prove their statement or point of view

Asking information chiefly out of curiosity rather than intent

Question than make a client admit something

Directing communication into areas of self intent

Using clichés or comforting statements of advice as a means to reassure the client

Giving opinions and approving or disapproving response

Telling client what to do

VITAL SIGNSVITAL SIGNSTEMPERATURE

1. Oral - Most accessible and convenient- Normal value: 37 o C – 98.6 o F- 2 – 3 minutes2. Rectal- Most reliable- Normal value: 37.7 o C – 99.6 o F- 3 – 5 minutes3. Axila- Less accurate- Normal value: 36.4 o C – 97.5 o F- 5 – 10 minutes4. Tympanic membrane- Directly reflects core temperature- Normal value: 37.7 o C – 99.9 o F- Automatic results

CONVERSION- Fahrenheit to Celsius = (F-32) x 5/9- Celsius to Fahrenheit = (C x 9/5) + 32

PULSE SITE1. Temporal 6. Femoral2. Carotid 7. Popliteal3. Apical 8. Posterior tibial4. Brachial 9. Dorsalis pedis5. Radial

When palpating for pulse use 2 – 3 fingers except when taking the apical pulse use stethoscope Apical pulse is in the 5th intercostals space Landmark is the angle of Louie 4th intercostals space left mid clavicular line child apical pulse When using the stethoscope use the flat part when looking for high pitch sounds like (lung and

bowel sounds) and use the bell for vascular or heart sounds

RESPIRATION- Adult: 12 – 20 c/min- Newborn – 30 – 60 c/min

ERRORS IN TAKING RESPIRATORY RATEPatient Factor

Insufficient rest before assessing Assessing immediately after a meal or while client smokes or has pain

Equipment Factor Stethoscope fits poorly or hearing impaired Bladder or cuff too wide Bladder or cuff too narrow

Errors in technique Arm unsupported Arm above heart level and not perpendicular to the body Cuff wrapped to loosely Deflating cuff to slowly Deflating cuff to quick Failure to identify auscultatory gap

Auscultatory gap Temporary cessation of sounds after initiation Gap of 10 – 40 mmHg Common among hypertensive Repeating assessment too quickly (wait for 2 – 3 minutes after taking again the bp, and maximum

of 3 takes same arm and if still inaudible rest arm for 5 – 15 minutes) Multiple examiner using different Kortkoff sounds for diastolic readings Failure to use the same arm consistently Effects Erroneously high readings

False low systolic and false high diastolic- False low reading- False high reading- Erroneously high readings- Erroneously low readings- False high readings- False low diastolic reading- False high diastolic reading- False low systolic bp and diastolic bp- False high systolic blood pressure, false low diastolic blood pressure

Inaccurate interpretation Inconsistent measurements For a client who’s blood pressure is to be taken for the first time, take the blood pressure of

both arms Difference of blood pressure for both arms should only be 10 mm Hg Use higher value as baselinePALPATORY SYSTOLIC PRESSURE Point of pulsation stops with the use of stethoscope Maximum pressure + 30 mmHg that is you limit when taking the blood pressure

KOROTKOFF SOUNDSPhases1. Characterized by a thud, thump and tapping sound2. Swooshing, whoosing sound3. Sound decrease in intensity when compared to Korotkoff one4. Muffling sound5. Disappearance of sound

- in adults record Korotkoff 1 and Korotkoff 5 of able to hear Korotkoff 4 record also- in children record Korotkoff 1 and Korotkoff 4

HYPERTENSIONAverage of 2 or more diastolic reading on at least 2 subsequent visits is 90 mmHg or higher or when an average of 2 or more systolic readings on at least 2 visits is higher than 140 mmHg

SYSTOLIC DIASTOLICOptimal/ NormalAbove NormalHypertension

Grade 1 (Mild)Grade 2 (Moderate)

Grade 3 (Severe)

120 – 129 130 – 139

140 – 159160 – 179Greater than 180

Greater than 140Less 80

80 – 8485 – 89

90 – 99100 – 109Greater than 110

Less 90